Tethered spinal cord following repair of myelomeningocele

Hudgins, Roger J.; Gilreath, Carita Lynn

doi:10.3171/foc.2004.16.2.8

Cited by 86 publications

(78 citation statements)

References 13 publications

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“…Some patients also experience loss of neurology and ability to walk secondary to release operations for tethered cord [25,27]. Moreover, a great number of patients chose to use a wheelchair, as they found themselves more mobile using a wheelchair rather than walking with crutches and orthoses.…”

Section: Discussionmentioning

confidence: 99%

“…The natural course of valgus unstable feet in children with myelomeningocele with respect to foot deformity, function or patient satisfaction has not been reported previously and is not further investigated in this study. The evaluation of corrective foot surgery in myelomeningocele children is further complicated by the neurological deterioration commonly occurring in these patients, often due to tethered cord and subsequent releases [25][26][27][28]. Patient selection and the indications for surgery in this study were based on the clinical judgement of valgus instability of the feet combined with an evaluation of the overall situation of the child, such as walking ability, and not solely on radiographic measurements or any other objective parameter.…”

Section: Discussionmentioning

confidence: 99%

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Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: A 12.8-year follow-up study

Høiness¹,

Kirkhus²

2009

Journal of Children's Orthopaedics

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Purpose Neurological deficit resulting in the lack of motor control in children with myelomeningocele often leads to a valgus position of the feet and ankles, usually in combination with planovalgus and pronation of the forefoot. The purpose of the study was to evaluate long-term patient satisfaction and clinical effects in ambulating children with lumbosacral myelomeningocele after having performed a Grice arthrodesis of a valgus unstable foot. The clinically most relevant radiographic measurements, such as the frontal and lateral talo-calcaneal angles, were used to evaluate the anatomical effects of the surgery, whereas the main research question was to reveal the patient satisfaction and usefulness of the procedure. Methods The modified Grice-Green extraarticular subtalar arthrodesis was performed by the same surgeon on one standing and 22 walking patients (12 female) with lumbosacral myelomeningocele and valgus instability during the period 1985-1999. Twelve patients had bilateral surgery, giving a total of 35 operated feet. The patients attended a thorough check-up at a mean of 12.8 years (standard deviation [SD] ± 3.2, range 7.7-20.2 years) after surgery. The mean age at surgery was 6.6 years (SD ± 1.8) and at follow-up 19.4 years (SD ± 3.8). Functional parameters, such as walking ability, pain and skin problems, and the need for braces and supportive orthopaedic shoes were noted at the follow-up interview. The parents were interviewed along with the patients in order to obtain all of the necessary information. Loaded radiographs in the lateral and frontal planes were taken of both feet and ankles pre-operatively and at follow-up, except for pre-operative radiographs in six patients that were not loaded and, thus, not included, except for the assessment of ankle valgus. Ankle valgus was assessed from lateral and frontal views of the ankle on a scale from grade 0 to grade 3 according to Malhotra. Frontal and lateral talo-calcaneal angles were measured for the assessment of subtalar varus or valgus. Lateral talo-first-metatarsal (Meary's) angles were measured to investigate the longitudinal arches of the feet. Results The mean lateral talo-calcaneal angle was reduced significantly (P \ 001) from 55.1°(SD ± 8.9) to 38.8°(SD ± 8.1). The mean frontal talo-calcaneal angle was reduced from 24.7°(SD ± 9.7) pre-operatively to 16.6°(SD ± 6.3) at follow-up (P \ 0.001). The mean lateral talo-first-metatarsal angle improved significantly from -16.1°(SD ± 24.7) pre-operatively to 0.9°(SD ± 15.1) at follow-up (P = 0.0015). The calcaneal pitch did not change significantly. In general, ankle valgus worsened during follow-up time, but not significantly (P = 0.113). The visual analogue scale (VAS) score of patient satisfaction improved significantly from 3.7 (SD ± 1.7) prior to surgery to 7.2 (SD ± 1.5) at follow-up (P \ 0.005). Nineteen patients (83%) were satisfied with the surgery and would thus recommend the procedure. Conclusions Based on the radiological findings and patient satisfaction, the patients participa...

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: A 12.8-year follow-up study

Høiness¹,

Kirkhus²

2009

Journal of Children's Orthopaedics

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“…Measures are therefore necessary to minimize the risk of iatrogenic injury during untethering procedures. 3,8,12,19,20 Previous reports, including a recent one by AlHolou and colleagues, 1 have described the benefits of surgical untethering in this patient population, clearly document ing the benefits of intervention. 7 In this study, we again assess outcomes of untethering in this population.…”

