[Classification and microsurgical treatment of primary tethered cord syndrome in adults].

OBJECTIVE: To summarize the clinical manifestation, classification, and experience of surgical treatment of primary tethered cord syndrome (TCS) in adults. METHODS: The authors retrospectively analyzed a series of 171 adult patients with primary TCS who were surgically treated under microscope from March 2007 to October 2019. There were 61 males and 110 females whose ages were 18-65 years, with an average age of (39.02±11.81) years. Clinically, the patients presented with various neurological symptoms and signs including lower back and legs pain, reflex changes, sensory disturbances, muscle weakness, and sphincter problems. They were divided into 5 types by clinical manifestations and neuro-imaging features: (1) filum terminale traction in 69 cases, (2) split cord malformation in 21 cases, (3) myelomeningocele in 20 cases, (4) lipomyelomeningocele in 36 cases, and (5) dermal sinus traction in 25 cases. All the patients underwent microsurgery to untether the spinal cord. The patients kept prone position 7 days postoperatively. The Kirollos grading was used to evaluate the outcome of intraoperative untethering. The visual analogue scale (VAS) was used to evaluate the pain, the score of critical muscle strength was used to evaluate the lower extremity motor function, and the Japanese Orthopaedic Association (JOA) sphincter function score was used to evaluate the bladder function. RESULTS: All of the 171 patients were treated with microsurgery to release the adhesion and cut off the filum terminalis. 61 cases of them received resection of the lesions according to the etiology. All the tethered spinal cord reached Kirollos grade Ⅰ untethering and the dural sac was reconstructed. Other than 5 patients had cerebrospinal fluid leakage and incision laceration and underwent re-suture, there was no surgical complication. The local pain was relieved, the lower limbs weakness or bowel and bladder dysfunction gradually recovered postoperatively. The period of follow-up ranged from 6 months to 12.5 years with an average of (5.62±2.31) years. The neurological function was improved in 153 cases and stable in 18 cases. There was no recurrence of tethered cord be found during the follow-up period. CONCLUSION: The primary TCS in adulthood could be classified into 5 types by clinical manifestations and neuro-imaging features and surgical treatment should be undertaken in regard to the classifications including dissection and resection of the lesion detethering the spinal cord and reconstruction of the dura sac under microscope. The outcome of surgical treatment is satisfactory.

[Reinforced radiculoplasty for the treatment of symptomatic sacral Tarlov cysts: A clinical analysis of 71 cases].

OBJECTIVE: To investigate the safety and efficacy of reinforced radiculoplasty in the treatment of symptomatic sacral Tarlov cysts (TCs). METHODS: A retrospective analysis was performed on the clinical data and follow-up data of 71 patients with symptomatic sacral TCs who underwent reinforced radiculoplasty in the Neurosurgery Department of Peking University Third Hospital from June 2018 to March 2021. All the operations were performed under neuroelectrophysiological monitoring. Intraoperative cyst exploration, partial resection of the cyst wall, narrowing of the leak, nerve root sleeve radiculoplasty and artificial dural reinforcement were performed. The incidence of postoperative complications and new neurological dysfunction was analyzed. Visual analogue scale (VAS) was used to assess the changes of pain before and after surgery. The Japanese Orthopedics Association (JOA) low back pain score was used to evaluate the changes in nerve function before and after surgery. RESULTS: In the study, 71 patients had 101 TCs, 19 (18.8%) TCs originated from the left S1 nerve, 26 (25.7%) originated from the left S2 nerve, 3 (3.0%) originated from the left S3 nerve, 14 (13.9%) originated from the right S1 nerve, 33 (32.7%) originated from the right S2 nerve, 6 (5.9%) originated from the right S3 nerve, all the TCs underwent reinforced radiculoplasty. Deep infection (1 case), subcutaneous effusion (1 case), fat li-quefaction (1 case) and urinary tract infection (4 cases) were recorded postoperatively. The patients were followed up for 12-43 months (median, 26 months). Two cases had new urinary retention after operation, and the catheter was removed at the end of the first and second months respectively. One case had new fecal weakness, which improved after 3 months. Compared with preoperation, VAS decreased significantly at the last follow-up [median, 6 (4-9) vs. 1 (0-5), Z=-7.272, P < 0.001], JOA score increased significantly [median, 20 (16-25) vs. 27 (18-29), Z=-7.265, P < 0.001]. There were 18 cured cases (25.4%), 41 excellent cases (57.7%), 8 effective cases (11.3%), and 4 invalid cases (5.6%). The total efficiency was 94.4% (67/71). Two (1.98%) cysts recurred. CONCLUSION: For patients with symptomatic sacral TCs, reinforced radiculoplasty can significantly improve the pain and nerve function, which is safe and reliable.

