title: Treatment of the occult tethered spinal cord for neuropathic bladder: results of sectioning the filum terminale.
abstract: 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.
authors.affiliation: 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
authors.forename: P D
authors.initials: PD
authors.lastname: Metcalfe
authors.forename: T G
authors.initials: TG
authors.lastname: Luerssen
authors.forename: S J
authors.initials: SJ
authors.lastname: King
authors.forename: M
authors.initials: M
authors.lastname: Kaefer
authors.forename: K K
authors.initials: KK
authors.lastname: Meldrum
authors.forename: M P
authors.initials: MP
authors.lastname: Cain
authors.forename: R C
authors.initials: RC
authors.lastname: Rink
authors.forename: A J
authors.initials: AJ
authors.lastname: Casale
mesh_terms: 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