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Tethered Cord Syndrome in Adulthood: Long-term Outcome
102S
Proceedings of the NASS 25th Annual Meeting / The Spine Journal 10 (2010) 1S–149S
CONCLUSIONS: Though adequately planned and executed pediatric tuberculous kyphosis surprises the most skilled surgeons. The first surgery is often the penultimate correction. Final correction may be required after disease has healed. Even though extensive anterior and posterior surgery might be difficult in active tuberculosis in pediatric patients, an attempt should be made to have the best feasible anterior reconstruction. This is the single most important factor determining maintenance of correction. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2010.07.268
220. Tethered Cord Syndrome in Adulthood: Long-term Outcome InJae Choi, MD, Chun Kee Chung, MD, Tea-Ahn Jahng, MD; Seoul National University hospital, Seoul, Republic of Korea BACKGROUND CONTEXT: Adult tethered cord syndrome is a complex clinicopathological entity that remains incompletely understood. And the long-term outcome of surgical treatment for adult TCS is not yet welldefined. Furthermore it remains unclear what factor plays a prognostic role in the surgical treatment of these patients. PURPOSE: We reviewed our clinical experience with adults undergoing tethered cord release to characterize the long-term outcome of neurologic function improvement after surgery, and to determine the factor that may have an increased likelihood of experiencing postoperative neurological outcome over time. STUDY DESIGN/SETTING: We retrospectively reviewed the medical records in 31 consecutive cases of adult patient underwent detethering surgical procedures for TCS. PATIENT SAMPLE: Clinical data obtained in all 31 patients (mean age 36 years, range 17–59; 19men and 12 women) are the subject of the present analysis. We made two group acceding to the tethered conus medullaris level, above and below L4 inferior endplate level. All patients received surgical treatment, detethering the spinal cord with removal of causative lesion if possible, soon after the initial diagnosis. OUTCOME MEASURES: Follow-up period was range from 8 to 170 months (mean 48 months). During follow-up period, we checked the Japanese Orthopedic Association (JOA) score for functional neurological status, and we evaluated the surgical outcome as the difference of JOA score, before and after detethering surgery. METHODS: To clarify the prognostic factors associated with the surgical outcomes, we evaluated the correlation between the difference in the JOA score and age, duration of preoperative symptoms, cause of TCS, preoperative neurological score and tethered conus level. The association of these variables with surgical outcomes was assessed using multiple regression, and Pearson’s Chi-Square test with Fisher’s exact test. Significance was accepted for p-values of !0.05. RESULTS: Conus level, as assessed by MR imaging, was distribute as follows: L2-3 in seven patients (26%), L4 in 6 (19%), L5 in 9 (29%) and S1-3 in 9 patients (29%). We made two group according to the tethered conus medullaris level, above and below L4 inferior endplate level. The cause of tethering was diverse: lipomyelomeningocele in 16 patients (52%), intradural lipoma in 8 (26%), postrepair myelomeningocele in 4 (13%), tight filium terminale in 2 (6.5%) and spit cord malformation in one patient (3.2%). According to our surgical criteria, the difference of JOA score, there were good result for 10 patients (32%), fair result for 13 patients (42%), and poor result 8 patients (26%). Sensory symptom improved in 8 patients (26%), was unchanged in 20 (65%), and deteriorated in three (9%); motor function improved in 5 patients (16%), was unchanged in 24 (77%), and deteriorated in 2 (7%); bladder function improved in only one patient (3%), was unchanged in 23 (74%), deteriorated in 7 patients (23%). The rate of improvement was greatest for sensory deficit, followed
by motor dysfunction, then bladder dysfunction. Patients whose tethered conus level was above L4 (p50.036) had an increased likelihood of experiencing improvement in surgical outcome. (Table.) Furthermore conus level was especially associated with sensory function improvement.(p50.031). Motor function outcome and bladder function outcome related with conus level, but they had no statistical significances. (p50.340, p50.134) Patients age, duration of preoperative symptoms, cause of TCS, and preoperative neurological score were not associated with improved surgical outcome. CONCLUSIONS: Our results showed that detethering surgery halted the progression of neurological deficit in the majority cases, but the symptomatic and functional improvements were disappointing. Especially the outcome of bladder function was worst. In addition, most cases that tethered conus located below L4 showed poor functional outcome. These findings may help surgical decision making and guide patient education. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2010.07.269
