Tarcan Tufan, Onol Fikret Fatih, Ilker Yalcin, Simsek Ferruh, Ozek Memet
Department of Urology, Division of Pediatric Urology, Marmara University School of Medicine, Istanbul, Turkey.
J Urol. 2006 Oct;176(4 Pt 1):1601-6; discussion 1606. doi: 10.1016/j.juro.2006.06.036.
The diagnostic criteria for secondary tethering of the spinal cord in children with prior closure of an open spinal defect are not well defined. Urological, neurological or orthopedic deterioration during followup remains the only strong indicator for the diagnosis of this condition. However, the outcome of untethering surgery cannot always be predicted. The aim of this study was to determine neurourological outcome after secondary untethering surgery in children with myelomeningocele.
Of 401 children with myelomeningocele followed at our multidisciplinary spina bifida clinic between 1996 and 2005, 56 (14%) were diagnosed with secondary tethering of the spinal cord (median age at diagnosis 4.1 years). The diagnosis was based on urological and neuro-orthopedic deterioration in 58% and 42% of children, respectively. Preoperative urological findings were compared with 6-month postoperative findings.
Febrile urinary tract infection, upper tract dilatation and vesicoureteral reflux were preoperatively documented in 48.2%, 19% and 30% of the 56 children, respectively. At 6 months postoperatively urine cultures were sterile in 34% of patients and upper tract dilatation completely resolved in 45%. For all grades of vesicoureteral reflux complete resolution occurred in 47% of patients. Urodynamic parameters in terms of cystometric bladder capacity and detrusor leak point pressure substantially improved 6 months after untethering surgery (125 vs 170 ml and 69.1 vs 47.5 cm H2O, respectively, p < 0.05). Assessment of urodynamic findings in 19 children at 1 year failed to demonstrate a significant change in these parameters. A subgroup analysis according to patient age at untethering surgery revealed urodynamic improvement was more significant in children who were diagnosed and treated before age 7 years.
Secondary tethering of the spinal cord is a major risk factor for urological and neurological deterioration in children with myelomeningocele. Close urological surveillance remains the most valuable tool in the early diagnosis. Our study shows that secondary untethering surgery may significantly improve urological outcome.
对于既往开放性脊柱裂已闭合的儿童，脊髓继发性栓系的诊断标准尚不明确。随访期间泌尿系统、神经系统或骨科功能恶化仍是诊断该疾病的唯一有力指标。然而，松解手术的结果并非总能预测。本研究的目的是确定脊髓脊膜膨出患儿继发性松解手术后的神经泌尿学结局。
1996年至2005年期间，在我们多学科脊柱裂诊所随访的401例脊髓脊膜膨出患儿中，56例（14%）被诊断为脊髓继发性栓系（诊断时的中位年龄为4.1岁）。诊断分别基于58%的患儿出现泌尿系统功能恶化和42%的患儿出现神经骨科功能恶化。将术前泌尿系统检查结果与术后6个月的结果进行比较。
56例患儿中，术前分别有48.2%、19%和30%记录有发热性尿路感染、上尿路扩张和膀胱输尿管反流。术后6个月，34%的患者尿培养无菌，45%的患者上尿路扩张完全消退。所有等级的膀胱输尿管反流中，47%的患者完全消退。松解手术后6个月，膀胱测压膀胱容量和逼尿肌漏点压力等尿动力学参数显著改善（分别为125 vs 170 ml和69.1 vs 47.5 cm H2O，p < 0.05）。对19例患儿术后1年的尿动力学检查结果评估显示，这些参数无显著变化。根据松解手术时的患者年龄进行亚组分析显示，7岁前诊断并接受治疗的患儿尿动力学改善更为显著。
脊髓继发性栓系是脊髓脊膜膨出患儿泌尿系统和神经系统功能恶化的主要危险因素。密切的泌尿系统监测仍是早期诊断最有价值的工具。我们的研究表明，继发性松解手术可能显著改善泌尿系统结局。
