Analysis On Children Urodynamic Study With Tethered Cord Syndrome Before And After Operation

Tethered cord syndrome (TCS), attributed to occult spina bifida, spinal meningocele, spinal lipoma and spinal cord trauma was a common and severe congenital or acquired disease. It defined as incontinence, deformity of both lower extremities and sensory motor dysfunction in a clinical syndrome caused by ischemia and hypoxia of conus medullaris. With further research on TCS, the normal level conus medullaris (NLCM) type of TCS was becoming more and more familiar to us. Children of the special TCS type were occult tethered cord syndrome (OTCS),and the conus were ended at L2 vertebral body on MRI. Because of the pathological changes of filum terminal, the conus became ischemic and hypoxia, finally resulted in nerve lesion. The clinical manifestation of children with OTCS typically presented with neurogenic urinary incontinence that has been refractory to medical management, which was not similar to common TCS types. MRI examination was difficult to diagnose. It was the most likely kind of misdiagnosis and missed diagnosis. Urodynamic study could be the best auxiliary examination to it.Because the neurogenic bladder and urethral disfunction incidence caused by TCS was high to 90%, or even led to renal failure. So how to prevent upper urinary tract damage was an important management to maintain the child's life. The lower urinary tract function could be improved after operation, and the effect might be different between different types. The effect could be evaluated by urodynamic examination before and after operation.ObjectiveOur research use urodynamic technical to investigate the therapeutic effect of different types of TCS before and after operation, and evaluate the effect between different types; Analysis the urodynamic manifestation of children with NLCM (normal level conus medullaris) type of TCS, to investigate the diagnosis and treatment of it, in order to provide a reference for clinical diagnosis and treatment. Materials and methods1 Research object and methodsEight five children with TCS who were performed urodynamic studies in the Third Affiliated Hospital of Zhengzhou University during the period from June 2009 to January 2010 were included in the study. They were divided into 4 types according to MRI:①single meningocele;②liparomphalus:adipose tissue encasing spinal cord and cauda eguina, and adhering to dura mate of spinal cord;③normal level conus medullaris;④other types. Among children less than 3 years were 66 cases, and 19 cases of NLCM type. All cases were performed by urodynamic study preoperative and 3 or 6 months postoperative according to International Children Continence Society (ICCS).2 Statistical analysisThe data was calculated using(x±s). The mean of each group was compared by one-way ANOVA, random sample T-test, Spearman correlation from ranks. SPSS 13.0 was used for studies. There was a statistical significance whenα=0.05.Results1 UroflowThirty five children with TCS were followed with uroflow examnation,5～8a BC were (140±20) ml, maximum uroflow rate (Qmax) were(9.7±3.2) ml/s, children older than 8a were (260±35) ml, Qmax were(11.3±2.6)ml/s, compared to prediction BC (30×age+30) was smaller (P<0.05). The rest 66 cases 16 cases were measured uroflow rate, BC was (28.6±5.3) ml, Qmax was (5.2±1.3) ml/s, compared to the normal reference values was smaller (P<0.05).2 Cystometry-flow19.9%(13/66) of bladder compliance in children were lower (<20 ml/cmH2O) before operation,36 cases showed detrusor overactivity.19 cases with NLCM the first sensation BC were smaller, and the bladder compliance were lower,16 cases recovered after operation. Voiding detrusor pressure:19 NLCM type cases had normal detrusor pressure, there were no significant difference before and after surgery (P>0.05); 16 cases within 3-year-old had abdominal voiding pressure, the remaining 50 cases were about (37±23) cmH20, which were in the normal range; 23 patients improved after operation,4 cases aggravated.5 cases were measured detrusor leak point pressure (Desturor leak Point Pressure, DLPP), DLPP (35±16 cmH20) (34～67 cmH2O),3 cases DLPP≥40 cmH2O. Twenty cases had increased voiding detrusor pressure and uncoordinated contraction of detrusor sphincter, including upper urinary tract dysfunction occurred in 15 cases,7 patients improved after surgery.3 The maximum detrusor pressure (MaxPdet)The MaxPdet of Lipoma-type TCS before operation was lower than simple meningocele type, and the increased value after operation was also lower (P<0.05); the increased urodynamic indicators of various types of TCS 6 months after operation were higher than 3 months after operation (P<0.05). The increased compliance 6 months after operation of NLCM type were higher than 3 months after operation (P<0.05).Conclusions1 Urodynamics examination is an objective evaluation method to children with TCS before and after operation. Detrusor sphincter dyssynergy is the main reason to upper urinary tract damage. Urodynamic indicaters could be improved after operation, various types of tethered improvement targets will be different, single meningocele type and NLCM postoperative recovery after surgery are better. Compared with 3 months after operation, urodynamic indicators 6 months after operation could still recover. Disease duration was correlated to postoperative recovery.2 Diagnosis of TCS children with normal level conus medullaris should be based on clinical characteristic, physical and radiological examinations, MRI, and urodynamics test, the latter is the key index to it. When neurological signs accompany such changes, early severing of the filum is indicated regardless of conus position.