Currarino综合征的神经外科处理和效果分析

目的探讨Currarino综合征(CS)相关的神经外科疾病的处理方法和效果。方法回顾性分析2013年10月至2020年9月解放军总医院第七医学中心神经外科收治的19例CS患儿的临床资料。所有手术均采用骶部后正中入路。根据CS相关的神经外科疾病, 分别采用畸胎瘤切除术(11例)、骶前脊膜膨出手术(12例)和脂肪瘤切除手术(3例)治疗。17例合并脊髓拴系者均行脊髓拴系松解术。采用门诊或互联网随访评估临床症状的改善情况, 通过影像学随访评估病变的变化情况。结果 10例畸胎瘤、5例骶前脊膜膨出囊达到全切除, 3例脂肪瘤达到全切除或次全切除。术后骶部切口感染1例。所有患儿术后均随访2年, 5例术前存在顽固性便秘的患儿症状缓解, 其余14例患儿的症状无改变。末次MRI随访结果显示, 10例畸胎瘤囊性包块全切除后无复发, 1例有少量残留;5例骶前脊膜膨出囊全切除后无复发, 7例缩小>75%;3例患儿的脂肪瘤达到全切除或次全切除;合并脊髓拴系患儿的脊髓拴系均完全松解。结论对于CS患儿, 采用合适的手术方法处理CS伴随的神经外科疾患的效果满意, 并发症少, 复发率低, 能够部分改善患儿的症状。     

婴儿脂肪瘤型脊髓拴系综合征的手术治疗方法及疗效分析

目的 通过对125例婴儿脂肪瘤型脊髓拴系综合征临床数据分析,评价其显微外科治疗方法及疗效.方法 清华大学玉泉医院医院自2004年1月至2012年1月收治并有效随访的婴儿脂肪瘤型脊髓拴系125例,患者术前均行神经系统、MRI、残余尿及神经电生理检查,术中在电生理监测下行显微外科手术治疗.疗效评估分为近期疗效和远期疗效,近期疗效根据Hoffman功能性分级、Kirollos术中松解分级和并发症评估,远期疗效根据临床表现、MRI、膀胱残余尿和神经电生理结果进行评估.统计学通过SPSS16.0分析处理数据.结果 近期随访:按Kirollos术中松解分级评定方法:108例(86.4％)达到Ⅰ级,13例(10.4％)达到Ⅱ级,4例(3.2％)为Ⅲ级;发生并发症14例,占11.2％.远期随访:根据Hoffman功能性分级:术后无症状组、轻度症状组症状组在术前和术后差异有统计学意义(P＜0.05),中度症状组、重度症状组在术前术后差异无统计学意义(P＞0.05);膀胱残余尿检查在术前和术后差异有统计学意义(P ＜0.05);MRI检查未发现脂肪瘤复发病例;神经电生理检查在术前和术后差异有统计学意义(P＜0.05).结论 婴儿脂肪瘤型脊髓拴系综合征的显微治疗可获得较好的疗效,术中神经电生理监测可提高手术安全性.     

儿童与成人脂肪瘤型脊髓拴系综合征的疗效对比性分析

目的通过对611例脂肪瘤型脊髓拴系综合征临床数据分析,比较儿童与成人脂肪瘤型脊髓拴系综合征的显微外科治疗疗效。方法清华大学玉泉医院自2004年1月-2010年1月收治并有效随访的脂肪瘤型脊髓拴系611例,分为儿童组和成人组,患者术前均行神经系统、MRI、残余尿及神经电生理检查,术中在电生理监测下行显微外科手术治疗。疗效评估分为近期疗效和远期疗效,近期疗效根据Hoffman功能性分级、Kirollos术中松解分级和并发症评估;远期疗效根据临床表现、MRI、膀胱残余尿和神经电生理结果进行评估。根据这些指标比较儿童组与成人组间的疗效差异。统计学通过SPSS16.0分析处理数据。结果近期随访：根据Hoffman功能性分级：术后改善的患者在儿童组和成人组间有明显差异（P〈0.05）,术后稳定的患者在在儿童组和成人组间无明显差异（P〉0.05）,术后加重的患者在儿童组和成人组间有明显差异（P〈0.05）;按Kirollos术中松解分级评定方法：Ⅰ级的患者在儿童组和成人组间有明显差异（P〈0.05）,Ⅱ级的患者在儿童组和成人组间有明显差异（P〈0.05）,Ⅲ级的患者在儿童组和成人组间有明显差异（P〈0.05）;儿童组发生并发症比成人组少。远期随访：膀胱残余尿减少的患者在儿童组和成人组间有显著性差异（P〈0.05）;MRI检查在儿童组和成人组间均未发现脂肪瘤明显复发病例;神经电生理改善的患者在儿童组和成人组间有显著性差异（P〈0.05）。结论儿童脂肪瘤型脊髓拴系综合征的显微治疗比成人可获得更好的疗效。     

