Spinal column shortening for tethered cord syndrome: a systematic review and individual patient data meta-analysis

Luke G. McVeigh BS1, Miracle C. Anokwute MD1, Sixia Chen PhD2, and Andrew Jea MD, MBA, MHA3
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  • 1 Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana;
  • | 2 Department of Biostatistics and Epidemiology, College of Public Health, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma; and
  • | 3 Division of Pediatric Neurosurgery, Oklahoma Children’s Hospital, Department of Neurosurgery, The University of Oklahoma College of Medicine, Oklahoma City, Oklahoma
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OBJECTIVE

Tethered cord release (TCR) is the gold standard treatment for tethered cord syndrome (TCS); however, there are significant shortcomings including high rates of retethering, especially in complex and recurrent cases. Spinal column shortening (SCS) is an alternative treatment for TCS intended to avoid these shortcomings. Early studies were limited to case reports and smaller case series; however, in recent years, larger case series and small cohort studies have been conducted. Given the increase in available data, a repeat systematic review and meta-analysis is warranted to assess the safety and efficacy of SCS for TCS.

METHODS

The authors conducted a systematic review using MEDLINE (OVID), Embase (Elsevier), and Web of Science records dating from 1944 to July 2021 to identify all articles investigating SCS for TCS. They performed standard and individual patient data (IPD) meta-analyses, with 2 independent reviewers using PRISMA-IPD guidelines. Primary outcomes were improvement of preoperative clinical symptoms of pain, motor weakness, and bladder and bowel dysfunction, and also surgical complication rate. Secondary outcomes included urodynamic improvement and health-related quality-of-life outcomes determined using patient-reported outcome tools. Individual study quality assessment was performed using a standardized assessment tool for case reports/series, and publication bias was assessed using funnel plot analyses.

RESULTS

The review yielded 15 studies with 191 cases of TCS treated with SCS. IPD were available in 11 studies with 89 cases. The average age at time of surgery was 28.0 years (range 5–76 years). The average follow-up time was 33.2 months (range 7–132 months). Improvement was observed at last follow-up in 60 of 70 (85.7%) patients with preoperative pain, in 38 of 60 (60.3%) patients with preoperative weakness, and in 36 of 76 (47.4%) patients with preoperative bladder or bowel dysfunction. Complications of CSF leak, new neurological deficit, wound infection, or reoperation occurred in 4 of 89 (4.5%) patients.

CONCLUSIONS

SCS may be considered a safe and efficacious treatment option for TCS in children and adults (level C evidence; class IIb recommendation), especially for recurrent and complex cases. Current evidence is likely to be affected by selection and publication bias. Prospective comparative studies of SCS and TCR for TCS are recommended to determine long-term duration of outcomes, long-term safety in skeletally immature children, and exact indications of SCS versus traditional TCR.

ABBREVIATIONS

GRADE = Grading of Recommendations, Assessment, Development and Evaluation; HRQOL = health-related quality of life; HSAD = homogeneous spinal-shortening axial decompression; IPD = individual patient data; JOA = Japanese Orthopaedic Association; PRO = patient-reported outcome; PSO = pedicle subtraction osteotomy; SCS = spinal column shortening; TCR = tethered cord release; TCS = tethered cord syndrome; VAS = visual analog scale; VCR = vertebral column resection; VCS = vertebral column subtraction.

Supplementary Materials

    • Supplemental Tables and Figure (PDF 1,247 KB)

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