ABSTRACT
The clinical presentation of tethered spinal cord and the results of tethered cord release were examined in a group of 30 low motor level (L3 and below) children with a history of myelomeningocele without concomitant CNS complications. Changes in orthopedic and/or neurologic status formed the basis of consideration for tethered cord release. Clinically, these patients presented with a new onset or recently progressing scoliosis, spasticity with or without contractures, decrease in motor function and low back pain at the site of closure. One or more of these findings was present in all cases and led to the suspicion of tethered spinal cord. The diagnosis of tethered cord was confirmed in all cases by MRI or CT myeolography. In order to isolate tethering as the etiology for the patients' clinical deterioration, patients with concomitant CNS complications, e.g. shunt dysfunction or hydromyelia were excluded from the study. Twenty-nine such patients, of an initial 59, who would have otherwise been considered, were excluded on the basis of this criteria of concomitant CNS complications. The results of release 1 year after the procedure were as follows: regarding scoliosis, in 75% of cases the curve either remained stable or decreased by more than 10 degrees, with 25% experiencing curve progression of > 10 degrees. The most recent follow-up in this group revealed that 11.8% experienced a decrease in curvature of >10 degrees; 47.1% remained stable, and 41.2% ultimately progressed 10 degrees. In the group with spasticity, 43.8% improved; 56.3% remained stable, and none worsened. Most (78.6%) of the children who had experienced a decline in motor function improved postoperatively, and all those with back pain experienced complete resolution. In conclusion, tethered cord release in symptomatic low lumbar and sacral level children with myelomeningocele appears to be of benefit, especially with respect to stabilization of scoliosis in selected patients, back pain at the site of closure, and prior decline in motor function. Results in the cases with spasticity were more equivocal.
Subject(s)
Meningomyelocele/surgery , Spina Bifida Occulta/surgery , Adolescent , Child , Child, Preschool , Diagnosis, Differential , Female , Follow-Up Studies , Humans , Infant , Magnetic Resonance Imaging , Male , Meningomyelocele/diagnosis , Myelography , Neurologic Examination , Postoperative Complications/diagnosis , Retrospective Studies , Spina Bifida Occulta/diagnosis , Spinal Cord/pathology , Spinal Cord/surgery , Tomography, X-Ray Computed , Treatment OutcomeABSTRACT
The results of the surgical treatment of clubfoot deformity in spina bifida by radical posteromedial-lateral release (PMLR) are presented. In all cases, the Cincinnati incision was used and the tendons excised, including the anterior tibial tendon. In 21 feet, a special K-wire was used to derotate the talus in the ankle mortise. The minimum follow-up was 2 years. The average age at surgery was 14 months. The overall results showed 63% good, 14% fair, and 23% poor results. In the 21 feet in which the talus K-wire was used, 76% had a good result, 14% fair, and 10% poor. The results were also analyzed based on the motor level. In the thoracic/high lumbar level, 50% had a poor result. In the low lumbar and sacral level groups together, of 45 feet, five had a poor result. This study shows that a radical PMLR can produce an overall good and fair result in 77% of the cases. The use of the K-wire to derotate the talus led to an improvement in the result. The tendon excision leading to a flail foot corrects any residual muscle imbalance. The poor results seen in the thoracic/high lumbar patients are likely to be related to the lack of weight bearing in view of their motor paralysis.
Subject(s)
Clubfoot/surgery , Meningomyelocele/surgery , Tendons/surgery , Bone Wires , Casts, Surgical , Child, Preschool , Clubfoot/etiology , Female , Humans , Infant , Locomotion , Male , Meningomyelocele/complications , Postoperative Care , Splints , Surgical Procedures, Operative/methods , Weight-BearingABSTRACT
Scoliosis interferes significantly with the functional ability of most children with a myelomeningocele. While it is recognized that tethered cord at the repair site causes neurological deterioration, it has been controversial whether tethered cord causes scoliosis. The spinal cord was untethered in 30 children with progressive loss of function and scoliosis. Of 6 children with curves greater than 50 degrees only 1 improved. Of the other 24 children their curves were stable or improved at 1 year follow-up. At late follow-up, 2-7 years, 63% were stable or improved while 38% began to progress. Tethered cord causes scoliosis and stability or improvement can be anticipated following untethering. Close long-term follow-up is essential to identify those individuals with retethering of their cord.
