1Department of Neurological Surgery, University of Washington, Seattle.
3Division of Neurosurgery, Seattle Children's Hospital, Seattle, Washington.
J Neurosurg Pediatr. 2023 Aug 11;32(5):607-616. doi: 10.3171/2023.6.PEDS23259. Print 2023 Nov 1.
Tethered cord syndrome refers to a constellation of symptoms characterized by neurological, musculoskeletal, and urinary symptoms, caused by traction on the spinal cord, which can be secondary to various etiologies. Surgical management of simple tethered cord etiologies (e.g., fatty filum) typically consists of a single-level lumbar laminectomy, intradural exploration, and coagulation and sectioning of the filum. More complex etiologies such as lipomyelomeningoceles or scar formation after myelomeningocele repair involve complex dissection and dural reconstruction. The purpose of this study was to evaluate operative complications and long-term outcomes of secondary retethering related to pediatric tethered cord release (TCR) at a tertiary children's hospital.
Medical records of children who underwent surgery for TCR from July 2014 to March 2023 were retrospectively reviewed. Data collected included demographics, perioperative characteristics, surgical technique, and follow-up duration. Primary outcomes were 60-day postoperative complications and secondary retethering requiring repeat TCR surgery. Univariate and multivariate analyses were performed to identify risk factors associated with complications and secondary retethering.
A total of 363 TCR surgeries (146 simple, 217 complex) in 340 patients were identified. The mean follow-up was 442.8 ± 662.2 days for simple TCRs and 733.9 ± 750.3 days for complex TCRs. The adjusted 60-day complication-free survival rate was 96.3% (95% CI 91.3%-98.4%) for simple TCRs and 88.7% (95% CI 82.3%-91.4%) for complex TCRs. Lower weight, shorter surgical times, and intensive care unit admission were associated with complications for simple TCRs. Soft-tissue drains increased complications for complex TCRs. The secondary retethering rates were 1.4% for simple TCRs and 11.9% for complex TCRs. The 1-, 3-, and 5-year progression-free survival rates in complex cases were 94.7% (95% CI 89.1%-97.4%), 77.7% (95% CI 67.3%-85.3%), and 62.6% (95% CI 46.5%-75.1%), respectively. Multivariate analysis revealed that prior detethering (OR 8.15, 95% CI 2.33-28.50; p = 0.001) and use of the operative laser (OR 10.43, 95% CI 1.36-80.26; p = 0.024) were independently associated with secondary retethering in complex cases.
This is the largest series to date examining postoperative complications and long-term secondary retethering in TCR surgery. Simple TCR surgeries demonstrated safety, rare complications, and low secondary retethering rates. Complex TCR surgeries presented higher risks of complications and secondary retethering. Modifiable risk factors such as operative laser use influenced secondary retethering in complex cases.
脊髓栓系综合征是一种由脊髓受到牵拉引起的综合征，表现为神经、肌肉骨骼和泌尿系统症状，可由多种病因引起。简单脊髓栓系病因（如脂肪脊索）的手术治疗通常包括单节段腰椎椎板切除术、硬脊膜内探查以及脊索的凝固和切断。更复杂的病因，如脂肪脊膜脊髓膨出或脊髓脊膜膨出修复后的瘢痕形成，涉及复杂的解剖和硬脑膜重建。本研究旨在评估三级儿童医院小儿脊髓栓系松解（TCR）后继发性再栓系的手术并发症和长期结果。
回顾性分析 2014 年 7 月至 2023 年 3 月间接受 TCR 手术的儿童病历。收集的数据包括人口统计学、围手术期特征、手术技术和随访时间。主要结局为术后 60 天的并发症和需要再次 TCR 手术的继发性再栓系。采用单变量和多变量分析确定与并发症和继发性再栓系相关的危险因素。
共确定了 340 名患者的 363 例 TCR 手术（146 例简单，217 例复杂）。简单 TCR 的平均随访时间为 442.8±662.2 天，复杂 TCR 的平均随访时间为 733.9±750.3 天。简单 TCR 的 60 天无并发症生存的调整率为 96.3%（95%CI 91.3%-98.4%），复杂 TCR 的为 88.7%（95%CI 82.3%-91.4%）。较轻的体重、较短的手术时间和入住重症监护病房与简单 TCR 的并发症相关。而软组织引流管的使用增加了复杂 TCR 的并发症。简单 TCR 的继发性再栓系率为 1.4%，复杂 TCR 的为 11.9%。复杂病例的 1、3、5 年无进展生存率分别为 94.7%（95%CI 89.1%-97.4%）、77.7%（95%CI 67.3%-85.3%）和 62.6%（95%CI 46.5%-75.1%）。多变量分析显示，先前的松解术（OR 8.15，95%CI 2.33-28.50；p=0.001）和手术激光的使用（OR 10.43，95%CI 1.36-80.26；p=0.024）与复杂病例中的继发性再栓系独立相关。
这是迄今为止对 TCR 手术术后并发症和长期继发性再栓系进行研究的最大系列。简单 TCR 手术表现出安全性、罕见的并发症和较低的继发性再栓系率。复杂 TCR 手术的并发症和继发性再栓系风险较高。可改变的危险因素，如手术激光的使用，影响了复杂病例中的继发性再栓系。