脊髓拴系综合征14例报告

脊髓拴系综合征(Tet hered spinal cordsyndrome)是一组发育畸形,包括脊髓圆锥被一种或几种硬膜内异常病变拴系,如粗短的终丝、纤维粘连、脊髓脊膜膨出、硬膜内脂肪瘤及脊髓纵裂畸形等。我院1973～1986年经手术治疗不同类型的囊性脊柱裂35例,其中伴有脊髓拴系综合征者14     

儿童脊髓栓系综合征的显微外科治疗

目的探讨儿童脊髓栓系综合征的临床特点、治疗方法和预后。方法回顾性分析21例脊髓栓系病儿的临床资料,均在显微镜下行脊髓栓系松解手术。结果 21例病儿成功行脊髓栓系松解术。MRI提示脂肪瘤大部分切除。术后随访3个月~3年,症状均有改善。结论儿童脊髓栓系早期手术治疗能取得较好的预后,待病儿出现明显并发症后再手术的效果较差。     

脊柱裂合并尿失禁手术治疗（368例临床分析）

本文报道采用改进的手术方法治疗368例脊柱裂合并尿失禁的经验。改进的手术包括由脊柱裂上下扩大椎板切除范围,切除压迫脊髓、马尾的各种病理性组织,切除存在的脂肪瘤、脊髓脊膜膨出囊、囊肿,切断牵张的终丝,仔细分解游离圆锥、马尾、解除脊髓拴系,以恢复其血运与神经功能。基本治愈与显效208例,占56.52%;好转128例,占34.78%;无效32例,占8.7%。初次手术者较再次手术者效果好。对复杂病例,采用显微手术方法,有利提高疗效。     

手术治疗儿童无症状脂肪瘤型脊髓拴系的Meta分析

目的评价预防性手术治疗儿童无症状脂肪瘤型脊髓拴系的风险和意义。方法在PubMed、Embase、Scopus、Web of Science、Cochrane databases数据库中检索手术治疗和单纯随访的儿童无症状脂肪瘤型脊髓拴系的相关研究,采用RevMan5．3和R软件对数据进行合并分析。结果共纳入5篇非随机临床对照试验的文献,合计403例患者,总随访时间为4．4～10．0年。其中单纯随访组124例,发生神经功能障碍者32例（25．8％）;手术组279例,发生神经功能障碍者30例（10．8％）,差异有统计学意义（P=0．05）。同时检索到9篇单纯手术的文献（278例）和1篇观察自然史的文献（56例）。合并统计单纯手术的9篇文献,采用随机效应模型计算术后神经功能障碍的发生率为10．0％,与随访组的28．6％（16／56）比较,差异有统计学意义（P〈0．01）。结论对于儿童无症状脂肪瘤型脊髓拴系,目前有限的文献资料支持预防性手术可以使患儿获益,今后尚需要更大样本的循证医学证据。     