Saturday, October 9, 2010 10:30–11:30 AM Concurrent Session 2: Tumor 221. Postoperative Radiotherapy Following En Bloc Resection of Sacrococcygeal Chordoma is Advisable: Long-term Results Wouter A. Moojen, MD, Carmen L.A. Vleggeert-Lankamp, MD, PhD, A.D.G. Krol, MD, PhD, Sander P.D. Dijkstra, MD; University Medical Center Leiden, Leiden, Netherlands BACKGROUND CONTEXT: Sacrococcygeal chordoma is a slow growing, malignant tumor with a clinical poor outcome due to a high local recurrence (LR) rate. Several studies emphasize that margin-free tumor resection is the most important predictor of LR free survival and overall survival in patients with sacrococcygeal chordoma. However, even after radical resection, a high recurrence rate up 80% remains. PURPOSE: The purpose of this report is to define the role of postoperative radiotherapy (RT) in the prevention of LR in long-term follow up. STUDY DESIGN/SETTING: A retrospective series of 15 patients (7 females and 8 males) who underwent surgical treatment for sacrococcygeal chordoma in one center between 1981 and 2003 were reviewed. PATIENT SAMPLE: The median age at surgery was 54 (range 31–70) years. The mean follow up was 8.5 (range 4 - 20) years or until death. Most patients suffered from local swelling and pain; only one patient had a mild urinary continence, no other pre- or postoperative neurological deficits were observed. Mean duration of preoperative complaints was 4.5 (range 0.8 - 8) years. In 10 patients an en bloc resection was (histological resection margins were free) performed, in 5 patients a subtotal resection was achieved. All but one patients with a subtotal resection received RT (4/5 patients) following surgery, patients with en bloc resection only received RT in case of LR (6/10 patients). OUTCOME MEASURES: Survival was defined as the time interval from diagnosis to either death (overall survival) or disease relapse (continuous disease-free survival). METHODS: Overall survival and continuous disease-free survival rates were compared between these two groups. RESULTS: After en bloc resection (no initial RT) all 10 patients had LR of the tumor with a mean time to recurrence of 3 (range 0.8 - 13) yrs. Six of these 10 patients received RT after LR and had a mean survival duration
All referenced figures and tables will be available at the Annual Meeting and will be included with the post-meeting online content.
Proceedings of the NASS 25th Annual Meeting / The Spine Journal 10 (2010) 1S–149S
CONCLUSIONS: Though adequately planned and executed pediatric tuberculous kyphosis surprises the most skilled surgeons. The first surgery is often the penultimate correction. Final correction may be required after disease has healed. Even though extensive anterior and posterior surgery might be difficult in active tuberculosis in pediatric patients, an attempt should be made to have the best feasible anterior reconstruction. This is the single most important factor determining maintenance of correction. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2010.07.268
220. Tethered Cord Syndrome in Adulthood: Long-term Outcome InJae Choi, MD, Chun Kee Chung, MD, Tea-Ahn Jahng, MD; Seoul National University hospital, Seoul, Republic of Korea BACKGROUND CONTEXT: Adult tethered cord syndrome is a complex clinicopathological entity that remains incompletely understood. And the long-term outcome of surgical treatment for adult TCS is not yet welldefined. Furthermore it remains unclear what factor plays a prognostic role in the surgical treatment of these patients. PURPOSE: We reviewed our clinical experience with adults undergoing tethered cord release to characterize the long-term outcome of neurologic function improvement after surgery, and to determine the factor that may have an increased likelihood of experiencing postoperative neurological outcome over time. STUDY DESIGN/SETTING: We retrospectively reviewed the medical records in 31 consecutive cases of adult patient underwent detethering surgical procedures for TCS. PATIENT SAMPLE: Clinical data obtained in all 31 patients (mean age 36 years, range 17–59; 19men and 12 women) are the subject of the present analysis. We made two group acceding to the tethered conus medullaris level, above and below L4 inferior endplate level. All patients received surgical treatment, detethering the spinal cord with removal of causative lesion if possible, soon after the initial diagnosis. OUTCOME MEASURES: Follow-up period was range from 8 to 170 months (mean 48 months). During follow-up period, we checked the Japanese Orthopedic Association (JOA) score for functional neurological status, and we evaluated the surgical outcome as the difference of JOA score, before and after detethering surgery. METHODS: To clarify the prognostic factors associated with the surgical outcomes, we evaluated the correlation