Subscribe to RSS
DOI: 10.1055/s-2004-832347
© Georg Thieme Verlag Stuttgart · New York
Surgical Aspects and Outcome of Delayed Tethered Cord Release
Operationstechnik und Ergebnisse bei sekundärem Tethered Cord SyndromPublication History
Publication Date:
18 November 2004 (online)
![](https://www.thieme-connect.de/media/zblneurochir/200404/lookinside/thumbnails/10.1055-s-2004-832347-1.jpg)
Abstract
Out of a total of 550 children followed up at our spina bifida center, we report on 81 patients who were reoperated upon for secondary tethered cord syndrome between 1993 and 2000. In four cases with preceding severe progressive scoliosis, untethering was followed by surgical correction and stabilization of curvatures. In 77 patients, the indication for surgery was based on late progressive neurological deterioration. The current clinical relevance of competing etiologic factors such as symptomatic Chiari malformation, hydromyelia, and shunt dysfunction, requiring different clinical management, had been previously carefully excluded. The children underwent magnetic resonance imaging (MRI) or myelo-computed tomography (m-CT) to identify the morphologic extent of tethering and any associated spinal malformations such as dermoid tumors (19 cases) or diastematomyelia (9 cases). Surgery became faster and safer through bilateral dural incision, undercutting arachnoid adhesions along the tethered area, although this procedure increased the need for dural grafting. Complete release of the conus medullaris and cauda equina was achieved in a total of 75 cases (93 %) including those who had undergone prophylactic surgery. A mean follow-up of 4.8 years in 77 patients operated upon for late progressive neurological deterioration confirmed stabilization of presenting symptoms in 65 cases (84 %) with 20 of them (26 %) even showing significant improvement. In 12 patients (16 %), including all cases of incomplete untethering (n = 4), there was further deterioration.
Zusammenfassung
Durch das sozialpädiatrische Zentrum unserer Kinderklinik werden derzeit etwa 550 Kinder unter der Diagnose eines dysraphischen Syndroms interdisziplinär betreut. Wir berichten in dieser Studie über 77 dieser Patienten, die zwischen 1993 und 2000 wegen eines symptomatischen sekundären Tethered Cord Syndroms operiert wurden. Differenzialdiagnostisch und -therapeutisch relevante andere Ursachen für die vorliegende klinischen Verschlechterung wie z. B. Chiari-Malformation, Hydromyelie oder Shunt-Dysfunktion wurden bezüglich ihrer aktuellen klinischen Relevanz so weit wie möglich ausgeschlossen. Mittels Kernspintomographie (MRT) oder Myelo-CT (m-CT) wurde die Ausdehnung des Tetherings erfasst und das Vorliegen eventueller Begleitpathologien wie z. B. Diastematomylie (9 Fälle) oder Dermoid-Tumor (19 Fälle) untersucht. Operationszeit und -risiko wurden durch eine entlang des Tetherings von mittig dorsal nach beidseits ventrolateral unterhalb der arachnoidalen Adhäsionen geführte Durainzision vermindert, obwohl diese Technik in der Regel die Notwendigkeit der Implantation einer Duraplastik erhöhte. Eine vollständige Myelolyse wurde bei 75 Patienten erreicht (93 %) einschließlich der vier Patienten, die aus prophylaktischer Indikation operiert wurden. Eine durchschnittliche Nachuntersuchungszeit von 4,8 Jahren bestätigte bei 77 Patienten eine Stabilisierung der klinischen Situation in 65 Fällen (84 %). Bei 20 dieser Patienten (26 %) konnte sogar eine signifikante Verbesserung der klinischen Symptomatik beobachtet werden. Bei 12 Patienten (16 %) einschließlich aller Fälle mit inkompletter Neurolyse (4) konnte eine weiter klinische Verschlechterung nicht verhindert werden.
Key words
Tethered cord syndrome - results - surgical technique - endoscopic assistance
Schlüsselwörter
Tethered Cord Syndrom - Operationstechnik - Ergebnisse - endoskopische Unterstützung
References
- 1 Archibeck M J, Smith J T, Carroll K L, Davitt J S, Stevens P M. Surgical release of tethered spinal cord: Survivorship analysis and orthopaedic outcome. J Pediatr Orthop. 1997; 17 773-776
- 2 Basar H, Aydoganli L, Yuksel M, Basar M, Akdemir G, Kaptanoglu E. The outcome of urological findings in operated tethered cord patients. Int Urol Nephrol. 1997; 29 167-171
- 3 Boor R, Schwarz M, Reitter B, Voth D. Tethered cord after spina bifida aperta: a longitudinal study of somatosensory evoked potentials. Childs Nerv Syst. 1993; 9 328-330
- 4 Bowman R M, McLone D G, Grant J A, Tomita T, Ito J A. Spina bifida outcome: a 25-year prospective. Pediatr Neurosurg. 2001; 34 114-120
- 5 Caldarelli M, Di Rocco C, Colosimo C, Fariello G, Di Gennaro M. Surgical treatment of late neurological deterioration in children with myelodysplasia. Acta Neurochir (Wien). 1995; 137 199-206
- 6 Cracco J C, Cracco R Q, Graziani L. Spinal evoked response in infants with myelodysplasia. Neurol. 1974; 24 359
