The spinal cord is an important nerve center, and the disorders that affect it, including the tethered cord, must be given special attention. Turkey has developed in the field of neurosurgery and treatment to become one of the leading countries in this field.
What is TCS?
The tethered cord syndrome is a functional disorder caused by the extension and stretching of the spinal cord due to its fixation caudal as a result of congenital and rarely acquired disorders (such as tumors), a term that can be applied to many diseases in which the spinal cord is fixed .
This abnormal fixation leads, with the passage of time and the growth of the spinal cord as a result of the child’s growth, to an increase in the expansion of the spinal cord, damage to the delicate and sensitive tissue in it, and the emergence of several neurological and systemic symptoms.
As a result of the varying speed of growth in people, the time for symptoms to appear varies, some of them have symptoms in early childhood, and some do not have symptoms until adulthood, and some of them have limited movement and do not give any symptoms.
What are the causes of this syndrome?
To understand that this syndrome is a physiological and functional disorder that results from the inability of the neurons in the spinal cord to use oxygen, that is, impaired oxidative metabolism, and this is due to a lack of oxygen supply (the ischemic effect) due to the stretching and extension of the nerve cord, and partly to a defect in the ion channels due to Extension of the cell membrane of axons and neurons.
Garceau first described 'filum terminal syndromeIn 1953 in 3 patients. Two decades later, in 1976, Hoffman and colleagues coined the term "tethered cord syndrome" to describe the symptoms of their patients with spinal cord elongation and thickening of the terminal filament. Yamada et al. expanded the term to include patients with other abnormalities that cause spinal cord immobilization in 1981.
This syndrome was seen as a disease of children only, but as we mentioned previously, the cause can be congenital or acquired and affects adults and children, although it is much more common in children.
Congenital (primary) causes:
These tissues that connect and stabilize the spinal cord arise from several congenital anomalies, in particular due to defective closure of the neural tube (from the side of the spinal cord) during fetal development, a condition known as Slotted steel spina bifida.
Types of spina bifida associated with tethered cord syndrome include:
Myelomeningocele is the incomplete formation of the bones of the neural canal in which the spinal cord resides, which leads to the protrusion of the nervous tissue to the outside (the hydrocele). Also include
Spinal cord splitting (diastematomyelia), and a benign fatty mass or tumor (lipoma) persisting in the spinal cord. Another fatty abnormality is lipomyelomeningocele, in which the lipoma emerges from the spinal canal under the meninges, but is covered by normal skin.
This disorder can also be seen in patients Arnold chiari malformation.
In many patients, the cause is mechanical due to thickening and loss of elasticity of the terminal line, a condition often found in children. The terminal suture is a thread of tissue (glial cells) that connects the tip of the spinal cord with the sacrum. This is due to the growth and replacement of abnormal fibrous tissue To the glial tissue leading to the attachment of the spinal cord from its caudal end.
Acquired (secondary) causes:
There are many acquired causes of this syndrome, and these reasons may be aggravating to prove that it is already present in a child or an adult, including: tumors, infections, bruises or previous operations on the spinal cord.
There can be a genetic basis for this syndrome due to the fact that most of the causes of this syndrome are congenital diseases, but we cannot directly link genetics with it because this syndrome is a functional disorder whose symptoms appear only when the spinal cord is stretched and stretched, and studies are still ongoing in this field where some researchers have found a genetic predisposition This syndrome in some patients.
Symptoms and signs
The difference between symptom and sign is that the symptom is what the patient complains of (such as pain for example), and the sign is what the doctor sees or measures through clinical examination or various tests.
Symptoms of this disorder vary with age, and of course there are common symptoms.
Symptoms in children
It includes several symptoms that vary in severity according to the speed of growth or the severity of the disorder, including:
- The presence of tufts of hair, lumps, benign lipomas, discoloration of the skin (red spots or loss of skin color) or even hemangiomas in the lower back and usually in the midline.
- Pain in the lower back and spreading to the legs (may be associated with numbness in the lower extremities) usually worse with movement and better at rest (cannot be determined because children cannot express the pain or its location).
- Delayed motor development, such as delay in walking.
- Variation in leg strength (one leg is stronger than the other), restless or abnormal gait, and sometimes leg cramps.
In severe cases, deformities of the legs or feet or spinal deformities can occur scoliosis Or lordosis (Al-Bazakh).
This syndrome is often associated with poor urine and stool control.incontinence or fecal) and frequent urinary tract infections.
Symptoms in adults
Constant pain in the back and legs is often severe and can spread to the genital area or rectum.
Back pain is often aggravated by bending forward, sitting upright with legs crossed, or by carrying a moderate weight (such as a child or a stack of books) at waist level. This type of pain is called
Sometimes the "3-B sign" is for bending, Buddha sitting, and baby holding.
Sensory and motor weakness in the legs may lead to numbness, muscle wasting (atrophy) and fatigue after walking short distances.
Intestinal and bladder dysfunction manifested by increased frequency or urgency of urination and constipation.
How is tethered cord syndrome diagnosed in Turkey?
The patient's history must be taken in detail because it helps in the diagnosis greatly, and attention should be paid to the presence of any of the above-mentioned symptoms or signs.
Magnetic resonance is the best diagnostic tool here, and CT or Echo can be done.
In some cases, electromyography may be used (EMG) and nerve conduction studies to assess muscle function.
An electromyogram is a test that records electrical activity in skeletal (voluntary) muscles at rest and during contraction. Abnormalities in this examination are seen only in patients with advanced tethered cord syndrome.
Tied Spinal Cord Syndrome Treatment in Turkey
Most pediatric neurosurgeons believe that an infant or young child diagnosed with this syndrome, regardless of its origin, should undergo detethering. However, there is much controversy surrounding the surgical management of this disorder. While some authors and surgeons advocate preventive surgery, others suggest that surgery should only be done when symptoms appear or are intensified.
The condition can be monitored and followed up in the absence of symptoms despite the presence of MRI confirmation.
Surgery is the treatment of choice if neurological symptoms are present. Surgeons choose the optimal method of surgery based on the cause or severity of the syndrome and the patient's acceptance of the surgery.
A laminectomy is performed in the vertebrae facing the place of attachment, then the dura is opened, and then the attached spinal cord is released, if possible, the cause or mass that led to the fixation is removed.
The postoperative follow-up is very important because there may be a reconnection and fixation of the spinal cord and thus we need a new surgery. Most patients perform well after surgery and the recovery period is from one to two weeks where the patient does not have to move much and stay in bed so that the condition does not relapse or leakage occurs for cerebrospinal fluid.
In back pain patients over 65 years of age, sessions of physical therapy and lifestyle changes to avoid pain-inducing factors can be performed.
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What is the best treatment for tethered cord syndrome?
Surgery is a preferred treatment option and has given the best results. Recently, detethering surgery has developed significantly in Turkey and the recovery rate has increased significantly.
Can adults get tethered spinal cord syndrome?
Yes, adults can be infected with it. Either confirmation or association is present in them from a young age, but they did not show any symptoms, or it was due to an acquired disease, tumor, or surgery on the spinal cord.
What is the best way to detect spinal cord stabilization?
Magnetic resonance imaging is the best diagnostic method after taking the clinical history in detail.