骶尾部脊髓脂肪瘤的手术技巧

目的 介绍骶尾部脊髓脂肪瘤的病理解剖及相应的手术技巧.方法 2005年9月至2012年1月,上海儿童医学中心手术治疗骶尾部脊髓脂肪瘤119例,年龄1个月至18岁,神经系统症状有大小便失禁和(或)双下肢功能障碍.手术方法包括:切除皮下和椎管内脊髓外的脂肪瘤,脊髓内的脂肪瘤大部分切除,将脊髓从两侧硬脊膜上剪开,圆锥从硬脊膜囊末端剪开并分离下来,松解脊髓栓系.结果 骶尾部脊髓脂肪瘤主要病理解剖与腰骶部脊髓脂肪瘤相似,不同之处在于圆锥生长在末端硬膜囊上,圆锥发出的脊神经从圆锥腹侧斜向下方发出,脂肪瘤仅生长到脊髓内,并未生长到脊髓下方的脊神经内.108例得到随访,随访时间0.5～7.0年.术前有症状的患儿,术后多数有不同程度改善,1例症状加重,6例术后症状一过性加重;10例无症状者术后9例仍然无症状,1例症状一过性加重.结论 只有充分认识骶尾部脊髓脂肪瘤病理解剖,才能最大限度地切除脂肪瘤,彻底解除脊髓栓系,同时又能避免神经损伤,重建脊髓的正常解剖结构,最大限度恢复神经功能.     

显微松解术治疗儿童脊髓栓系综合征疗效分析

目的 总结分析儿童脊髓栓系的显微松解手术效果.方法 西安西京医院2007年1月至2011年12月收治脊髓圆锥和马尾部神经症状患儿80例.MRI显示全部病例伴有腰骶椎板缺如、脊髓低位、终丝增粗、脊髓末端占位.接受脊髓栓系松解手术(包括脊膜膨出囊和腰骶椎管内病变切除),28例患儿术中获得脊髓圆锥和马尾神经电生理监测,术后对67例患儿随访.结果 患儿术后住院期内自述症状缓解或减轻者69％ (55/80).大、小便异常的患儿中,术后改善者占62％(40/65);下肢感觉、运动以及发育和营养症状40例中,18例术后早期下肢感觉功能好转(45％),11例运动障碍出现改善(28％).随访时大小便功能较术前明显改善者占79％ (45/57);下肢感觉和运动障碍较术前明显改善者占63％ (22/35);术中接受脊髓圆锥和马尾神经电生理监测的患儿,比未接受监测者,自评症状改善率明显增加.结论 显微分离技术和神经电生理监测手段,是保障松解手术效果的关键因素.     

小儿先天性神经管闭合不全的MRI诊断分析

目的探讨分析小儿先天性神经管闭合不全的MRI特征及临床表现,提高对该疾病的诊断能力。方法回顾性分析经手术病理或随访证实21例神经管闭合不全病儿的临床和影像学资料。结果 21例神经管闭合不全病儿MRI上多合并畸形改变,主要表现为脊髓脊膜膨出7例,脊膜膨出6例,脂肪型脊髓脊膜膨出8例,其中合并脊髓拴系综合征11例,脊髓纵裂2例,脊髓空洞积水2例,椎管内脂肪瘤4例,髓外硬膜内囊肿1例;伴发其他畸形4例。MRI诊断与手术病理或随访诊断符合率为90.5%(19/21)。结论 MRI可以对先天性神经管闭合不全进行良好的定位及定性诊断,具有较大临床应用价值。     

Surgical treatment of complex spinal cord lipomas

Purpose

This paper shows the long-term benefits of total/near-total resection of complex spinal cord lipomas and meticulous reconstruction of the neural placode, and specifically, its advantage over partial resection, and over non-surgical treatment for the subset of children with asymptomatic virgin lipomas.

Methods

The technique of total resection and placode reconstruction, together with technical nuances, are described in detail. We added 77 patients with complex lipomas to our original lipoma series published in 2009 and 2010, to a total of 315 patients who had had total or near-total resection and followed for a span of 20 years. Long-term outcome is measured by overall progression-free survival (PFS) with the Kaplan–Meier analysis, and by subgroup Cox proportional recurrence hazard analysis for the influence on outcome of 4 predictor variables of lipoma type, presence of symptoms, prior surgery, and post-operative cord–sac ratio. These results are compared to an age-matched, lesion-matched series of 116 patients who underwent partial lipoma resection over 11 years. The results for total resection is also compared to two large published series of asymptomatic lipomas followed without surgery over 9 to 10 years, to determine whether prophylactic total resection confers better long-term protection over conservative treatment for children with asymptomatic lipomas..

