Spinal cord traction, vascular compromise, hypoxia, and metabolic derangements in the pathophysiology of tethered cord syndrome

Filippidis, Aristotelis S.; Kalani, M. Yashar S.; Theodore, Nicholas; Rekate, Harold L.

doi:10.3171/2010.3.focus1085

Cited by 70 publications

(36 citation statements)

References 41 publications

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“…The radicular and medullary arteries and veins will be under tension and thus narrowed with an increase in spinal canal length (flexion) and will be relaxed in the extended posture of the pons-cord tract. 19,54 Mechanically though, it seems logical and is generally accepted that the loss of cervical lordosis is usually accompanied with axial or ventroflexion traction. 25 When the cervical spine is put into flexion, it has been shown that axial rotation increases dramatically, thus putting more torsional strain upon the annuals fibrosis, resulting in possible herniation and excess strain on spinal ligaments.…”

Section: Discussionmentioning

confidence: 99%

Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial

Moustafa

Diab

2014

Journal of Chiropractic Medicine

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Objective: The purpose of this study was to investigate the immediate and long-term effects of a 1-year multimodal program with the addition of 2 different traction approaches on the pain, function, disability, and nerve root function in patients with discogenic cervical radiculopathy (CR). This study also attempted to identify the optimal traction angle based on the maximum recovery of the peak-to-peak amplitude of the flexor carpi radialis (FCR) H-reflex. Methods: This randomized clinical trial with one-year follow-up included a total of 216 (101 female) patients with unilateral lower discogenic CR were randomly assigned to 1 of 3 groups. The standard care group (C) received the multimodal program (pain relief methods, muscle strengthening, and thoracic spine manipulation). The ventroflexion traction group (A) received the same multimodal program as group C, with added traditional ventroflexion traction. The novel traction group (B) received the same multimodal program as group C in addition to a flexor carpi radialis (FCR) H-reflex-based traction method. Primary outcomes were the Neck Disability Index (NDI) and secondary outcomes included neck pain, arm pain, and the amplitude and latency of the H-reflex. Patients were assessed at 3 intervals (pre-treatment, 4 weeks post-treatment, and the 1-year follow-up). Results: The mixed linear model with repeated measures indicated a significant group × time effect in favor of the novel cervical traction group (B) for measures of NDI (F = 412.6, P b .0005), neck pain (F = 108.9, P b .0005), arm pain (F = 91.3, P b .0005), H-reflex amplitude (F = 207.7, P b .0005), and H-reflex latency (F = 58.9 P b .0005). We found that the extension position of cervical spine (5°extension) was the position that achieved the maximum improvement in the novel cervical traction method. Conclusions: This preliminary study showed that a multimodal program with a novel cervical traction method added improved NDI, neck pain, arm pain, and the amplitude and latency of FCR H-reflex for a group of patients with chronic discogenic CR.

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Section: Discussionmentioning

confidence: 99%

Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial

Moustafa

Diab

2014

Journal of Chiropractic Medicine

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“…In addition to age, the number of compounding comorbidities present increases the risk for postoperative complications, consistent with the multivariate analysis conducted by Lad et al Bui et al 2 summarized the common comorbidities in patients with TCS, which can include cutaneous manifestations, orthopedic abnormalities (i.e., leg-length discrepancy, foot asymmetry, foot deformity, and progressive scoliosis), and urological problems (i.e., neurogenic bladder, incontinence, and frequent urinary 2 Other common comorbidities include degenerative disc disease, spinal stenosis and spondylosis, anorectal abnormalities, split cord malformation, OEIS syndrome (omphalocele, extrophy of the cloaca, imperforate anus, and spinal malformations with TCS), VATER associations, and the Currarino triad (anorectal malformation, presacral mass, and sacral bone abnormalities). 1,3,8,910 To date, no large-scale study has been conducted to determine the prevalence of these comorbid conditions with TCS.…”

Section: Discussionmentioning

confidence: 99%

Disparities in clinical and economic outcomes in children and adolescents following surgery for tethered cord syndrome in the United States

