Evaluation of anorectal function in patients with tethered cord syndrome: saline enema test and fecoflowmetry

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Object. Disturbance in anorectal function is a major factor restricting the activities of daily living in patients with spinal cord disorders. To detect changes in anorectal motilities due to a tethered spinal cord, anorectal functions were evaluated using a saline enema test and fecoflowmetry before and after patients underwent untethering surgery.

Methods. The bowel functions in five patients with a tethered cord syndrome (TCS) were evaluated by performing a saline enema test and fecoflowmetry. The contractile activity of the rectum, the volume of infused saline tolerated in the rectum, anal canal pressure, and the ability to evacuate rectal content were examined.

The characteristic findings in anorectal motility studies conducted in patients with TCS were a hyperactive rectum, diminished rectal saline-retention ability, and diminished maximal flow in saline evacuation. A hyperactive rectum was considered to be a major contributing factor to fecal incontinence. In one asymptomatic patient diminished anal squeezing pressure was exhibited and was incontinent to liquid preoperatively, but recovered after surgery. Two patients who underwent surgery for myeloschisis as infants complained of progressive fecal incontinence when they became adolescents. In one patient fecal incontinence improved but in another patient no improvement was observed after untethering surgery.

Conclusions. Fecodynamic studies allow the detection of neurogenic disturbances of the anorectum in symptomatic and also in asymptomatic patients with TCS. More attention should be paid to the anorectal functions of patients with TCS.

Article Information

Address reprint requests to: Hiroyuki Kayaba, M.D., Central Clinical Laboratory, Akita University Hospital, 1–1–1, Hondo, Akita 010–8543, Japan. email: kayaba@hos.akita-u.ac.jp.

© AANS, except where prohibited by US copyright law.

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    Case 1. Pressure fluctuations of the rectum and anal canal during saline enema test. A: Preoperatively no rectal contractions were observed. The anal canal could not maintain sufficient pressure above the rectum after 50 ml of saline was infused. After a 150-ml infusion of saline, the anal canal became completely flaccid, allowing saline to flow out when 250 ml was infused. The urge to defecate was absent. B: A series of rectal contractions synchronous with the relaxations of the anal canal (open circles) appeared after surgery. The patient first felt the urge to defecate when 150 ml of saline was injected. She experienced a strong urge at 350 ml and was continent at 500 ml.

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    Case 1. Fecoflowmetric curves before and after surgery. The fecoflowmetric curves obtained before (A) and after (B) untethering surgery were both classified as “segmental,” which is usually seen in patients with chronic constipation. The maximum flow rate reached 39.3 ml/second, and 471 of 500 ml of injected saline was evacuated postoperatively.

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    Case 5. Pressure fluctuations of the rectum and anal canal during saline enema test. At 9 years of age the patient could tolerate a 150-ml saline injection. A: A series of rectal contractions (open circles) accompanying relaxations of the anal canal were induced after a 120-ml saline infusion. B: At 13 years of age, when she noticed progressive leg weakness and worsening of urinary and fecal incontinence, a hyperactive rectum and lowered tolerable volume (60 ml) were exhibited. C: Tracings recorded 2 years after untethering surgery demonstrated no sign of a hyperactive rectum. Full relaxation of the anal canal accompanied by rectal contraction was seen after a 300-ml infusion of saline.

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    Case 5. Fecoflowmetric curves before and after surgery. Fecoflowmetric curves recorded at ages 9 years (A), 13 years (B) and 15 years (C). Deterioration of control of bowel movement was obvious by age 13 years (B). After untethering surgery improvement was shown (C), even though it was not satisfactory.

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    Comparison of saline enema test and fecoflowmetry parameters. The parameters in the saline enema test and fecoflowmetry are shown in box plots. Horizontal bars represent the 10th, 25th, 50th, 75th, and 90th percentiles from bottom to top in that order. The saline volume required to induce anal canal relaxation was significantly lower in the patients who underwent surgery for TCS (A) than in controls, as was the volume required to induce rectal contractions (B). In the patients a significantly lower volume could be tolerated before untethering surgery (C) than in controls. The maximum flow rate was significantly lower in the patients than in controls (D). *p < 0.05, **p < 0.01.

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