Results

The PFS after total resection for all lipoma types and clinical subgroups is 88.1 % over 20 years versus 34.6 % for partial resection at 10.5 years (p?<?0.0001). Culling only the asymptomatic patients with virgin (previously unoperated) lipomas, the PFS for prophylactic total resection for this subgroup rose to 98.8 % over 20 years, versus 67 % at 9 years for one group of non-surgical treatment and 60 % at 10 years for another group of conservative treatment. Our own as well as other published results of partial resection also compare poorly to non-surgical treatment for the subset of asymptomatic virgin lipomas. Multivariate subgroup analyses show that cord–sac ratio is the only independent variable that predicts outcome, with a 96.9 % PFS for ratio <30 % (loosest sac), 86.2 % for ratio between 30 and 50 %, and 78.3 % for ratio >50 % (tightest sac), and a threefold increase in recurrence hazard for high ratios (p?=?0.0009). Pre-operative patient profiling using multiple correspondence analysis shows the ideal patient for total resection is a child less than 2 years old with a virgin asymptomatic lipoma, who, with a PFS of 99.2 %, is virtually cured by total resection.

Conclusion

Total/near-total resection of complex lipomas and complete reconstruction of the neural placode achieves far better long-term protection against symptomatic recurrence than partial resection for all lesions; and for the subset of asymptomatic virgin lipomas, also better than non-surgical treatment. Partial resection in many cases produces worse outcome than conservative treatment for asymptomatic lesions.     

Ultrasound measurement of lumbosacral spine in children

The aim of this study was to establish normal ultrasound measurements of lumbosacral spine in children as a screening assessment of tethered cord or postoperative retethering of cord. Sonography of lumbosacral spine was performed in 108 neurologically normal children (mean age = 2.1 years) using 5- to 12-MHz linear transducer. M-mode was applied at the posterior and anterior subarachnoid spaces just below the conus medullaris and at the L(5)/S(1) dural sac to document cerebrospinal fluid pulsation of the cauda equina. The oscillation rate and amplitude were measured. Sixteen children with spinal cord anomalies (6 with low tethered cord and 10 postoperative cases of low tethered cord) were also examined. The mean posterior/anterior subarachnoid spaces of normal children were 2.6 mm/1.8 mm at the terminal dural sac. The mean oscillation amplitude and rate of the cauda equina were 0.52 mm and 121/min at the L(5)/S(1) dural sac. The oscillation amplitude at this level demonstrated a statistically significant difference between normal and abnormal groups. In conclusion, we recommend taking the fifth percentile of the normal oscillation amplitude at the L(5)/S(1) dural sac as a reference. Any oscillation amplitude of less than 0.3 mm in a symptomatic patient should alert the clinician to possible cord abnormality, cord tethering, or retethering in postoperative cases.     

Occult spinal dysraphism: lessons learned by retrospective analysis of 149 surgical cases about natural history, surgical indications, urodynamic testing, and intraoperative neurophysiological monitoring

Purpose

Prophylactic surgery is indicated for lipoma of the filum, while it is still debated for the conus lipomas and more complex tethering malformations of the cord.

Methods

We retrospectively reviewed the preoperative and postoperative clinical histories and long-term outcomes of 149 operated patients (33 adults, 116 children). Intraoperative neurophysiological monitoring (NPM) was utilized since 1998. Their malformative lesions were reclassified following recent Pang’s embryological criteria for surgical complexity. In nine cases, the spinal tethering malformation was associated with an anorectal malformation (ARM) and in nine with a Chiari I malformation (CM1).

Results

One hundred nineteen (80 %) patients were symptomatic at the time of surgery, 66 (44 %) having presented with progressive preoperative deterioration. Postoperative surgery-related deterioration was observed in 6 % of the cases operated on under the intraoperative NPM control. Surgery did not improve any deficit, especially of sphincter functions, independently from the type of associated malformation (ARM, CM1). Urodynamic testing was a reliable predictor both in the preoperative and in the follow-up period of subsequent neurological deterioration. In the long-term follow-up, an increasing percentage of retethering was observed, especially concerning complex cases submitted to partial excision. The surgical risk increased with repeated operations.

