Pathology

The term tethered cord syndrome, as used in this chapter, signifies a pathologic fixation of the spinal cord in an abnormally low position so that the spinal cord, with activities and growth, undergoes mechanical stretching, distortion, and ischemia. Many conditions can cause tethering of the spinal cord; these include tight filum terminale, split cord malformations, lipoma, dermal sinus, and meningomyelocele. The remainder of this section addresses the care and treatment of these conditions, excluding meningomyelocele.

Presentation

The patient with tethered cord presents in one of two groups: symptomatic or asymptomatic. Both groups frequently, but not invariably, have a midline cutaneous dorsal abnormality. These may consist of a dimple, hairy patch or fawn’s patch, hemangioma, lipoma, or a skin tag ( Figs. 159-1 and 159-2 ). If there is no external manifestation, the problem usually goes unrecognized until symptoms begin to develop.

Skin tag and angiomatous changes in a child with a tethered cord and spinal lipoma.

A 5-year-old female with fawn’s patch.

Symptoms, when present, can be grouped into three general areas: sensorimotor, sphincteric, and orthopaedic. Sensorimotor symptoms can include pain, delayed walking, sensory loss (usually in the dermatomes of the lumbosacral roots), and motor weakness of the distal leg or foot (the most common symptom, presenting in 76% of cases). Sphincteric symptoms are usually insidious, with frequent urinary tract infections secondary to incomplete emptying, hydronephrosis with renal involvement secondary to reflux, and fecal incontinence. In addition, these patients may develop urinary incontinence or become impotent. The orthopaedic problems are related to gait disturbance and abnormalities of the foot or scoliosis. Adult patients with tethered cords may also present with back pain that may radiate to the legs, urinary difficulties, and lower extremity weakness. Patients may present either as asymptomatic in childhood and symptomatic in adulthood or with a progression of symptoms once they reach adulthood perhaps due to repeated microtrauma to the cord. Often in adults the disease may have an insidious onset or may have a predisposing factor such as exercise, lifting heavy loads, or even birth trauma.

Diagnostic Aids

Any infant or child with a midline cutaneous lesion such as a dimple, hair patch, hemangioma or symptoms mentioned earlier may be suspected as having a tethered cord ; the workup is to determine the anatomy of the anomaly.

A careful neurologic examination with attention paid to evaluation of motor and sensory function as well as sphincter tone is imperative. If the history indicates possible bladder involvement, a urologic evaluation is indicated. Plain films may be obtained as a screening procedure and may show a widened interpedicular distance and defects at one or more levels. The procedure of choice is magnetic resonance imaging (MRI) ( Fig. 159-3 ). Often, this is the only necessary imaging study, and treatment can be planned on the basis of MRI alone. It is generally prudent to image the entire spinal cord at least once to rule out other associated anomalies such as a syrinx or a type I Chiari malformation. If there are any remaining concerns or issues, a myelogram with subsequent computed tomography (CT) may be helpful.

T1-weighted MRI scan demonstrating a tethered spinal cord.

Treatment

Once the problem is identified, the treatment of the tethered cord is surgical. Although controversy existed in the past (over the concept of prophylactic surgery of asymptomatic patients), most surgeons now believe that the risk of waiting for deterioration to occur is not justified because the deficit is often not reversible. Therefore, surgery is recommended, even in the asymptomatic patient, although one study suggests that careful follow-up and monitoring for upper motor neuron signs using urodynamic assessments, in order to time surgical intervention with the appearance of upper motor neuron signs, may be possible. In adults, those with back pain and lower extremity pain seem to benefit more than those with sphincter problems.

The goal of surgery is to untether the spinal cord and to avoid incurring further neurologic deficit. It is crucial to expose areas of normal anatomy and then proceed to the abnormal area. Optimal surgical approach should be as low as possible in the lumbar spine as to decrease risk of injury to the conus. Spinal deformity or instability after multilevel lumbar or thoracolumbar total laminectomy is not uncommon in children and adolescents. Limiting laminae removal and facet destruction may decrease this incidence. Fusion may be required to correct postlaminectomy deformity and to stabilize the spine. Operative approach at the L3/L4 junction may be preferable to the L5/S1 level, as the lumbar sacral junction may increase the risk of postoperative instability.

Surgical treatment may include a single level laminectomy with partial superior or inferior laminotomies. One alternative surgical approach is bilateral laminotomies at one or two lumbar levels with the use of a high-speed drill. Elevation of the lamina is done in a lobster tail fashion to expose the tethered cord elements. Following surgical resection, the lamina may be replaced and sutured in place to restore the posterior spinal column and tension band.

