Tethered Cord Release: What are the orthopaedic indicators and when is orthopaedic surgery needed?

Cameron Arkin1, BA, Theresa Meyer1, MS, RN, CPN, Jill Larson1, MD, Vineeta Swaroop1, MD

1Ann & Robert H. Lurie Children’s Hospital of Chicago | 225 East Chicago Avenue, Chicago, IL 60611

Introduction / Methods

Conclusions

Background ResultsClinical manifestations of tethered cord syndrome can be neurologic, urologic and/or orthopaedic, yet little is published regarding the incidence and type of orthopaedic conditions that precipitate need for tethered cord release (TCR).

Study Aims:1. Categorize the clinical orthopaedic findings associated

with tethered cord syndrome

2. Identify which of these orthopaedic manifestations required further surgical intervention despite TCR.

Study Design: Retrospective reviewInclusion Criteria: • Seen at our multidisciplinary Spina Bifida clinic • Enrolled in the National Spina Bifida Patient Registry

(NSBPR) • Underwent a TCR between 2007-2017Exclusion Criteria: • Diagnosis of occult tethered cord• Insufficient data Cohort:• Group 1: fatty filum/ low lying cord• Group 2: lipomyelomeningocele, meningocele,

myelocystocele, diastematomyelia, MM manqué• Group 3: myelomeningocele (MM)• 251 patients identified, 97 (39%) with orthopaedic

indicators• There was no statistical variation in sex, ethnicity, and

race across groupsVariables:• Demographic, clinical and surgical data was collected

from NSBPR and patient charts• Indicator for TCR was noted as orthopaedic,

urological, both, or asymptomatic • Orthopaedic surgical procedures performed within 18

months of TCR were collectedStatistics: • Chi square tests for categorical variables

3

18

3

7

10

3

2

1

1

Foot Deformity Reconstruction

Foot/Ankle Contracture Release

Hip Bony Surgery

Hip Contracture Release

Knee Contracture Release

Tibia Torsion Correction

Femur Torsion Correction

Tibia Epiphysiodesis

Spinal Fusion

Post TCR Orthopedic Surgeries

Orthopaedic TCR Indicators

• 39% of TCR patients had preoperative orthopaedic indicators

• Type of orthopaedic indicator varies based on diagnosis

• The most common orthopaedic indicator in fatty filums and low lying cords was gait deviation, in lipomyelomeningoceles, meningoceles, myelocystoceles, diastematomyelia, and MM manqué was weakness in lower extremities, and in myelomeningoceles was tone abnormality

• 30% of patients who underwent a TCR required further orthopaedic surgery

• Orthopaedic surgery post TCR was performed in 3 (3%) patients in group 1, 8 (11%) in group 2, and 18 (27%) in group 3

• The most common orthopaedic surgery across all diagnoses was a foot/ankle contracture release

• Comprehensive orthopaedic evaluation is a critical component of the work up and treatment of tethered cord syndrome

Group 1 Group 2 Group 3 p-valueTotal Patients with Ortho Indicators (n=97) 32 (33%) 19 (20%) 46 (47%)

TCR Indicator (n=274) (n=115) (n=85) (n=74) < 0.00001Ortho only 12 (11%) 17 (20%) 27 (37%)

Ortho & Urologic 21 (18%) 7 (8%) 22 (30%)Urologic only 60 (52%) 20 (24%) 24 (32%)

Asymptomatic 22 (19%) 41 (48%) 1 (1%)MMT Improvement

TCR1 7/9 (78%) 5/8 (63%) 7/16 (44%)TCR2 0/1 (0%) 0/5 (0%) 0/2 (0%)TCR3 N/A N/A 1/1 (100%)

Average age at TCR1 (years) 4.56 (0.75-12.25) 3.40 (0.17-19.08) 6.19 (0.25-23.00)