Conclusions

This study demonstrates that the rate of the natural deterioration associated with a conservative approach is higher than in patients operated on prophylactically, if the operation is performed by a team with a special expertise. However, the first surgical procedure should be aimed at detethering the conus completely, with the aid of intraoperative NPM; even in expert hands, it is associated with a high risk of clinical deterioration. Based on these results, we are increasing the percentage of children to whom surgery is offered when still asymptomatic as well as the degree of the lipoma excision to prevent retethering. However, in cases of rethetering and subjects presenting in adult age, we suggest to consider for surgery only those symptomatic. Urodynamic testing and magnetic resonance imaging in prone position were, in our experience, the best tools for screening those patients at risk of symptomatic retethering.     

Introduction of a urodynamic score to detect pre- and postoperative neurological deficits in children with a primary tethered cord

OBJECT: An increasing number of asymptomatic children are diagnosed with occult spinal dysraphism, raising the question of their optimal management. Urodynamic study (UDS) is the most reliable method of detecting neuro-urological abnormalities in these children. The rate of postoperative retethering ranges from 10 to 20% and is not always immediately clinically significant. The aim of this prospective study was to develop a reliable method that could be used in the preoperative assessment and postoperative follow-up of children with a tethered cord syndrome (TCS). METHODS: From 1989 to 1997, 15 children underwent spinal cord untethering for TCS. Preoperatively, patients were assessed with MRI and UDS. Postoperative UDS were repeated at 6- to 12-month intervals. Four UDS parameters were identified, graded, and added to obtain a UDS score. A group of 38 children without dysraphic condition was used as control and allowed the calculation of a normal score. CONCLUSIONS: There was a statistically significant difference in the preoperative UDS scores between the control group and the study group ( p<0.001). Postoperatively, there was a statistically significant improvement ( p<0.001) in UDS scores. UDS score is a reliable tool for identifying and quantifying neuro-urological disorders in patients with TCS. Postoperatively, this score was useful in the early diagnosis of spinal cord retethering.     

胎儿MRI对椎管内脂肪瘤产前诊断及预后评估的价值

目的探讨胎儿MRI对椎管内脂肪瘤产前诊断及其治疗方案选择的价值。方法回顾分析18例胎儿期诊断为椎管内脂肪瘤患儿的临床资料。分析比较产前超声和胎儿MRI与出生后MRI的诊断符合率;统计分析患儿的症状、体征及脂肪瘤类型,总结胎儿期发现椎管内脂肪瘤及其处理的经验。结果本组18例患儿中,以出生后MRI为标准,产前超声正确诊断9例(50%),胎儿MRI正确诊断13例(72.2%),两者诊断符合率的差异有统计学意义(P=0.029)。根据出生后MRI及手术中所见,其中混杂型脂肪瘤6例、尾侧型脂肪瘤5例、移行型脂肪瘤4例、背侧型脂肪瘤3例。出生后存在症状的患儿5例,均为混杂型脂肪瘤。其中17例患儿行手术切除椎管内脂肪瘤,1例混杂型脂肪瘤患儿因无症状予以观察随访。结论胎儿MRI对椎管内脂肪瘤的产前诊断比超声检查更有优势。胎儿MRI能够从多角度、多层次进行观察,对椎管内脂肪瘤的大小、形态、位置及其与脊髓神经的关系显示更清晰,对脊髓圆锥位置的判断更准确,对椎管的显示更直观。对于没有症状的混杂型脂肪瘤患儿可以选择暂时观察,待出现症状后再考虑手术;其他所有类型的脂肪瘤以及存在症状的混杂型脂肪瘤均应选择早期手术治疗。     