Intraoperative care should be exercised, as the periosteum under the lamina may appear as a separate layer and be mistaken for the dura. Once identified, the dura is opened and the exposed the filum is often identified in the midline and may appear fatty, fibrous, or thickened. Care should again be taken to inspect the filum to rule out the presence of attached nerve roots. Vascular supply should be identified on the anterior surface and cauterized prior to resection as subarachnoid blood may potentiate nerve root adhesions. After release has been completed, the clinician should assess for CSF leak following watertight dural closure with a Valsalva maneuver. Closure may be facilitated by the use of a tapered needle with a suture to needle ratio close to 1 and reinforced with fibrin glue or dual glue to further reduce the probability of CSF leak.

Electrophysiologic monitoring, especially the use of intraoperative electromyography (EMG), may be helpful. This is performed by inserting needle electrodes into the appropriate muscles and the anal sphincters under anesthesia. Then during surgery the level of each root is accurately established by intradural nerve root stimulation, and before dividing any structure, it is stimulated to confirm that no neural structures are involved. A conventional bipolar stimulator, similar to those used for a dorsal rhizotomy, may be employed, although any nerve stimulator may be used. The advantage of this technique is that the response to EMG is rapid and provides a substantial safety margin during the surgery for the tethered cord syndrome. The use of intrathecal analgesic should be considered in coordination with pediatric anesthesia. Intradural morphine and clonidine are useful in reducing postoperative discomfort and may reduce the need for postoperative analgesic. Pediatric patients receiving intrathecal therapy should be monitored in an intensive care during the postoperative period.

Complications

Several complications may occur during surgery. The incidence of infection should be low, as with any clean neurosurgical procedure.

CSF leak is a uncommon complication. After careful dural closure, fibrin glue is used and a Valsalva procedure usually performed to check for leakage. If postoperative cutaneous leakage occurs, reoperation is mandatory. The patient should be kept flat for 3 days after surgery, with sedation if necessary.

Another potential complication is urinary retention. A Foley catheter is always inserted after the induction of anesthesia and removed on the third to fifth day. If the child is unable to initiate micturition after catheter removal, intermittent catheterization is used until normal voiding is reestablished. If the child does void, a postvoid residual urine volume should be checked to verify adequate emptying. No more than 30 ml of urine should be left after the child has voided.

Outcome

The shorter the duration of symptoms, the better the prognosis. A study by Archibeck and colleagues demonstrated a 50% revision rate by 5 years after initial revision and a 57% revision rate by 2 years after the second release. In addition, 50% of patients required at least one orthopaedic procedure after tethered cord release. In a study by Cornette and associates of 12 patients operated on for tethered cord, none required a second operation. However, the series is small, although the follow-up period was reasonable (58 months). In terms of urologic outcome, improvement in symptoms as well as urologic dynamic parameters is expected in most patients, although few if any will return to normal. A retrospective review by Frainey and coworkers. demonstrated that preoperative urinary continence and isolated cutaneous lesions were both positive predictors of normal postoperative urinary function Improvements may be noted in detrusor function, EMG recordings, and pressures.

Embryology and Pathology

Split cord malformation (SCM) is a term that was introduced by Pang and colleagues in 1992 to describe diastematomyelia based on the dural tube and the nature of the septum. Two types of SCM exist: type I (diastematomyelia with septum) and type II (diastematomyelia without septum). Type II is usually more common.

By the end of the second week of gestation, the human embryo normally consists of a bilaminar structure: (1) an epiblast, or layer of cells next to the amnion, and (2) a hypoblast, or layer of cells next to the yolk sac. From there, the cells divide to form the primitive streak. During gastrulation the embryo becomes trilaminar as adjacent epiblastic cells migrate medially toward the primitive streak to become mesoderm. The primitive streak begins to regress by day 16, and the notochordal process begins. As the notochord elongates, it canalizes, initially forming a connection through the embryo to join the amnion and yolk sac. This connection is then lost as the open notochord separates from the endoderm and again forms a blind tube.

In the case of the split cord malformations, there is an adhesion between the ectoderm and endoderm. This leads to the formation of an “accessory neurenteric canal around which condenses an endomesenchymal tract that bisects the developing notochord and causes formation of two hemineural plates.” The formation of type I or type I SCM depends on what happens to the endomesenchymal tract. If it develops toward bone and cartilage, there will be two dural sacs and a type I. If the tract regresses or leaves a fibrous septum, a type II will develop.

