Treatment of the occult tethered spinal cord for neuropathic bladder: results of sectioning the filum terminale.
OBJECTIVE
Occult tethered cord syndrome applies to patients with signs and symptoms consistent with a caudal spinal cord malformation despite normal neuroimaging. Although several reports of successful surgical treatment exist, controversy remains with respect to patient selection and efficacy. We present a large series with excellent clinical followup, neuroimaging and urodynamic characterization.


METHODS
We present our experience with 36 patients at a single institution with preoperative clinical findings, neuroimaging and urodynamics available. Postoperative outcomes were assessed clinically and with urodynamics. We determined predictive parameters to improve patient selection.


RESULTS
Approximately 0.04% of pediatric urology clinic visits resulted in neurosurgical referral for the potential of an occult tethered cord. They occurred after failure of a mean of 2 years of aggressive medical management. Daytime urinary incontinence was present in 83% of patients and 47% had encopresis. Preoperative urodynamics were markedly abnormal in all patients with mean bladder capacity 55% of expected capacity. Clinical improvement in urinary symptoms was seen in 72% of patients with resolution of incontinence in 42%. Bowel symptoms improved in 88% of cases, including resolution of encopresis in 53% within 3 months of surgery. Urodynamic improvements were demonstrated in 57% of cases. We were unable to determine preoperative factors that were more likely associated with surgical success.


CONCLUSIONS
In a highly select population with severe urinary and fecal dysfunction sectioning a normal-appearing filum terminale can result in significant improvement. We were unable to identify factors that may increase the chance of surgical success.
Metcalfe
P D
PD
Department of Pediatric Urology, James Whitcomb Riley Hospital for Children, Indiana University School of Medicine, 702 North Barnhill Drive, Indianapolis, IN 46202, USA. pmetcalf@iupui.edu
Luerssen
T G
TG
King
S J
SJ
Kaefer
M
M
Meldrum
K K
KK
Cain
M P
MP
Rink
R C
RC
Casale
A J
AJ
D000293:Adolescent; D002420:Cauda Equina / Q000601:surgery*; D002648:Child; D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008279:Magnetic Resonance Imaging; D008297:Male; D016136:Spina Bifida Occulta / Q000150:complications / Q000175:diagnosis / Q000601:surgery*; D001750:Urinary Bladder, Neurogenic / Q000209:etiology / Q000503:physiopathology*; D014549:Urinary Incontinence / Q000209:etiology / Q000503:physiopathology; D014563:Urodynamics