Alsowayan O, Alzahrani A, Farmer J-P, Capolicchio J-P, Jednak R, El-Sherbiny M
Department of Pediatric Surgery, Division of Pediatric Urology and Neurosurgery, The Montreal Children's Hospital and McGill University Health Center, Shriners Hospital of Montréal, QC, Canada; Department of Urology, College of Medicine and King Fahd Hospital of the University, University of Dammam, Saudi Arabia.
Department of Pediatric Surgery, Division of Pediatric Urology and Neurosurgery, The Montreal Children's Hospital and McGill University Health Center, Shriners Hospital of Montréal, QC, Canada.
J Pediatr Urol. 2016 Oct;12(5):285.e1-285.e5. doi: 10.1016/j.jpurol.2016.02.012. Epub 2016 Mar 15.
Primary tethered spinal cord (TSC) refers to a group of abnormalities associated with a posterior bony spinal defect that develops beneath an intact dermis and epidermis. There is relative agreement that patients with symptomatic TSC will require surgical intervention. However, it is still debatable as to how to approach asymptomatic patients with primary TSC.
To study the clinical and urodynamic (UDS) outcomes of patients with primary TSC after spinal cord untethering (SCU).
Charts of patients with primary TSC between 1998 and 2010 were retrospectively reviewed. Patients that underwent before and after SCU clinical and UDS evaluation with minimum of 5-years follow-up were included. Continence status was assessed in children ≥5 years. Patients with dry intervals of ≥4 h were considered continent. Urologic and neuro-orthopedic manifestations, as well as UDS parameters, were compared before and after SCU. Categorical data were compared using Fisher-Exact test and continuous variables were compared using Wilcoxon-Signed-Rank test. A P-value <0.05 was considered significant.
Twenty-two patients met the inclusion criteria. The median age at time of SCU was 11.5 months (range 3-211). The median age at time of follow-up UDS after SCU was 22 months (range 9-218). The median age at time of last follow-up was 153.5 months (range 65-228). The median follow-up time was 71 months (range 60-192). A total of 14/22 patients had clinical manifestation before SCU, while 8/22 were asymptomatic and diagnosed based on magnetic resonance imaging/UDS findings. Of the symptomatic patients, 86% had symptom improvement after SCU. The UDS parameters showed statistically significant improvement in the median percentage of change of actual bladder capacity (P = 0.01), median intravesical pressure for patients with pre-operative pressure ≥40 cm/H2O at total cystometric bladder capacity (P = 0.012), and median bladder compliance at 75% bladder capacity (P = 0.01) (Table).
Tethered spinal cord syndrome (TSCS) is a clinical entity that presents with neurological, urological, and/or orthopedic symptoms caused by primary or secondary tethering of the spinal cord, which may result in ischemic damage of the neural tissue and symptom development. While some authors believe that surgical management should be reserved for symptomatic patients, others prefer prophylactic surgery to avoid possible irreversible neurological damage. The present study provides detailed discussion of the clinical and UDS outcomes for patients with primary TSC that underwent SCU.
For patients with primary TSC, spinal cord untethering is beneficial in terms of clinical and UDS outcomes. A prospective long-term study with large numbers could further highlight outcomes for this particular group of patients.
原发性脊髓拴系（TSC）是指一组与后方脊柱骨缺损相关的异常情况，该缺损发生于完整的真皮和表皮之下。对于有症状的TSC患者需要进行手术干预，这一点相对达成了共识。然而，对于如何处理原发性TSC的无症状患者仍存在争议。
研究脊髓松解术（SCU）后原发性TSC患者的临床及尿动力学（UDS）结果。
回顾性分析1998年至2010年间原发性TSC患者的病历。纳入接受SCU前后临床及UDS评估且随访至少5年的患者。对≥5岁儿童的控尿状态进行评估。干燥间隔≥4小时的患者被视为控尿良好。比较SCU前后的泌尿系统和神经骨科表现以及UDS参数。分类数据采用Fisher精确检验进行比较，连续变量采用Wilcoxon符号秩检验进行比较。P值<0.05被认为具有统计学意义。
22例患者符合纳入标准。SCU时的中位年龄为11.5个月（范围3 - 211个月）。SCU后随访UDS时的中位年龄为22个月（范围9 - 218个月）。末次随访时的中位年龄为153.5个月（范围65 - 228个月）。中位随访时间为71个月（范围60 - 192个月）。22例患者中，共有14例在SCU前有临床表现，而8例无症状，根据磁共振成像/UDS结果确诊。有症状的患者中，86%在SCU后症状改善。UDS参数显示，实际膀胱容量变化的中位百分比（P = 0.01）、术前膀胱测压总容量时压力≥40 cm/H₂O的患者膀胱内压中位数（P = 0.012）以及膀胱容量75%时的膀胱顺应性中位数（P = 0.01）有统计学意义的改善（表）。
脊髓拴系综合征（TSCS）是一种临床病症，由脊髓的原发性或继发性拴系引起神经、泌尿和/或骨科症状，这可能导致神经组织的缺血性损伤和症状发展。虽然一些作者认为手术治疗应仅用于有症状的患者，但另一些人则倾向于预防性手术以避免可能的不可逆神经损伤。本研究详细讨论了接受SCU的原发性TSC患者的临床及UDS结果。
对于原发性TSC患者，脊髓松解术在临床及UDS结果方面是有益的。一项大规模的前瞻性长期研究可能会进一步突出这类特殊患者的治疗结果。