Shweikeh

Al-Khouja

Nuño

et al. 2015

PED

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OBJECT Tethered cord syndrome (TCS) is a common spinal abnormality. In this study, the authors analyzed demographics, complications, and outcomes in children and adolescents who underwent surgery for TCS. METHODS Using the national Kids' Inpatient Database (KID), the authors retrospectively identified patients with a primary diagnosis of TCS who were treated with spinal laminectomy and discharged in 2000, 2003, 2006, and 2009. Descriptive analysis was provided for patient- and hospital-level characteristics. Mortality, complications, non-routine discharges, in-hospital length of stay (LOS), and total charges were documented for the entire cohort and age-specific cohorts (0–5, 6–10, 11–15, and 16–20 years). Comparisons by complications and age groups were conducted. RESULTS A total of 7397 children and adolescents met the criteria in the 4 studied years. The mean age was 5.7 years; 55.3% of patients were younger than 5 years, 21.5% were 6–10 years, and 16.2% were 11–15 years. Most surgeries were performed in patients who were female (55.0%) and white (64.4%) and were performed at large (49.8%), teaching (94.2%), and urban (99.1%) children's (89.3%) hospitals. The trend showed an increase in prevalence from 2000 (19.9%) to 2009 (29.6%). Common comorbidities included anomalies in spinal curvature (16.7%), urinary or bladder dysfunction (14.3%), and spinal stenosis/spondylosis (1.4%). Non-routine discharges (3.3%) were significantly higher with advancing age, increasing from 2.2% in those younger than 5 years to 9.0% in those older than 15 years (p < 0.0001). There was a similar increasing trend for complications (6.8% to 13.9%, respectively, p < 0.0001) and average LOS (3.5 to 5.1 days, respectively, p < 0.0001). Hospital charges increased with age from an average of $28,521 in those younger than 5 years to $36,855 in those older than 15 years (p < 0.0001). CONCLUSIONS There was a steady trend of increasing operative treatment for TCS over the more recent years. The nationwide analysis was also indicative of an existing disparity, based on age, in complications, outcomes, and charges following TCS surgical correction. Older children tended to have more complications, longer LOS, more non-routine discharges, and higher hospital costs. The results are highly supportive of surgery at a younger age for this condition. Future research should investigate this correlation, especially considering the efforts to control and reduce health care costs.

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“…15,16 Retethering may produce neurological symptoms through nerve root traction and ischemia or tension distributed through the spinal cord. 3,4,12 We present a case of simple tethered cord due to a fatty filum terminale with 3 distinct episodes of recurrence, each presenting with fecal incontinence and resolving with operative intervention. At the last procedure, a discrete sacral nerve root was recognized and individual nerve roots were separated from the filum before its eventual complete resection.…”

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confidence: 99%

Fecal incontinence as a predominant symptom in a case of multiply recurrent tethered cord: diagnosis and operative strategies

Behaine

Latif

Greenfield

2015

PED

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T eThered cord syndrome (TCS) may be associated with myelomeningocele, lipomyelomeningocele, and lumbosacral lipoma or fibrolipomatous filum terminale or may be secondary to arachnoiditis or postsurgical scarring following an initial operative approach. Rates of retethering after sectioning a fatty filum terminale are low. 15,16 Retethering may produce neurological symptoms through nerve root traction and ischemia or tension distributed through the spinal cord. 3,4,12 We present a case of simple tethered cord due to a fatty filum terminale with 3 distinct episodes of recurrence, each presenting with fecal incontinence and resolving with operative intervention. At the last procedure, a discrete sacral nerve root was recognized and individual nerve roots were separated from the filum before its eventual complete resection. Symptoms had not returned at the 9-month follow-up. This case represents a unique clinical course and interesting pathophysiology that, to the best of our knowledge, has not been reported. case report History and ExaminationA healthy 4-year-old boy initially presented with severe constipation and abdominal pain concomitant with low-back and leg pain for which he was being managed with bowel regimens without improvement. Magnetic resonance imaging of the spine demonstrated a fatty filum terminale and tethered cord. The patient underwent tethered cord release at another institution, and his symptoms partially improved for 6 months before a recurrence of his initial symptoms. First RecurrenceThe patient's physical therapist noted new mild weakness of the left leg. Magnetic resonance imaging confirmed release of the filum terminale with the lipoma clearly disconnected, and the surgeon declined to reexplore. The child presented to our office at this time for a second opinion. We offered to perform an exploration at the original surgical abbreviatioN TCS = tethered cord syndrome. Recurrent manifestations of tethered spinal cord after an initial operative intervention for a simple fatty filum terminale is fairly uncommon. The authors present the case of an unusual clinical course in which there were 3 distinct episodes of recurrence, each time presenting predominantly as fecal incontinence and resolving with operative intervention. Typical signs of tethering were absent on radiological evaluation, and operative intervention was based on clinical grounds. Intraoperatively, sacral nerve roots to the anal sphincter were found tethered to the filar stump with electrophysiological evidence of regained activity on disentanglement. To the best of the authors' knowledge, a similar clinical course or operative findings have not been reported.

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Spinal cord traction, vascular compromise, hypoxia, and metabolic derangements in the pathophysiology of tethered cord syndrome

Cited by 70 publications

References 41 publications

Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial

Multimodal Treatment Program Comparing 2 Different Traction Approaches for Patients With Discogenic Cervical Radiculopathy: A Randomized Controlled Trial

Disparities in clinical and economic outcomes in children and adolescents following surgery for tethered cord syndrome in the United States

Fecal incontinence as a predominant symptom in a case of multiply recurrent tethered cord: diagnosis and operative strategies

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