Prevention of Tethered Cord Syndrome Combined with Myelomeningocele

Introduction Childbirth with open spinal dysraphic change is a fact associated with the social, personal, or religious factors. One of the main problems that the neurosurgeon must resolve is related to the protection of the neural tissue from further damage during the early postnatal period, or at a later age, with the development of ischemic and mechanical damage due to tethering effect.

Aim To analyze the factors leading to further damage of the nerve elements, to summarize known-to-date solutions, and to present new technical solutions.

Material and Methods In the period from 2010 to 2015, 25 children (10 girls and 15 boys) with open spinal dysraphic disorder were operated in Tokuda Hospital, Sofia. Up to 72 hours of birth, 7 children were operated, up to 1 month 10 children were operated, and after more than a month 8 children were operated. Operative technic is standardized—dissection of cystic defect, release and reconstruction of the neural plaque, hermetic closure of the dural defect, and reconstruction of the vertebral canal and the soft tissues. In the cases with delayed neurosurgical treatment, the nervous plate is sealed (but responsible to neurostimulation) that makes it difficult to reconstruct and to be released and integrated in the CSF spaces; in those cases, we expand the dural sac with lyophilized pericardium, and we seal the line of suturing with fibrin glue. When the reconstruction is not possible and a large cystic defect with a tethering effect is present, we performed a one or two levels laminectomy to the cranial 1–2 and we suture the neural plate to the rostral end of the enlarged dural defect. In some of the cases, we use a single strips of pericardium fixed to the tops of the malformated vertebral arches to achieve modelling of the vertebral canal. We cover the bone defect with a flap of lumbosacral fascia layer by layer with subsequent recovery of soft tissue defect.

Results Postoperatively, no additional neurological deterioration, no liquorrhea, and no mortality were observed.

Conclusion The dysraphic disorders are characterized by the development of different disorders of the distal section of the spine cord, the meninges, and the structure of the spine. The combination of progressive dysfunction, paraparesis inferior, incontinence/retention, deformities, atrophy, spine pain syndrome, and the typical MRI and CT scan result is very important for the proper diagnosis.

Keywords myelocelle; tethered cord effect; surgical treatment; results