To investigate effects of surgical treatment on adult tethered cord syndrome (TCS). Disclaimer. School-age children are typically out of school for 2 weeks. There are different types of tethered cord. This means a shorter, Walk on their own (if appropriate for age), Diazepam (Valium) to prevent muscle spasms. In our study, in patients with severe Hoffman grading and without satisfied remission of symptoms, there were tendencies of longer medical history, more complications, and complicated symptoms; and for patients with relatively short medical history, Hoffman grading was shown to be mild and postoperative symptoms were improved obviously, which were similar with the above conclusions. Yamada S, Lonser RR. Hertzler DA 2nd, DePowell JJ, Stevenson CB, et al. . Equipment. The care team will review your childs symptoms and how tethered cord syndrome is affecting their quality of life. may email you for journal alerts and information, but is committed
Pathology and treatment of tethered cord syndrome with lipoma. 5. Long-term results showed a good prognosis in patients in whom first-time (that is, nonrevision) surgery achieved successful untethering, with a 10-year rate of neurological stabilization in 89% of Group A and a 10-year rate of neurological stabilization in 81% of Group B patients. Spinal column shortening is an indirect detethering surgery which shortens and fuses the spine to relieve longitudinal pressure on the spinal cord. Chern JJ, Dauser RC, Whitehead WE, Curry DJ, Luerssen TG, Jea A. Spine (Phila Pa 1976). Over time, the syrinx can get bigger and can damage the spinal cord and compress and injure the nerve fibers that carry information to the brain and from the brain to the rest of the body. Meanwhile, patients with shorter disease courses were suggested to accompany with obvious improvement of symptoms postoperatively when compared to those patients preoperatively; besides, the course of disease was within 1 year regarding those patients showing a completely recovery of the abovementioned symptoms. WebMedian time to symptomatic improvement was least for pain (1 month), then motor (2.3 months), and then urinary symptoms (4.3 months; p = 0.04). With a recommendation for surgery this figure rose to 47% within 5 years. Your child may need an operation to help the spinal cord move freely. After a mean clinical follow-up period of 4 years, significant improvement occurred in 22 of 27 patients presenting with pain, 13 of 27 patients with motor or sensory dysfunction, and 11 of 18 patients with bowel and bladder disturbance. Neurophysiologic intraoperative monitoring is when doctors place electrodes (wires with a sticker on one end) on your childs head, arms and legs. The authors reviewed their experience of newly diagnosed adult TCS patients to identify and explore TCS misdiagnosis, recognition, subtype pathology . The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. In children surgery prevents further neurological deterioration. WebAdult spinal deformity, which can result from disk degeneration, spinal arthritis, and prior surgeries that fail to align the spine, is an increasing problem among aging Americans. Therefore, it is necessary to remove contents within the cyst and to reduce the size of the cyst as far as possible, followed by free cystic wall, and then to minimize the stretching of the nerve tissue. Tethered cord syndrome: an updated review. [2], In 1886, Von Reeklinghausen reported autopsy results of the patients with lumbosacral hypertrichosis accompanied with spina bifida, showing that the spinal cord was adhered to fat in the lumbosacral region, conus terminalis was indicated to be tensed. The most common operative findings were tight filum terminale, split cord malformation, and lipomyelomeningocele, paralleling those observed in pediatric studies. Wang XG, Zhou YD, Ji SJ, et al. Federal government websites often end in .gov or .mil. This abnormal attachment is associated with progressive stretching and increased tension of the spinal cord as a child ages, potentially resulting in a variety of . 14. WebPatients were examined by the same neurologist in a standardized fashion before and after surgery, and most were followed for at least 2 years postoperatively. And if you do have to take laxatives - just go ahead and do that. In conclusion, SSO appears to provide clinical improvement at least comparable to that achievable with the untethering procedure, especially in more challenging cases where successful untethering is quite difficult to achieve, such as cases of patients with complex malformations, arachnoid adhesions, and revision surgery. The care team will evaluate if your child is an ideal candidate for a tethered cord release surgery. "The best age to perform a detethering is 6 months to 1 year old, but it is still very treatable in older children. Because neurological deficits are generally irreversible, early surgery is recommended. To be included, patients (1) had to be>18 years old at the time of surgery and (2) had to have undergone spinal surgery for TCS. The mean duration of follow-up was 4.73.5 years (range, 2.0 to 15.5 years). 