- 7 Di Rocco C. Management of tethered spinal cord. Surg Neurol. 1997; 48 320-321
- 8 Haberl H, Tallen G. Operative Behandlung beim sekundären Tethered Cord. In: Michael T, von Moers A, Strehl AE (eds). Spina bifida (Interdisziplinäre Diagnostik, Therapie und Beratung). de Gruyter, Berlin, New York 1998; 102-109
- 9 Herman J M, McLone D G, Storrs B B, Dauser R C. Analysis of 153 patients with myelomeningocele or spinal lipoma reoperated upon for a tethered cord presentation, management and outcome. Pediatr Neurosurg. 1993; 19 243-249
- 10 Hoffman J H, Hendrick E B, Humphreys R P. The tethered spinal cord. Its protean manifestation, diagnoses and surgical correction. Child's Brain. 1976; 2 145-155
- 11 Houser E E, Bartholomew T H, Cookson M S, Marlin A E, Little N A. A prospective evaluation of leak point pressure, bladder compliance and clinical status in myelodysplasia patients with tethered spinal cords. J Urol. 1994; 151 177-181
- 12 Johnson D L, Levy L M. Predicting outcome in the tethered cord syndrome: A study of cord motion. Pediatr Neurosurg. 1995; 22 115-119
- 13 Just M, Schwarz M, Ludwig B, Ermert J, Thelen M. Cerebral and spinal MR-findings in patients with postrepair myelomeningocele. Pediatr Radiol. 1990; 20 262-266
- 14 Lagae M, Verpoorten C, Casaer R. et al . Conservative versus neurosurgical treatment of tethered cord patients. Z Kinderchir. 1990; 45 (Suppl 1) 16-17
- 15 Mayfield J K. Comprehensive orthopaedic management in myelomeningocele. In: Rekate HL (ed). Comprehensive Management of Spina Bifida. CRC Press, Boston 1991; 113-164
- 16 McLone D G. Continuing concepts in management of children with spina bifida. Pediatr Neurosurg. 1992; 18 254-256
- 17 McLone D G, La Marca F. The tethered spinal cord: diagnosis, significance, and management. Semin Pediatr Neurol. 1997; 4 192-208
- 18 Park T S, Cail W S, Maggio W M, Mitchell D C. Progressive spasticity and scoliosis in children with myelomeningocele: Radiological investigation and surgical treatment. J Neurosurg. 1985; 62 367-375
- 19 Peter J C. Management of tethered spinal cord. Surg Neurol. 1997; 48 321-322
- 20 Peterson M C. Tethered cord syndrome in myelodysplasia: correlation between level of lesion and height at time of presentation. Dev Med Child Neurol. 1992; 34 604-610
- 21 Phuong L K, Schoeberl K A, Raffel C. Natural history of tethered cord in patients with meningomyelocele. Neurosurgery. 2002; 50 989-993 discussion 993-995
- 22 Pierz K, Banta J, Thomson J, Gahm N, Hartford J. The effect of tethered cord release on scoliosis in myelomeningocele. J Pediatr Orthop. 2000; 20 362-365
- 23 Reigel D H. Tethered spinal cord. In: Humphreys RP (ed). Concepts in Paediatric Neurosurgery. Vol. 4. Karger, Basel 1983; 142-164
- 24 Reigel D H, Tchernoukha K, Bazmi B, Kortyna R, Rotenstein D. Change in spinal curvature following release of tethered spinal cord associated with spina bifida. Pediatr Neurosurg. 1994; 20 30-42
- 25 Sarwark J F, Weber D T, Gabrieli A P, McLone D G, Dias L. Tethered cord syndrome in low motor level children with myelomeningocele. Pediatr Neurosurg. 1996; 25 295-301
- 26 Shurtleff D B, Duguay S, Duguay G, Moskowitz D, Weinberger E, Roberts T, Loeser J. Epidemiology of tethered cord with meningomyelocele. Eur J Pediatr Surg. 1997; 7 (Suppl I) 7-11
- 27 Tamaki N, Shirataki K, Kojima N, Shouse Y, Matsumoto S. Tethered cord syndrome of delayed onset following repair of myelomeningocele. J Neurosurg. 1988; 69 393-398
- 28 Torre M, Planche D, Louis-Borrione C, Sabiani F, Lena G, Guys J M. Value of electrophysiological assessment after surgical treatment of spinal dysraphism. J Urol. 2002; 168 1759-1762 discussion 1763
- 29 van der Meulen W D, Hoving E W, Staal-Schreinemacher A, Begeer J H. Analysis of different treatment modalities of tethered cord syndrome. Childs Nerv Syst. 2002; 18 513-517
- 30 Wilson D A, Prince J R. MR imaging determination of the location of the normal conus medullaris throughout childhood. AJR Am J Roentgenol. 1989; 152 1029-1039
- 31 Witkamp T D, Vandertop W P, Beek F J, Notermans N C, Gooskens R H, van Waes P F. Medullary cone movement in subjects with a normal spinal cord and in patients with a tethered spinal cord. Radiology. 2001; 220 208-212
- 32 Yamada S, Iacono R P, Andrade T, Mandybur G, Yamada B S. Pathophysiology of the tethered cord syndrome. Neuro Surg Clinics NA. 1995; 6 311-323
- 33 Yamada S, Zinke D E, Sanders D. Pathophysiology of “tethered cord syndrome”. J Neurosurg. 1981; 54 494-503
- 34 Zerah M, Pierre-Khan A, Renier D, Sainte-Rose C. et al . Lumbosacral lipomas. Long-term results and 291 consecutively treated cases. Childs Nerv Syst. 1995; 11 544-545
Dr. med. Hannes Haberl
Neurochirurgische Klinik der Humboldt-Universität · Charité · Campus Virchow
Augustenburger Platz 1
13353 Berlin
Germany
Phone: +49/30-45 05-6 00 91
Fax: +49/30-45 05-6 09 03
Email: hannes.haberl@charite.de