title: Management of multiple tethering in spinal dysraphism.
abstract: BACKGROUND
  The most challenging component of spinal dysraphism is cord tethering. Tethering can occur due to single or multiple lesions within the same patient. It is imperative to aggressively identify and release all the tethering lesions in order to provide maximum benefit to the patient. With increasing number of tethering lesions, the clinical profile and outcome show significant differences, and this difference is significantly more when more than two tethering lesions coexist in the same patient.
  
  
  METHODS
  Out of the 248 patients of spinal dysraphism who underwent surgical management at Sanjay Gandhi Institute of Medical Sciences, Lucknow, India, between 1997 and 2007, 160 were included in the study. Patients were classified into two groups based on the number of tethering lesions. The first group (Group A) comprised cases of spinal dysraphism with tethering demonstrable at one or two sites. The second group (Group B) comprised patients with radiological or intraoperative evidence of multiple tethering lesions (more than two).
  
  
  RESULTS
  There were 119/160 patients in Group A, while 41/160 patients were in Group B (with more than two sites of tethering). The preoperative neurological examination revealed significant differences between the two study groups. The clinical profile and the surgical outcomes have shown significant differences in the two study groups. These differences are statistically significant.
  
  
  CONCLUSIONS
  We strongly believe that the mere presence or absence of tethering is not a sufficient documentation to predict its effect on the cases of spinal dysraphism. Tethering is a complex entity that needs to be further classified in terms of the number of tethering lesions, which significantly affect the pre- and postoperative status of the patients. We would like to suggest the term "Spina Bifida Multiplex" for the cases where more than two lesions are found to be responsible for tethering.
authors.affiliation: Department of Neurosurgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, U.P., India. rajkumar@gmail.com
authors.forename: Raj
authors.initials: R
authors.lastname: Kumar
authors.forename: Pallav
authors.initials: P
authors.lastname: Garg
authors.forename: Samir Kumar
authors.initials: SK
authors.lastname: Kalra
authors.forename: Ashok Kumar
authors.initials: AK
authors.lastname: Mahapatra
mesh_terms: D002675:Child, Preschool; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D009436:Neural Tube Defects / Q000209:etiology* / Q000473:pathology* / Q000601:surgery; D016135:Spinal Dysraphism / Q000150:complications* / Q000473:pathology* / Q000601:surgery; D016896:Treatment Outcome