The spinal cord above and below the split is normal. The two hemicords themselves are usually the same size, but in 10% of patients, they are grossly asymmetric. When this occurs, the spinal cord itself, above and below the bifurcation, is asymmetric, being smaller on the side of the smaller hemicord.

The anterior spinal artery and the central canal bifurcate to accompany each hemicord, so that each has its own blood supply. The two hemicords give rise to the spinal nerve roots on their respective sides. Although splitting of the spinal cord at more than one site and cases of incomplete splitting of the spinal cord with a resultant partial cleft cord have been reported, the majority of cases involve a single, complete cleft through the spinal cord and meninges. In cases in which there are two hemicords without an intervening septum, a single dural sac surrounds both. In such cases, symptoms may result from tethering of the cord by fibrous bands or a thickened filum terminale.

In cases in which the meninges themselves are also bifurcated, there is almost always an intervening septum. Its position is at the caudal end of the split; therefore, ascent of the neural elements is prohibited. The septum, or spur, is usually attached to both the dorsal elements and the dorsal aspect of the vertebral body. Because of the incidence of spina bifida, the spur may continue dorsally between unfused laminae. These spurs may present anywhere along the spine, but 70% of the time they are between L1 and L5. They are less likely in the thoracic spine and occur with only a 1% incidence in the cervical spine. The spur is initially cartilaginous and may mature to calcified bone with time.

Other associated anomalies, such as vertebral body abnormalities, may occur. Hemivertebrae, butterfly vertebrae, blocked vertebrae, and spina bifida may contribute to a kyphoscoliosis. The scoliotic defect and segmental vertebral anomalies are commonly located near the level of the split cord malformation. In addition, many children with these anomalies have hypertrichosis over the level of the spur, clubfoot, or pes cavus. Twenty percent of cases are associated with other abnormalities of the spine, including hydromyelia, lipoma, dermal sinus, and neurenteric, epidermoid, and arachnoid cysts. Unless a preexisting myelomeningocele exists, Chiari malformations are not usually associated with split cord malformations.

Pathophysiology

The clinical symptoms most likely evolve from traction of the spinal cord against the restricting septum or bony spur. As with other forms of tethered spinal cord, the ascent of the cord within the dural sac and spinal canal is prohibited. The average age of presentation is 6 years, with neurologic symptoms first becoming evident with the onset of walking. With the onset of walking, however, increased traction of the distal spinal cord against the restricting septum results in new symptoms. To support this, Yamada and associates have studied the oxidative metabolism of the distal spinal cord and have found a decrease when the cord is under axial tension.

Presentation

Boxes 159-1 and 159-2 include presenting symptoms and physical signs of patients with split cord malformations. In general, signs and symptoms fall into three categories: (1) cutaneous abnormalities, (2) pain, and (3) neurologic deficits (from spinal cord traction).

In newborns and infants in whom neurologic deficits may not yet have developed, cutaneous lesions bring the child to the attention of the neurosurgeon. Most commonly, a patch of hair or hypertrichosis is noted in the thoracic or lumbosacral midline posteriorly. This hair, usually coarse and long, is sometimes referred to as faun’s tail. The surrounding skin is associated with an intradermal angiomatous malformation, giving the skin a pinkish blue color. In addition, a dermal sinus, lipoma, abnormally protuberant spinous process, or meningocele may be associated with the spur.

As the child develops, begins to walk, and acquires bowel and bladder control, the neurologic sequelae of split cord malformations usually appear. Hypoplastic lower extremity and foot deformities are sometimes present at birth. Progressive kyphoscoliosis may also become noticeable. With the onset of walking, a limp, an ulcer secondary to areas of anesthesia, and the new onset of bowel or bladder incontinence after a period of normally developed continence all indicate tethering. Although spasticity and other long-tract signs are not common, hyporeflexia and loss of sensation in the sacral dermatomes are common.

If the patient with split cord malformation has successfully progressed through development with few or none of the aforementioned symptoms, the most common complaint, particularly in older children and adults, is back or leg pain. This may be due to subtle concomitant scoliosis or to the spinal bony deformity itself. The presence of unilateral symptoms is a key difference in the presentation of split cord malformation versus tethered cord syndrome.