8600 Rockville Pike [11] In this paper, we suggest that it is possible to cut off the filum terminale if there will have no injury to the nerve under electrophysiological monitoring, corresponding prognostic outcome will be better than that that without disconnection of filum terminale. Of 40 cases without occupying lesions of TCS, the symptoms were improved in 14 cases and stabilized in 26 cases, there was no deteriorated case. Shinjo T, Hayashi H, Takatani T, Boku E, Nakase H, Kawaguchi M. J Clin Monit Comput. Neurosurgeons have long performed procedures that inadvertently shorten the spinal column, such as partially or fully removing vertebrae when a cancerous tumor arises within the bone. In adults, symptoms of tethered cord usually develop slowly. J Neurosurg. Methods: 5 Going from horizontal to vertical felt like being hit in the back of the head with a baseball bat. Please enable it to take advantage of the complete set of features! Disclosures Hiroaki Nakashima, none The surgical procedure performed at L1 is described below. For patients combined with subcutaneous giant lipoma in the lumbosacral region, the subcutaneous tumor was removed, and the drainage tube was placed into the left empty cavity, followed by pressurized dressing and vacuum aspiration. To investigate effects of surgical treatment on adult tethered cord syndrome (TCS). This abnormal attachment is associated with progressive stretching and increased tension of the spinal cord as a child ages, potentially resulting in a variety of . 6 Surgery for a Tethered Spinal Cord. Typically, there is also a short filum and, as a result of both anomalies, a tethered cord. Epub 2018 Mar 8. Asian J Neurosurg. A T12 to L1 diskectomy and L1 upper one-third vertebral body resection were performed thereafter. For most children who have tethered cord surgery, their symptoms do not progress or get worse. Tethered cord syndrome is a stretch-induced functional disorder associated with the fixation (tethering) effect of inelastic tissue on the caudal spinal cord, limiting its movement. If the nerves are stretched, they may not work properly, and this can cause problems for your child. My headaches began as intolerance to light and sound. 4. World J Clin Cases. After untethering surgery, CSF leakage, neurologic deterioration, hematoma, difficult wound healing, and meningitis have been reported (Table 5).1 18. Therefore, he believed that the dysfunction of the nerve cells in the spinal cord might be caused by the impairment of mitochondrial oxidative metabolism. The surgical scheduler will work with you and family to coordinate a surgical date that fits best into your and your childs schedules. 6 11 Miyakoshi et al reported complete clinical recovery without complications in 2009, which led to the hope that SSO would be the way to reduce perioperative complications and provide better neurologic outcomes.10 Although Kokubun et al also reported good clinical results after SSO in 2011,11 there have been no reports until now of a comparative study or review of these two procedures. Tethered cord syndromea study of the short-term effects of surgical detethering on markers of neuronal injury and electrophysiologic parameters. In adults, dethetering of the spinal cord . Httmann S, Krauss J, Collmann H, et al. 9 Patients with such complex pathologies have been found to have a 9 to 50% chance of worsening pain and sensorimotor deficits after untethering.7 Unlike pediatric patients, adults experience degenerative changes that further complicate treatment.5 What is Adult Tethered Cord? Based on this small retrospective case series, SSO appears to provide clinical improvement at least comparable to that of the untethering procedure, especially in more challenging cases (complex malformations or revision surgery). During this call, the nurse will help decide which type of anesthesia is best for your child and if your child may have any risks with anesthesia. Although it was difficult to compare clinical outcomes due to the small numbers of patients and heterogeneity, SSO might be preferable for improving the symptoms in adult TCS after considering these baseline differences. In surgically treated patients, pain relief can often be achieved, and long-term neurological stabilization tends to persist more often than it does in conservatively treated patients. Stretching and tension, especially in a growing child, can cause neurologic damage. 