between the difference in the JOA score and age, duration of preoperative symptoms, cause of TCS, preoperative neurological score and tethered conus level. The association of these variables with surgical outcomes was assessed using multiple regression, and Pearson’s Chi-Square test with Fisher’s exact test. Significance was accepted for p-values of !0.05. RESULTS: Conus level, as assessed by MR imaging, was distribute as follows: L2-3 in seven patients (26%), L4 in 6 (19%), L5 in 9 (29%) and S1-3 in 9 patients (29%). We made two group according to the tethered conus medullaris level, above and below L4 inferior endplate level. The cause of tethering was diverse: lipomyelomeningocele in 16 patients (52%), intradural lipoma in 8 (26%), postrepair myelomeningocele in 4 (13%), tight filium terminale in 2 (6.5%) and spit cord malformation in one patient (3.2%). According to our surgical criteria, the difference of JOA score, there were good result for 10 patients (32%), fair result for 13 patients (42%), and poor result 8 patients (26%). Sensory symptom improved in 8 patients (26%), was unchanged in 20 (65%), and deteriorated in three (9%); motor function improved in 5 patients (16%), was unchanged in 24 (77%), and deteriorated in 2 (7%); bladder function improved in only one patient (3%), was unchanged in 23 (74%), deteriorated in 7 patients (23%). The rate of improvement was greatest for sensory deficit, followed
by motor dysfunction, then bladder dysfunction. Patients whose tethered conus level was above L4 (p50.036) had an increased likelihood of experiencing improvement in surgical outcome. (Table.) Furthermore conus level was especially associated with sensory function improvement.(p50.031). Motor function outcome and bladder function outcome related with conus level, but they had no statistical significances. (p50.340, p50.134) Patients age, duration of preoperative symptoms, cause of TCS, and preoperative neurological score were not associated with improved surgical outcome. CONCLUSIONS: Our results showed that detethering surgery halted the progression of neurological deficit in the majority cases, but the symptomatic and functional improvements were disappointing. Especially the outcome of bladder function was worst. In addition, most cases that tethered conus located below L4 showed poor functional outcome. These findings may help surgical decision making and guide patient education. FDA DEVICE/DRUG STATUS: This abstract does not discuss or include any applicable devices or drugs. doi: 10.1016/j.spinee.2010.07.269
Saturday, October 9, 2010 10:30–11:30 AM Concurrent Session 2: Tumor 221. Postoperative Radiotherapy Following En Bloc Resection of Sacrococcygeal Chordoma is Advisable: Long-term Results Wouter A. Moojen, MD, Carmen L.A. Vleggeert-Lankamp, MD, PhD, A.D.G. Krol, MD, PhD, Sander P.D. Dijkstra, MD; University Medical Center Leiden, Leiden, Netherlands BACKGROUND CONTEXT: Sacrococcygeal chordoma is a slow growing, malignant tumor with a clinical poor outcome due to a high local recurrence (LR) rate. Several studies emphasize that margin-free tumor resection is the most important predictor of LR free survival and overall survival in patients with sacrococcygeal chordoma. However, even after radical resection, a high recurrence rate up 80% remains. PURPOSE: The purpose of this report is to define the role of postoperative radiotherapy (RT) in the prevention of LR in long-term follow up. STUDY DESIGN/SETTING: A retrospective series of 15 patients (7 females and 8 males) who underwent surgical treatment for sacrococcygeal chordoma in one center between 1981 and 2003 were reviewed. PATIENT SAMPLE: The median age at surgery was 54 (range 31–70) years. The mean follow up was 8.5 (range 4 - 20) years or until death. Most patients suffered from local swelling and pain; only one patient had a mild urinary continence, no other pre- or postoperative neurological deficits were observed. Mean duration of preoperative complaints was 4.5 (range 0.8 - 8) years. In 10 patients an en bloc resection was (histological resection margins were free) performed, in 5 patients a subtotal resection was achieved. All but one patients with a subtotal resection received RT (4/5 patients) following surgery, patients with en bloc resection only received RT in case of LR (6/10 patients). OUTCOME MEASURES: Survival was defined as the time interval from diagnosis to either death (overall survival) or disease relapse (continuous disease-free survival). METHODS: Overall survival and continuous disease-free survival rates were compared between these two groups. RESULTS: After en bloc resection (no initial RT) all 10 patients had LR of the tumor with a mean time to recurrence of 3 (range 0.8 - 13) yrs. Six of these 10 patients received RT after LR and had a mean survival duration
All referenced figures and tables will be available at the Annual Meeting and will be included with the post-meeting online content.