Incidence of symptomatic retethering after surgical management of pediatric tethered cord syndrome with or without duraplasty.
BACKGROUND
Cord retethering and other postoperative complications can occur after the surgical untethering of a first-time symptomatic tethered cord. It is unclear if using duraplasty vs. primary dural closure in the initial operation is associated with decreased incidence of either immediate postoperative complications or subsequent symptomatic retethering. It is also unclear if different etiologies are associated with different outcomes after each method of closure. We reviewed our pediatric experience in first-time surgical untethering of symptomatic tethered cord syndrome (TCS) to identify the incidence of postoperative complications and symptomatic retethering after duraplasty vs. primary closure.


METHODS
We retrospectively reviewed 110 consecutive pediatric (<18 years old) cases of first-time symptomatic spinal cord untethering at our institution over a 10-year period. Incidence of postoperative complications and symptomatic retethering were compared in cases with duraplasty vs. primary dural closure use.


RESULTS
Mean age was 5.7 +/- 4.8 years old. "Complex" etiologies included lipomyelomeningocele or prior lipomyelomeningocele repair in 22 (20%) patients, prior myelomeningocele repair in 35 (32%), and concurrent lumbosacral lipoma in 18 (16%). "Noncomplex etiologies" included fatty filum in 26 (24%) and split cord malformation in five (4%). Seventy-five (68%) cases underwent primary dural closure vs. 35 (32%) with duraplasty. Twenty-nine (26%) patients experienced symptomatic retethering at a median [interquartile range (IQR)] of 30.5 [20.75-41.75] months postoperatively. There was no difference in incidence of postoperative cerebrospinal fluid leak, surgical site infection, or median [IQR] length of stay in patients receiving primary dural closure [4 (5%), 7 (9%), and 5 (4-6) days, respectively] vs. duraplasty [3 (9%), 3 (9%), and 6 [5-8] days, respectively], p > 0.05. Complex etiologies were more likely to retether than noncomplex etiologies after primary closure (33.6% vs. 6.6%, p = 0.05) but not after duraplasty (13.7% vs. 5.4%, p = 0.33). Duraplasty graft type (polytetrafluoroethylene vs. bovine pericardium) was not associated with pseudomeningocele or retethering.


CONCLUSIONS
In our experience, the increased rate of symptomatic retethering observed with complex pediatric TCS (pTCS) etiologies after primary dural closures was not observed when duraplasty was instituted. Expansile duraplasty may be valuable specifically in the management of patient subgroups with complex pTCS etiologies.
Samuels
Roger
R
Department of Neurosurgery, Johns Hopkins School of Medicine, 600 N Wolfe Street, Meyer 8-161, Baltimore, MD 21287, USA.
McGirt
Matthew J
MJ
Attenello
Frank J
FJ
Garcés Ambrossi
Giannina L
GL
Singh
Neil
N
Solakoglu
Can
C
Weingart
Jon D
JD
Carson
Benjamin S
BS
Jallo
George I
GI
D002648:Child; D002675:Child, Preschool; D004388:Dura Mater / Q000601:surgery*; D005260:Female; D006801:Humans; D015994:Incidence; D007223:Infant; D008297:Male; D009436:Neural Tube Defects / Q000453:epidemiology* / Q000209:etiology / Q000601:surgery*; D019635:Neurosurgical Procedures / Q000379:methods; D011183:Postoperative Complications / Q000453:epidemiology*; D012008:Recurrence; D016896:Treatment Outcome