8 7 We would like to thank our colleagues from the Department of Neurosurgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, and the Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University. Treatment of posttraumatic syringomyelia. Frequent micturition, diminished knee and ankle reflexes, and difficulty in bending were exhibited in partial patients. Federal government websites often end in .gov or .mil. MeSH terms SSO was performed at the level of T12 or L1 (Fig. The mean operation time was 220.2 109.0 minutes for untethering surgery and 399.5 9.6 minutes for SSO; as these numbers clearly indicate, the time was significantly longer for the SSO group ( p = 0.01). Diagnosis: Adult tethered cord is Yamada S, Won D J, Pezeshkpour G. et al. J Surg Case Rep. 2020 Mar 24;2020(3):rjaa041. It is not possible to predict whether your childs current symptoms will reverse. 9 Although untethering surgery has been a standard treatment in patients with adult tethered cord syndrome (TCS), spine-shortening osteotomy (SSO) has recently been performed as an alternative technique. These electrodes connect to a computer that lets doctors know how well the nerves in your childs head, arms and legs are working throughout the surgery. This allows the covering of the spinal cord to seal so Surgery is the only treatment for tethered cord. When surgeons operate around the spinal cord, the area where the CSF lies is opened so they can untether the spinal cord. Surgery may also restore some function or These patients included those who had either tight terminal filum or secondary lesions that restricted the movement of the caudal spinal cord. Pelissou-Guyotat I, Sindou M, Pialat J, Goutelle A. Solmaz I, Izci Y, Albayrak B, Cetinalp E, Kural C, Sengul G, Gocmez C, Pusat S, Tuzun Y. . Naoki Ishiguro, none Rajpal S, Tubbs RS, George T, Oakes WJ, Fuchs HE, Hadley MN, Iskandar BJ. 2007 Mar;6(3):210-5. doi: 10.3171/spi.2007.6.3.210. As the child grows taller, the spinal cord is stretched. Prompt untethering after diagnosis leads to improved . Definition. WebIn adults, symptoms are aggravated by trauma, maneuvers associated with stretching of the spine (flexion), disc herniation, and spinal stenosis. Get the latest news, explore events and connect with Mass General. His motor weakness marginally improved after SSO; however, he did not improve sufficiently to be able to walk by himself. In children, the surgery to de-tether the spinal cord is more common and can be done at many institutions; the procedure is also lower risk in children than in adults. [4] In 1953, Garceau described the filum terminal syndrome, suspected that the tensive filum terminal pulled the spinal cord might cause defecation dysfunction and other symptoms. First, it was a retrospective review of a small number of patients, due to the fact that the number of adult patients with TCS is relatively low, so securing a large number of patients for the study (especially patients with SSO) was difficult even though the study was a multicenter one. 2019 Feb;33(1):155-163. doi: 10.1007/s10877-018-0127-2. Intraoperative feasibility of bulbocavernosus reflex monitoring during untethering surgery in infants and children. This keeps the spinal cord from moving freely. Klekamp[14] advocated that for small lipoma and cone did not show obvious compression, the symptom is mainly caused by tethered, simply releasing of the tethered is suitable to prevent postoperative adhesion and not to destroy lipoma; and for larger lipoma compressed the conus medullaris, decreasing the volume of lipoma from internal, retaining the capsule, and sewing up the incision will be more effective to reduce the possibility of adhesion. WebIn adults, symptoms of tethered cord often develop slowly, but they can become quite severe. Conclusions: official website and that any information you provide is encrypted 5 12 The causes of tethering, preoperative duration of symptoms, and completeness of untethering could cause the outcomes to vary. According to Hoffman grading system, the neurologic symptoms were improved in 22 patients (27%), stabilized in 60 patients (73%). Untethering (tethered cord release) is the gold standard treatment for TCS. Tethered cord is usually present at birth . Tethered Cord Syndrome in Children and Adults. Tethered cord means that the spinal cord movement is limited within the spinal column due to abnormal tissue attachments. Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. . In adults, if the only abnormality is a thickened, shortened filum, then a limited lumbosacral laminectomy may suffice, with division of the filum once identified. Before Object: The mean estimated blood loss during surgery (300 ml in the open group vs 167 ml in the mini-open group, p = 0.313) and the mean length of stay (7 days in the open group vs 6.3 days in the mini-open group, p = 0.718) were similar between the 2 groups. Tethered cord due to spina bifida occulta presenting in adulthood: a tricenter review of 61 patients. Urologic dysfunction subjectively improved in 36% of the patients with that complaint. 2011 Jun 15;36(14):E944-9. J Neurosurg. Tremors or spasms in the leg muscles. Data is temporarily unavailable. Other clinical features at presentation included foot deformity in 9 patients (64%) and scoliosis in 4 patients (29%). Symptoms often stabilize or improve after surgery; 6 however, retethering (along with renewed symptoms) may reoccur especially during rapid WebRecovery from the surgery is one to two weeks of very limited activity to ensure proper healing of the surgical site and to prevent leaking of any cerebrospinal fluid. 3 This way, the care team can best assess your childs condition at their first appointment. In addition, in terms of cost-effectiveness, SSO is substantially more costly than untethering, which means that SSO can be a financially viable option mainly just in very challenging cases of adult TCS. 2014; 192:221-7. . As with any surgery, tethered cord surgery has risks and complications. It is pulled tightly at the end, reducing blood ow to spinal nerves and causing damage to the spinal cord from both the stretching and the decreased blood supply. The operation curative effects with curative rates for TCS with different symptoms, and signs are shown in Table 2 in detail. If they do experience a headache, your child will lay back down flat. Postraumatic syringomyelia involves development of a fluid-filled cavity (called a cyst or syrinx) within the spinal cord following a spinal cord injury. Medicine. An official website of the United States government. 5 WebConclusions: Tethered spinal cord syndrome in adults is an uncommon entity that can become symptomatic. In 1891, Jones [14] described what probably is Adult tethered cord syndrome (ATCS) is a rare entity that usually presents with multiple neurological symptoms, including lower extremity pain, backache, lower extremity muscle weakness, and bowel/bladder disturbances. 17. Unauthorized use of these marks is strictly prohibited. The result may be nerve damage and severe pain. Scheduled medications for pain relief during the early post-operative period at home include: There may be additional pain medications given as needed for breakthrough pain. The nurse will help schedule the COVID-19 PCR test. We report a 63-year-old man with sudden-onset severe right chest and upper back pain, followed by . This can cause many different symptoms called tethered cord syndrome. A representative case of spine-shortening osteotomy. Thus, additional prospective randomized large-scale studies are needed to confirm our results. This can lead to infection if the incision is on the low back. All patients received a 0.5 to 3.5-year follow-up by outpatient or telephone, with an average follow-up period of 2.5 years. A hairy patch overlying the spine in any area is almost always associated with an underlying splitting of the spinal cord by a band of fibrous tissue or bone (a diastematomyelia). Tethered cord syndrome (TCS) refers to a series of neurological dysfunction caused by the retraction of the conus medullaris related to a variety of reasons, which is manifested by both lower extremities orbicularis weakness, sensory abnormalities, defecation dysfunction, and so on.[1]. The patient was a 36-year-old man who had undergone myelomeningocele repair during infancy. Clinical features at presentation are summarized in Table 1. Would you like email updates of new search results? Wolters Kluwer Health
Application of microsurgical technique for intraspinal lipoma tethered cord syndrome: report of 611 cases. Request an appointment or second opinion, refer a patient, find a doctor or view test results with MGfC's secure online services. The mean age of the patients was 46 13 years (range 23-74 years) and the mean follow-up duration was 61 62 months. Her curves when checked were Top - 23 and bottom - 23. Pain or anti-inflammatory medication. Tethered cord, also called tethered spinal cord syndrome, occurs when the spinal cord abnormally attaches to tissue inside the spinal canal, usually at the base of the spine. bDepartment of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA. 96(32):e7808,