[Diagnosis and surgical treatment of tethered cord syndrome accompanied by congenital dermal sinus tract in adults].

OBJECTIVE: To summarize the clinical manifestations, imaging characteristics and experience of surgical treatment of tethered cord syndrome (TCS) accompanied by dermal sinus tract (DST) in adulthoods. METHODS: The authors retrospectively analyzed a series of 25 adult patients with TCS due to DST that were surgically treated under microscope from September 2010 to October 2019. There were 10 males and 15 females with an average age of 29.7 years (rang, 18-48 years). Characterized cutaneous malformation and dermal sinus were found in the lumbosacral region in all the 25 patients. Clinically, all the patients presented with chronic back and lower-extremity pain, numbness and weakness of lower limbs, and bowel and bladder dysfunction. Two cases were admitted to the emergency room with acute infectious cerebral spinal fluid (CSF) leakage complicated with meningitis. According to magnetic resonance imaging (MRI) images, the subdural course of DST whose traction of the spinal cord, the location of the conus medullaris, the presence of subdural lesions, and the diameter of the internal filum terminale were evaluated. The surgical procedure included separating and excising of the DST, section of the internal filum terminale, detethering of the TCS, and reconstruction of the dural sac under microscopy. The patients remained in prone position in 7 days postoperation. RESULTS: MRI showed that the position of the conus medullaris was lower than the level of lumbar 2 vertebrae, and the distal part of the DST entered the subdural stretched part of the spinal cord, to constitute one of the factors of TCS in all the 25 patients. Twenty patients had fatty infiltration of internal filum terminale and another patient had thickened (approximately 5 mm in diameter) internal filum terminale resulting in tightening the conus medullaris. A total of 25 operations were performed including completely dissection and resection of the DST through the skin down to the subdural space, section of the internal filum terminale, detethering of the TCS, and the subdural dermoid cysts were removed in two patients. There were no postoperative complications. The postoperative pathology was consistent with the structure of the DST and internal filum terminale. The local pain was relieved, and the lower-extremity weakness and bowel and bladder dysfunction were gradually relieved postoperatively. The period of follow-up ranged from 3 months to 9 years (mean, 3.9 years). The neurological function of all the patients was intact, and MRI showed that the physiological curvature of the thoracolumbar spine remained normal. There was no recurrence of TCS observed during the follow-up. CONCLUSION: The adult TCS accompanied with DST is characterized by typical cutaneous malformation in the lumbosacral region and tethering of the spinal cord. The patients are usually combined with internal filum terminale enlargement tightening of conus medullaris as well. The surgical treatment including totally resection of the DST and section of the internal filum terminale to detethering the TCS at the same time under microscopy. The outcome of surgical treatment is satisfactory.

[Minimally invasive treatment of cervical1-2 epidural neurilemmoma].