mentioning

confidence: 99%

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

Pouratian¹,

Elias²,

Phillips

et al. 2010

FOC

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Object Many patients develop neurological symptoms related to spinal cord tethering after perinatal repair of myelomeningocele. This is referred to as secondary tethered cord syndrome (STCS). The authors describe their methodology and evaluate the intraoperative utility and postoperative outcomes of electrophysiologically guided untethering for STCS. In addition, the authors describe the use of electrophysiological guidance to identify an “autonomous placode” in the untethering of the cord in STCS. Methods The authors retrospectively identified 46 untethering procedures in 38 patients who had undergone perinatal myelomeningocele repair and in whom the index surgery was for tethered cord release at the site of the repair. In all cases, both passive (electromyography) and active (detection of compound muscle action potentials) electrophysiological monitoring was used. The proximity to neural elements was determined based on the current used; eliciting compound muscle action potentials with a ≤ 10-mA stimulation was assumed to represent direct neural stimulation. Clinical records were reviewed to evaluate the utility of electrophysiological guidance and patient outcomes. Results The median age at the time of untethering was 9.5 years (range 0.5–54 years). The median follow-up time was 42 months (range 3–172 months). Progressive bowel and bladder dysfunction, diagnosed either clinically or by cystometrogram, and low-back pain were the most common presenting symptoms. Intraoperative findings indicated that the most common causes of tethering were dense scar (76%) and a tethered placode (39%). Electrophysiological monitoring identified functional neural tissue near tethered elements and provided intraoperative guidance in all cases. In 41% of cases (19 cases), the untethering plan was noted to have been significantly influenced by intraoperative neurophysiological findings. Moreover, an autonomous placode was identified in 6 patients who were nonambulatory preoperatively and had presented with increasing pain and spasticity. In electrophysiologically silent areas, more aggressive dissection and untethering were possible. Symptoms of low-back pain, lower-extremity paresthesia, and lower-extremity spasticity were most likely to improve after untethering surgery (91, 88, and 82%, respectively). Sectioning above the electrophysiologically defined autonomous placode resulted in significant improvement in back pain and lower-extremity spasticity in 5 of 6 patients. There was 1 case of immediate postoperative neurological deterioration (fecal incontinence). All patients remained clinically stable or improved on long-term follow-up, except for 6 (16% of patients) who required a total of 7 additional procedures for recurrent symptoms (median time to repeat surgery 36 months). Complications were noted in 8 cases, including infections and CSF leaks. Conclusions Surgical untethering of STCS halts progression and often improves preoperative symptoms. Electrophysiological monitoring, using both a threshold-based interpretation system and continuous electromyography monitoring, provides an efficient, effective, and reliable method for intraoperative guidance, thereby limiting iatrogenic injury and providing a means to identify and untether autonomous placodes. Electrophysiological monitoring also allows for more aggressive dissection and untethering in functionally silent regions, possibly decreasing retethering rates.

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“…3,9,16 Risk factors for the development of scoliosis in these patients include motor level, ambulatory status, and last intact laminar arch, with scoliosis developing in almost 100% of patients with a thoracic motor level. 9,16 In addition, virtually all patients with MM radiographically demonstrate a tethered spinal cord, 6,13 although only 10-30% exhibit symptoms. 1,2,15 This occurs due to a difficulty in closing the dura mater around the neural placode to keep it bathed in CSF and prevent adherence to the dura.…”

mentioning

confidence: 99%

A patient with myelomeningocele: is untethering necessary prior to scoliosis correction?

Samdani¹,

Fine²,

Sagoo³

et al. 2010

FOC

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Object Tethering of the spinal cord is thought to increase the chance of neurological injury when scoliosis correction is undertaken. All patients with myelomeningocele (MM) are radiographically tethered, and untethering procedures carry significant morbidity risks including worsening neurological function and wound complications. No guidelines exist as regards untethering in patients with MM prior to scoliosis correction surgery. The authors' aim in this study was to evaluate their experience in patients with MM who were not untethered before scoliosis correction. Methods Seventeen patients with MM were retrospectively identified and 1) had no evidence of a clinically symptomatic tethered cord, 2) had undergone spinal fusion for scoliosis correction, and 3) had not been untethered for at least 1 year prior to surgery. The minimum follow-up after fusion was 2 years. Charts and radiographs were reviewed for neurological or shunt complications in the perioperative period. Results The average age of the patients was 12.4 years, and the following neurological levels were affected: T-12 and above, 7 patients; L-1/L-2, 6 patients; L-3, 2 patients; and L-4, 2 patients. All were radiographically tethered as confirmed on MR imaging. Fourteen of the patients (82%) had a ventriculoperitoneal shunt. The mean Cobb angle was corrected from 82° to 35°, for a 57% correction. All patients underwent neuromonitoring of their upper extremities, and some underwent lower extremity monitoring as well. Postoperatively, no patient experienced a new cranial nerve palsy, shunt malfunction, change in urological function, or upper extremity weakness/sensory loss. One patient had transient lower extremity weakness, which returned to baseline within 1 month of surgery. Conclusions The study results suggested that spinal cord untethering may be unnecessary in patients with MM who are undergoing scoliosis corrective surgery and do not present with clinical symptoms of a tethered cord, even though tethering is radiographically demonstrated.

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Tethered spinal cord following repair of myelomeningocele

Cited by 86 publications

References 13 publications

Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: A 12.8-year follow-up study

Grice arthrodesis in the treatment of valgus feet in children with myelomeningocele: A 12.8-year follow-up study

Electrophysiologically guided untethering of secondary tethered spinal cord syndrome

A patient with myelomeningocele: is untethering necessary prior to scoliosis correction?

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