Division of Neurosurgery, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia.
Department of Urologic Sciences, University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia; University of British Columbia and British Columbia Children's Hospital, Vancouver, British Columbia.
J Urol. 2016 Apr;195(4 Pt 2):1183-8. doi: 10.1016/j.juro.2015.09.082. Epub 2016 Feb 28.
Occult tethered cord syndrome, in which there is normal neuroanatomic imaging despite clinical and urodynamic evidence of neuropathic bladder behavior, is controversial. Several uncontrolled series describe improvement in bladder function following section of the filum terminale. We performed a pilot randomized, controlled study comparing medical treatment to surgical section of the filum plus medical treatment in children with occult tethered cord syndrome.
Children refractory to standard medical management for 1 year or more with normal conus position on magnetic resonance imaging and abnormal urodynamics were randomized. Exclusion criteria included any neurological conditions, spinal dysraphism, bladder outlet obstruction and an atonic bladder. Patients were assessed at randomization and 1 year later with a standardized urodynamic score, the validated PEMQOL (Pediatric Enuresis Module on Quality of Life™) scale, and a validated bowel and bladder dysfunction score.
After 8 years we accrued 21 patients. The bowel and bladder dysfunction score improved in the surgical and medical arms (20% and 24%) and the urodynamic score improved slightly (6% and 4%, respectively). The PEMQOL Child and Family Impact Scales improved modestly in both groups. All differences were nonsignificant. Interim analysis indicated that more than 700 patients in each arm would be required to demonstrate a statistical difference with respect to urodynamic score based on our preliminary data.
There appears to be no objective difference in urological outcome between medical management plus or minus filum section for patients with occult tethered cord syndrome. These data challenge the existence of the concept of occult tethered cord syndrome, in which bowel and bladder dysfunction score is attributed to tethering by the filum despite a normally located conus.
尽管存在神经源性膀胱行为的临床和尿动力学证据，但正常神经解剖影像学的隐匿性脊髓栓系综合征仍存在争议。有几个未对照的系列研究描述了终丝切断后膀胱功能的改善。我们进行了一项试点随机对照研究，比较了药物治疗与手术切断终丝加药物治疗在隐匿性脊髓栓系综合征儿童中的疗效。
对 1 年以上标准药物治疗无效且磁共振成像上圆锥位置正常但尿动力学异常的儿童进行随机分组。排除标准包括任何神经疾病、脊髓脊膜膨出、膀胱出口梗阻和弛缓性膀胱。患者在随机分组时和 1 年后分别采用标准化尿动力学评分、经过验证的 PEMQOL（儿童遗尿症生活质量评估量表）和经过验证的肠膀胱功能障碍评分进行评估。
8 年后，我们共纳入 21 例患者。手术和药物治疗组的肠膀胱功能障碍评分均有改善（分别为 20%和 24%），尿动力学评分略有改善（分别为 6%和 4%）。两组的 PEMQOL 儿童和家庭影响量表评分均有改善。所有差异均无统计学意义。中期分析表明，根据我们的初步数据，每组需要超过 700 例患者才能在尿动力学评分方面显示出统计学差异。
对于隐匿性脊髓栓系综合征患者，药物治疗加或不加终丝切断的泌尿外科结局似乎没有差异。这些数据对隐匿性脊髓栓系综合征概念提出了挑战，即尽管圆锥位置正常，但肠膀胱功能障碍评分归因于终丝的牵拉。
