Department of Neurosurgery, Fondazione IRCCS Istituto Neurologico "Carlo Besta", 20133, Milan, Italy.
Pediatric Surgery Unit, Children's Hospital "Vittore Buzzi", Milan, Italy.
Childs Nerv Syst. 2021 Mar;37(3):941-949. doi: 10.1007/s00381-020-04838-6. Epub 2020 Jul 29.
Early de-tethering procedures are performed on spinal dysraphisms to prevent neuro-urological deterioration caused by growth. Partial lipoma removal may cause delayed deterioration by re-tethering, while complete removal may increase the risk of postoperative worsening. The present study evaluates the risk of postoperative deterioration and the protective potential of intraoperative neurophysiological monitoring (IOM), with a special reference to the conus lipomas treated with the radical approach.
Forty toddlers (< 24 months) underwent complete perioperative neurological and urological assessment, including urodynamic study (UDS). The dysraphisms were subgrouped according to Pang's classification. IOM was applied in all patients: transcranial motor evoked potentials (tMep) combined with mapping were recorded in all cases while bulbocavernosus reflex (BCR) was evaluable just in 7 cases.
At preoperative evaluation, 11 children already had UDS impairment and 2 had motor disturbances before neurosurgery. At 1-month follow-up, preoperative motor disturbances were stable, 7/11 UDS alterations normalized, and the remaining 4 were stable. At 6-month follow-up, all motor deficits and 8/11 preoperative UDS alterations had improved. Unfortunately, 7 children with previously normal UDS experienced a new impairment after surgery: 2/7 normalized while 5/7 did not recover. This postoperative permanent urodynamic impairment occurred in 4 chaotic lipoma (CLchaos) and in one terminal myelocystocele (TMC) that means a surgical deterioration rate of 22% for the high risk cases.
This small highly selected series confirms that early de-tethering may stop or revert the spontaneous neuro-urological deterioration: in fact, preoperative UDS impairment was frequent (27.5%) and improved in all the low surgical risk cases (limited dorsal myeloschisis, filar, transitional and dorsal lipomas). On the contrary, in CLchaos and TMC, early de-tethering was unable to revert preoperative UDS impairment, and radical surgery carried a high risk of new neuro-urological deterioration directly caused by the operation. In our experience, IOM had a protective role for motor functions, while it was less effective for the neuro-urological ones, probably due to the anesthesiology regimens applied. In conclusion, among the dysraphisms, CLchoas proved to be the worst enemy that often camouflages at MRI. Affording it without all possible IOM weapons carries a high risk to harm the patient.
对脊髓脊膜膨出患者进行早期松解术，以防止因生长而导致的神经尿动力学恶化。部分脂肪瘤切除可能通过重新束缚而导致延迟恶化，而完全切除可能增加术后恶化的风险。本研究评估了术后恶化的风险和术中神经生理学监测（IOM）的保护潜力，特别关注采用根治性方法治疗的终丝脂肪瘤。
40 名幼儿（<24 个月）接受了完整的围手术期神经学和尿动力学评估，包括尿动力学研究（UDS）。根据 Pang 的分类对脊膜膨出进行了亚组分类。所有患者均应用 IOM：所有病例均记录经颅运动诱发电位（tMep）结合图，而仅在 7 例中评估球海绵体反射（BCR）。
术前评估时，11 名儿童已存在 UDS 异常，2 名儿童在神经外科术前存在运动障碍。在 1 个月的随访中，术前运动障碍保持稳定，7/11 例 UDS 改变正常，其余 4 例保持稳定。在 6 个月的随访中，所有运动缺陷和 8/11 例术前 UDS 改变均得到改善。不幸的是，7 名先前 UDS 正常的儿童在手术后出现新的异常：2/7 例恢复正常，而 5/7 例未恢复。这种术后永久性尿动力学损害发生在 4 例混沌脂肪瘤（CLchaos）和 1 例终末脊髓脊膜膨出（TMC）中，这意味着高风险病例的手术恶化率为 22%。
这项小型的高度选择系列研究证实，早期松解术可阻止或逆转自发性神经尿动力学恶化：事实上，术前 UDS 异常很常见（27.5%），且所有低手术风险病例（局限性背侧脊髓脊膜膨出、丝状、过渡性和背侧脂肪瘤）均得到改善。相反，在 CLchaos 和 TMC 中，早期松解术无法逆转术前 UDS 异常，根治性手术直接导致手术引起的新的神经尿动力学恶化的风险较高。根据我们的经验，IOM 对运动功能具有保护作用，而对神经尿动力学的作用则较小，这可能是由于应用了麻醉方案。总之，在脊膜膨出中，CLchaos 被证明是最糟糕的敌人，它经常在 MRI 上伪装。如果不使用所有可能的 IOM 武器对其进行治疗，会给患者带来很高的风险。
