Case: 05
Category: Spinal Dysraphism
2017-08-09 10:34:39
Tethered cord syndrome
Description
lpmmc
1. No need to investigate with MRI in neonatal period if the skin is healthy and no neurological deficit
2. No need of local USG since its operator dependent and even when the lesion is picked up we still do MRI Scan . X-rays would just tell about the spina bifida it does not tell about the intradural patholgy . Ct scan is inferior in detecting the pathology and also exposes the child to radiation So Mri Remains the investigation of choice ideal if I see a child before 1 months we get MRI by 4-5 Months age . we need to reassure the parents no harm happens while waiting.
3 When the child starts sitting with support and without support is the time when the spinal cord starts taking the irreversible damage due to the movements of the trunk. so elective detethering to be done by 6 months
4. Detethering surgery is a major undertaking and child has to be fit to undergo surgery lasting more than two hour, blood loss . also during the post op period is CSF leak happens the child should have enough reserve to come out of the same so we wait till 6 months or atleast 7kgs
5. It is not right to wait till deficit develops, as deficit is rarely reversible. Surgery must be done before deficit develops
6. In a child without deficit, there is little risk of post-op deficit. There may be temporary neurogenic bladder.
7. These children almost never develop hydrocephalus post-op, rarely have hydrocephalus pre-op. Without clinical suspicion ,it is not necessary to do MRI of head . also there is no chiari herniation in lipomeningomyelcocole since the embryologically the defect happens in secondary neurulation and meninigomyelocole is defect that happens is primary neurulation
8. In addition to excision of lipoma, one require division of filum terminale and lysis of adhesions between cord and dura to complete the detethering surgery rather than excision of the subcutaneous lipoma that will make the things worse.