At Mass General, the brightest minds in medicine collaborate on behalf of our patients to bridge innovation science with state-of-the-art clinical medicine. A potential predictor of long-term bladder function after detethering surgery in patients with tethered cord syndrome. All of the included 82 cases of patients received preoperative enhanced magnetic resonance imaging (MRI) examination, and there were several characteristics listed as follows: thickened filum terminale in a diameter of >2 mm; elongated, tapering, and low position of the coni medullaris, the coni medullaris located below the plane of vertebral body (L2) was considered to be low position of the coni medullaris; coni medullaris or the filum terminale attached closely to the posterior wall of the thecal sac, in a relatively straight shape; a large subarachnoid space was existed in the sacral canal; possible existence of occupying lesions adhered to the coni medullaris or the cauda equina, such as lipoma, dermoid cyst, and epidermoid cyst; potential existence of myelomeningocele or changes after prosthesis (Fig. Surgical management of tethered spinal cord in adults: report of 54 cases. Bristow RG, Laperriere NJ, Tator C, et al. Lew SM, Kothbauer KF. Muscle weakness was present in 10 patients (71%), 8 (57%) had leg pain and sciatica, and 6 (43%) had back pain. As first-line treatment, patients presenting with TCS typically undergo direct spinal cord untethering, often as young children or infants. 9 Moreover, successful untethering correlates with the complexity of the malformation and is extremely difficult to accomplish without causing intraoperative complications.9 Consequently, untethering surgery for adult patients with complex tethering pathologies remains challenging.9. Back and leg pain improved in 50 and 63% of patients, respectively. SSO is a highly invasive type of surgery, but as the average age of adults with TCS ranges from 35 to 46 years,1 Some error has occurred while processing your request. The patient with symptoms following resection of a lipomyelomeningocele: do increases in the lumbosacral angle indicate a tethered spinal cord? Results: 6 This can cause the spinal cord to stretch out as the spine grows, leading to possible nerve damage, pain and other symptoms. Besides, there was no deteriorated case. 11 Miyakoshi et al reported that all of the neurologic symptoms in the subjects of one of their studies were relieved without complications after SSO,10 and it was hoped on the basis of that study that SSO would become a preferable approach for TCS in adults, but the number of patients in their study was small (n=3). Many recent reports of TCS in adult patients have grouped retethering patients with newly diagnosed ones without separately analyzing each entity and outcome. Maurya VP, Rajappa M, Wadwekar V, et al. Abstract. Physicians: To refer a patient, call 410-955-7337. With a recommendation for surgery this figure rose to 47% within 5 years. 7 Iskandar BJ, Oakes WJ, McLaughlin C, Osumi AK, Tien RD. Abstract. This causes extra stress on the nerves and can cause a range of symptoms known as tethered cord syndrome. After identification of the terminal filum, we confirmed electromyography activity on bipolar stimulation before clip ligation and definitive sectioning. Accessibility Recovery was mostly seen in infants and only in one older child. It is recommended that routine examination of filum terminale should be performed in the operation, associated with the disconnection of the diseased filum terminale subject to adhesion or thickening and shortening. Surgical complications were generally minor. Primary is typically a form of OSD while secondary usually occurs following a myelomeningocele repair or other type of spinal cord surgery History and Exam Tethered spinal cord is most commonly diagnosed in infancy by the discovery of a abnormality noticed on the skin of the back. Neurosurg Focus. Tyagi R, Kloepping C, Shah S. Spinal cord stimulation for recurrent tethered cord syndrome in a pediatric patient: case report. In this study, we evaluated the feasibility of BCR monitoring during untethering surgery in infants and children to predict postoperative urinary and bowel dysfunction. You will have many questions about the disorder, and we are here to answer them. The diagnosis of TCS is made with a high degree of clinical suspicion. But previous investigation estimated that no more than 40% of dermoid cyst could be completely removed.
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