Diagnostic Aids

Aids that confirm the diagnosis of split cord malformation are usually radiologic. Although plain radiographs or unenhanced computed tomographs of the spine may reveal the bony spur, a widened interpedicular distance, spina bifida occulta, or other segmental vertebral anomalies, MRI in all three axes can be more revealing and is the procedure of choice ( Fig. 159-4 through 159-7 ). Associated lipomas, hydromyelia, and other intraspinal and intradural defects may also be observed incidentally, allowing for a more focused treatment approach. If there are any questions or if further clarification is required, myelography and postmyelographic CT best delineate the hemicords, the dural sac, and the presence and extent of the intervening bony septum ( Fig. 159-8 ). Plain and CT myelography may reveal aberrant nerve roots, intradural bands, a thickened filum terminale, or a concomitant intradural lipoma. In addition, one study reported up to a 75% incidence of abnormal urologic dynamic studies in patients with SCM, despite a lack of symptoms. Therefore, obtaining preoperative and postoperative urologic dynamic studies may be of some benefit. Again, as in the tethered cord syndrome, the entire spinal cord should be imaged.

T1-weighted MRI scan demonstrating a tethered spinal cord with associated lipoma.

Plain axial CT scan revealing the bony septum ( arrow ) of split cord malformation.

Sagittal T2-weighted MRI scan demonstrating split cord malformation, with the septum spanning from the ventral to the dorsal elements ( arrow ).

Axial T1-weighted MRI scan revealing the septum ( arrow ) and hemicords of split cord malformation.

Axial postmyelogram CT scan demonstrating split cord malformation resulting from a nonossified fibrous septum ( arrow ). Note the delineation of the hemicords.

Treatment

Other than incidental findings of split cord malformation in newborns, any patient with signs or symptoms referable to split cord malformation should be promptly untethered to relieve symptoms, preserve function, and possibly reverse neurologic deficits. In the otherwise normal newborn, surgery should be delayed for about 3 months because the older child will be larger, will tolerate anesthesia better, and will have developed more resilient meninges and soft tissues, allowing for more favorable surgical closure.

The goal of surgery is to untether the hemicords by removing the cartilaginous, fibrous, or bony septum, as well as the dural tunnel about the septum, which itself tethers the cord. In addition, any surrounding dural adhesions restricting the motion of the spinal cord should be lysed. The filum terminale should also be released at this time if there is evidence of tethering.

Under general anesthesia the patient should be positioned as for a laminectomy, in the prone position, either on chest rolls or on a flexed frame with adequate room for abdominal-wall motion. Unless an associated tethered filum terminale that requires incision is expected, there is no need for preoperative placement of sphincter and lower extremity EMG electrodes.

Before making a standard midline incision to the lumbosacral fascia, the spine should be palpated. Occasionally, a protruding spinous process or bony spur may be felt, allowing for a more localized incision. In addition, a localizing plain radiograph with a skin marker is used and correlated with the preoperative MRI. If a cutaneous lesion, such as a patch of hair, is present, it may be beneficial to create an elliptical incision circumferentially around the defect. Because the underlying bony and soft-tissue defect may not be clear, it is helpful to incise the fascia and perform a subperiosteal reflection of the paraspinous musculature at the levels above and below the level of the lesion, understanding that midline fusion defects may also exist here. The monopolar electrocautery should be used cautiously in retracting the muscles, because areas of expected protective bone may be missing. After the laminae above and below the lesion are exposed, their spinous processes are removed using a rongeur. A partial laminectomy is then performed at the caudal aspect of the lamina above the septum and the rostral aspect of the lamina below the septum. After careful curettage of the underside of both these laminae, the ligamentum flavum, if still intact, is elevated laterally with Penfield forceps and incised longitudinally through its outer layer. A blunt instrument is then gently inserted through the remaining ligament, and a small cottonoid patty is placed between the dura mater and the ligamentum flavum for protection. A small, angled Kerrison punch is then used to remove the ligamentum flavum until the anatomically normal dura mater is exposed completely laterally. With a Penfield no. 4 dissector, the septum is then felt over the dura from above and from below. A small-mouthed rongeur or angled Kerrison punch or high-speed drill is used to remove the lamina and overhanging bone of the involved level until only the spur is left. Because of the substantial epidural venous plexus associated in and around the bony spur and deep to the two hemicords, bleeding and cauterization of these vessels should be controlled prior to and during the removal of the spur ( Fig. 159-9 ). After decompression, with movement of the hemicords, hemostasis may be difficult. Any extruding segment of spur is removed using a rongeur, and a small dissector is used to probe and dissect the dural sheath away from the bony spicule down to the level of the dorsal vertebral body. A high-speed diamond-bit drill is then used to carefully thin down the spicule as far as possible while protecting the surrounding dura.

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