OBJECTIVE: To explore the minimally invasive surgical method for cervical1-2 epidural neurilemmoma. METHODS: The clinical features, imaging characteristics and surgical methods of 63 cases of cervical1-2 epidural neurilemmoma from July 2010 to December 2018 were reviewed and analyzed. Pain and numbness in occipitocervical region were the common clinical symptoms. There were 58 cases with pain, 30 cases with numbness, 3 cases with limb weakness and 2 cases with asymptomatic mass. Magnetic resonance imaging (MRI) showed that the tumors located in the cervical1-2 epidural space with diameter of 1-3 cm. The equal or slightly lower T1 and equal or slightly higher T2 signals were found on MRI. The tumors had obvious enhancement. Individualized laminotomy was performed according to the location and size of the tumors, and axis spinous processes were preserved as far as possible. Resection of tumor was performed strictly within the capsule. RESULTS: Total and subtotal resection of tumor were achieved in 60 and 3 cases respectively, and no vertebral artery injury was found. The operation time ranged from 60 to 180 minutes, with an average of 92.83 minutes. The hospitalization time ranged from 3 to 9 days, with an average of 5.97 days. All tumors were confirmed as neurilemmoma by pathology. There was no postoperative infection or cerebrospinal fluid leakage. There was no new-onset dysfunction except 9 cases of numbness in the nerve innervation area. The period of follow-up ranged from 6 months to 8 years (median: 3 years). All the new-onset dysfunction recovered completely. Pain disappeared in all of the 58 patients with pain. Numbness recovered completely in 27 patients while slight numbness remained in another 3 patients. Three patients with muscle weakness recovered completely. The spinal function of all the patients restored to McCormick grade Ⅰ. No recurrence was found on MRI. No cervical spine instability or deformity was found on X-rays. CONCLUSION: It is feasible to resect cervical1-2 epidural neurilemmoma by full use of the anatomical space between atlas and axis and individual laminotomy. It is helpful to prevent cervical instability or deformity by minimizing the destruction of cervical2 bone and preserving normal muscle attachment to cervical2 spinous process. Strict intracapsular resection can effectively prevent vertebral artery injury.

[Clinical study of 21 cases of sacral cysts containing fila terminale].

OBJECTIVE: To summarize the characteristics of sacral cysts containing fila terminale and to explore the surgical treatment methods. METHODS: The clinical features, imaging characteristics and surgical methods of 21 cases of sacral cysts containing fila terminale from July 2010 to March 2017 were reviewed and analyzed. Lumbosacral and perineal pain, weakness of the lower limbs and bladder and bowel dysfunction were the common clinical symptoms. MRI showed that the cysts located in the sacral canal. The lower T1 and higher T2 signals were found on MRI. There were fila terminale within the cysts which tethered the spinal cord. No enhancement was visible within the lesion. The key steps of operation included the resection of the cyst wall, the cutting off of the fila terminale, the release of the tethered cord and the reconstruction of the cisterna terminalis. RESULTS: The total and subtotal resections of cyst walls were achieved in 14 and 7 cases, respectively. The fila terminales were separated and cut off in all the cases, and the tethered cords were released completely. The reconstructions of the cisterna terminalis were accomplished in all the cases. There was no new-onset dysfunction except for 7 cases of mild numbness around anus postoperatively. Pathological examinations confirmed that the cyst wall was fibrous connective tissue, and hyperplasia of fibrous tissue and/or adipose tissue was found within the thickened fila terminale. The lumbosacral and perineal pain disappeared. The weakness of the lower extremities and the bladder and bowel dysfunction gradually improved. The period of follow-up ranged from 3 months to 7 years (average: 2.25 years). The spinal function of all the patients restored to McCormick grade Ⅰ. Only 1 case encountered recurrence of cyst. CONCLUSION: The sacral cysts containing fila terminale are rare. The common symptoms include lumbosacral and perineal pain and symptoms of tethered cord. MRI is helpful to the diagnosis, which shows the signal of cerebrospinal fluid and the fila terminale in the cyst as well as tlow-placed conus medullaris. Microsurgery should remove the cyst wall, cut off the fila terminale, release the tethered cord and reconstruct the cisterna terminalis.

Comparative clinical study on seldom segment with multiple segment intramedullary primary spinal cord tumors.