Congenital lumbosacral lipomas

Congenital lumbosacral lipomas can be responsible for progressive defects. The general feeling is that tethering of roots, filum, or cord probably explains this evolution, and that untethering of these structures could prevent late deterioration. Like the vast majority of neurosurgeons, we too have routinely and systematically operated on lumbosacral lipomas, even in the absence of neurological deficits. This policy stemmed from our belief that spontaneous neurological deterioration was frequent, recovery from preoperative deficits rare, and surgery both efficient and benign in nature. After 22 years of experience, we felt that it was necessary to review our series of 291 lipomas (38 lipomas of the filum and 253 of the conus) operated on from 1972 to 1994. To reassess the value of pro-phylactic surgery, we attempted an accurate evaluation of (1) the risk of pathology, (2) the risks involved in surgery, (3) the postoperative outcome with respect to preoperative deficits, and (4) the postoperative outcome in asymptomatic patients at 1 year and at maximum follow-up. Special attention was paid to 93 patients whose postoperative follow-up was more than 5 years (average 8.7, median 8, range 5–23 years). Of these 93 patients, 39 were asymptomatic preoperatively (7 with lipoma of the filum and 32 with lipoma of the conus). Lipomas of the filum and of the conus are entirely different lesions and were studied separately. In 6 cases prenatal diagnosis had been possible. The mean age at surgery was 6.4 years. Low back skin stigmata were present in 89.4% of cases. Preoperative neurological deficits existed in 57% of the patients and were congenital in 22%. Clinical signs and symptoms recorded were pain in 13.3% of the patients and/or neurological deficits affecting sphincter (52%), motor (27.6%) and sensory (22.4%) functions. Deficits were progressive in 22.4% of cases, slowly progressive in 58.8% of these and rapidly progressive in the remaining 41.2%. In 36 patients (13.2%) the lipomas were seen to grow either subcutaneously or intraspinally. Among these patients, 21 were infants, 2 were obese adolescents, and 10 were pregnant women. The metabolism of the fat within the lipomas was studied in 11 patients and found to be similar to that at other sites. Lipomas were associated with various other malformations, either intra- or extraspinal. These associated anomalies were rare in the case of lipomatous filum (5.2%) but frequent with lipomas of the conus, except for intracranial malformations (3.6%). Therapeutic objectives were spinal cord untethering and decompression, sparing of functional neural tissue and prevention of retethering. Procedures used to achieve these goals were subtotal removal of the lipoma, intraoperative monitoring, duroplasty, and sometimes closure of the placode. Histologically, lipomas consisted of normal mature fat. However, 77% of them also included a wide variety of other tissues, originating from ectoderm, mesoderm, or entoderm. This indicates that lipomas are either simple or complex teratomas. The results of the study are as follows. (1) Surgery was easy and safe when performed for treatment of lipomas of the filum (no complications), but difficult and hazardous in the case of lipomas of the conus (20% local, 3.9% neurological complications). (2) All types of deficit could be improved by surgery, which was beneficial in all cases of lipoma of the filum and 50% of cases of lipoma of the conus. (3) In asymptomatic patients long-term surgical results depended on the anatomical type of the lipoma. They were excellent in lipomas of the filum. In lipomas of the conus they were good in the short term but eroded with time. At more than 5 years of follow-up only 53.1% of the patients were still free of symptoms. (4) Reoperations were performed in 16 patients (5.5%), 5 (31.2%) of whom improved postoperatively, while in 7 (43.7%) progression stopped, in 3 (18.7%) deterioration continued and in 1 (6.2%) the condition was worse after surgery. (5) The natural history of the malformation, that is to say the risk of spontaneous aggravation, has only been evaluated in hospital in-patients, so that the true level of risk remains unknown. This means we cannot interpret the actuarial curve following surgery for asymptomatic lipoma of the conus. In conclusion, there are two different types of lipoma: lipoma of the filum, for which surgery is harmless and beneficial in both the short and the long term, and lipoma of the conus, for which surgery involves considerable risks and is of questionable benefit in the long term. This raises the question as to whether prophylactic surgery is indicated for patients with asymptomatic lipomas of the conus, and whether the outcome is any better than it would be if the lipoma were left to take its natural course. The lack of basic information remains a stumbling block to management of these patients. Until this is remedied, we are unable to recommend prophylactic surgery in patients with asymptomatic lipomas of the conus. Received: 25 November 1996     

Incidence of symptomatic retethering after surgical management of pediatric tethered cord syndrome with or without duraplasty