OBJECTIVE: Several clinical studies were performed on multi-segment intramedullary primary spinal cord tumors. However, no clinical study focused on the relationship between different vertebral segments intramedullary tumors involvement and neurological functions, as well as prognosis of the patients. This prospective study was performed to compare clinical analysis on neurological functions and prognosis of the patients with intramedullary spinal cord primary tumors. METHODS: A prospective cohort study was performed in a single medical center, Neurosurgical Department, Peking University Third Hospital. Between Jan. 1, 2010 and Dec. 30, 2015, 135 patients underwent microsurgery for intramedullary primary spinal cord tumors. The intramedullary tumor length occupying 3 or more vertebral body levels was considered as multiple segments intramedullary primary spinal cord tumor, and occupying one or two vertebral body levels considered as seldom segments. Preoperative and postoperative functions were assessed using IJOA (improved Japanese orthopaedic association) scoring system, and analyzed using the appropriate statistical tests. RESULTS: Among the 135 patients, 52 cases had seldom segments intramedullary primary spinal cord tumors, and 83 cases had multiple segments. In the seldom group, 32 (62%) patients presented with normal urine and stool function, 8 (15%) patients with severe dysfunction, 7 (14%) with slight dysfunction, and 5 (9%) with incontinence, and 30 (58%) patients demonstrated various degrees of limbs weakness. The preoperative IJOA scores of the patients were 16.9±2.4. The postoperative IJOA scores at the end of 3 months were 16.6±2.3. The current IJOA scores until the end of the follow-up were 17.5±4.4. In the multiple group, 37 (45%) patients presented with normal urine and stool functions, 26 (31%) patients with slight dysfunction, 11 (13%) with severe dysfunction, and 9 (11%) with incontinence, and 62 (75%) patients demonstrated various degrees of limbs weakness. The preoperative IJOA scores of the patients were 15.6±3.4. The postoperative IJOA scores at the end of 3 months were 15.5±3.8. The current IJOA scores until the end of the follow-up were 16.9±5.8. The difference of presenting urine and stool dysfunction (Z=-1.35, P=0.18) was not statistically significant between the different patient groups. However, the difference of presenting limbs weakness (Z=-2.06, P=0.04) was statistically significant between the two groups. Most patients with multiple segment intramedullary tumors suffered from various limbs weakness. The difference of the preoperative IJOA score (P=0.02) and the postoperative early IJOA score (P=0.004) of the patients was statistically significant between the seldom and multiple segments groups. Preoperative and early postoperative neurological function of the patients was better with seldom segments tumor than with multiple segments tumor. Most patients with multi-segment intramedullary tumors experienced various limbs weakness. However, the difference of long-term neurological function (P=0.12) between the seldom and multiple segments groups was not statistically significant. The neurological function of the patients with multiple segments intramedullary tumor was remarkably improved after physical therapy. CONCLUSION: Perioperative neurological function of the patients with seldom segments primary tumor was superior to that of the patients with multiple segments primary tumor, especially for limb strength. The neurological function of the patients with multiple segments intramedullary primary tumor was remarkably improved after physical therapy during long-term follow-up.

[Changes in plasma concentration of interleukin-6 in elderly patients with coronary artery disease complicated with heart failure].

OBJECTIVE: The aim of this study was to observe the concentrations of plasma interleukin-6(IL-6) in elderly patients with coronary artery disease(CAD). METHODS: Forty-eight CAD patients with heart failure, 15 CAD patients without heart failure, and 30 normal subjects were studied. The plasma concentration of interleukin-6(IL-6) was measured by enzyme-linked immunosorbent assay. RESULTS: The plasma concentration of IL-6 in CAD patients with heart failure was significantly higher than that without heart failure and normal subjects, respectively (P < 0.05). There was no significant difference between CAD patients without heart failure and normal subjects in the plasma levels of IL-6. There was a negative correlation between the concentration of IL-6 and left ventricular ejection fraction(LVEF) (r = -0.60, P < 0.01). The plasma concentration of IL-6 of the group with re-hospitalization because of severe heart failure was significantly higher than that of the group without hospital readmission (P < 0.01). CONCLUSION: The plasma concentration of IL-6 in CAD patients with heart failure may provide the important information for the severity of the disease and for the prognostic prediction in the disease.