Background  Cord retethering and other postoperative complications can occur after the surgical untethering of a first-time symptomatic tethered cord. It is unclear if using duraplasty vs. primary dural closure in the initial operation is associated with decreased incidence of either immediate postoperative complications or subsequent symptomatic retethering. It is also unclear if different etiologies are associated with different outcomes after each method of closure. We reviewed our pediatric experience in first-time surgical untethering of symptomatic tethered cord syndrome (TCS) to identify the incidence of postoperative complications and symptomatic retethering after duraplasty vs. primary closure. Materials and methods  We retrospectively reviewed 110 consecutive pediatric (<18 years old) cases of first-time symptomatic spinal cord untethering at our institution over a 10-year period. Incidence of postoperative complications and symptomatic retethering were compared in cases with duraplasty vs. primary dural closure use. Results  Mean age was 5.7 ± 4.8 years old. “Complex” etiologies included lipomyelomeningocele or prior lipomyelomeningocele repair in 22 (20%) patients, prior myelomeningocele repair in 35 (32%), and concurrent lumbosacral lipoma in 18 (16%). “Noncomplex etiologies” included fatty filum in 26 (24%) and split cord malformation in five (4%). Seventy-five (68%) cases underwent primary dural closure vs. 35 (32%) with duraplasty. Twenty-nine (26%) patients experienced symptomatic retethering at a median [interquartile range (IQR)] of 30.5 [20.75–41.75] months postoperatively. There was no difference in incidence of postoperative cerebrospinal fluid leak, surgical site infection, or median [IQR] length of stay in patients receiving primary dural closure [4 (5%), 7 (9%), and 5 (4–6) days, respectively] vs. duraplasty [3 (9%), 3 (9%), and 6 [5–8] days, respectively], p > 0.05. Complex etiologies were more likely to retether than noncomplex etiologies after primary closure (33.6% vs. 6.6%, p = 0.05) but not after duraplasty (13.7% vs. 5.4%, p = 0.33). Duraplasty graft type (polytetrafluoroethylene vs. bovine pericardium) was not associated with pseudomeningocele or retethering. Conclusion  In our experience, the increased rate of symptomatic retethering observed with complex pediatric TCS (pTCS) etiologies after primary dural closures was not observed when duraplasty was instituted. Expansile duraplasty may be valuable specifically in the management of patient subgroups with complex pTCS etiologies.     

Magnetic resonance imaging of the spine in children

We reviewed the magnetic resonance imaging (MRI) scans of the spine of 42 children who had neurologic signs compatible with lesions of the spinal cord. Twenty-three of the children had abnormalities identified by MRI. The spectrum of abnormalities included posttraumatic lesions, tumor, tethered cord, and syringohydromyelia. Tethered cord with or without lipoma and syringohydromyelia were the most common findings, affecting six and four children, respectively. Thirteen children studied by MRI also underwent conventional metrizamide myelography and/or computed tomography. In 12 cases, the findings of MRI were comparable to those of myelography and computed tomography. These observations indicate that MRI effectively detects lesions of the spinal cord in children. Because MRI can be performed on an outpatient basis and avoids the risks of metrizamide myelography, we conclude that MRI should be considered to be the preferred screening technique for children with suspected spinal cord disorders.     

Magnetic resonance imaging of lumbosacral lipomas in infants

Magnetic resonance imaging (MRI) was conducted on infants with lumbosacral lipomas. Based on Chapman's classification (1982), these MRIs were classified into three representative types: caudal, dorsal and transitional. As confirmed by intraoperative observations, the relation between the lipomas and the spinal cord was clearly disclosed in the preoperative MRI. However, in the dorsal type, the intraoperative view of the margin between the lipomas and spinal cord was different from the MRI findings. Postoperative MRI disclosed the existence of residual lipomas and the change in the low conus medullaris. Moreover, preoperative and postoperative changes in the hydromyelia could be observed.     

32例颈髓肿瘤显微外科治疗研究

目的 探讨颈髓肿瘤的诊断、手术入路选择及手术操作技巧.方法 回顾性分析湘雅二院神经外科自2003年6月至2005年6月经手术治疗的32例颈髓肿瘤患者的临床资料.所有患者均经术前MRI确诊,经显微手术切除,术后均行MRI复查.结果 手术显微镜下全切肿瘤29例,大部分切除3例,其中2例为星形细胞瘤,1例为脂肪瘤.术后无神经功能障碍加重及死亡者.结论 MRI对颈髓肿瘤的诊断具有最重要的价值.据此可以明确肿瘤的大致类型、位置及毗邻关系.选择合适的手术入路.显微外科手术是治疗颈髓肿瘤的有效方法,熟练应用显微外科技术和手术操作技巧是治疗成功的关键因素.