J Korean Neurosurg Soc.  2020 May;63(3):358-365. 10.3340/jkns.2020.0072.

Urological Evaluation of Tethered Cord Syndrome

• Park K

• KMID: 2501723
• DOI: http://doi.org/10.3340/jkns.2020.0072

Abstract

To describe how to perform urological evaluation in children with tethered cord syndrome (TCS). Although a common manifestation of TCS is the development of neurogenic bladder in developing children, neurosurgeons often face difficulty in detecting urological problems in patients with TCS. From a urological perspective, diagnosis of TCS in developing children is further complicated due to the differentiation between neurogenic bladder dysfunctions and transient bladder dysfunctions owing to developmental problems. Due to the paucity of evidence regarding evaluation prior to and after untethering, I have shown the purpose and tools for evaluation in my own practice. This may be tailored to the types of neurogenic bladder, developmental status, and risks for deterioration. While the urodynamic study (UDS) is the gold standard test for understanding bladder function, it is not a panacea in revealing the nature of bladder dysfunction. In addition, clinicians should consider the influence of developmental processes on bladder function. Before untethering, UDS should reveal synergic urethral movement, which indicates an intact sacral reflex and lack of TCS. Postoperatively, the measurement of post-void residual urine volume is a key factor for the evaluation of spontaneous voiders. In case of elevation, fecal impaction, which is common in spinal dysraphism, should be addressed. In patients with clean intermittent catheterization, the frequency-volume chart should be monitored to assess the storage function of the bladder. Toilet training is an important sign of maturation, and its achievement should be monitored. Signs of bladder deterioration should be acknowledged, and follow-up schedule should be tailored to prevent upper urinary tract damage and also to determine an adequate timing for intervention. Neurosurgeons should be aware of urological problems related to TCS as well as urologists. Cooperation and regular discussion between the two disciplines could enhance the quality of patient care. Accumulation of experience will improve follow-up strategies.

Keyword

Neural tube defects; Urodynamics; Spinal dysraphism; Urinary bladder, Neurogenic

Figure

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  Fig. 1. Urodynamic assessment classifies a neurogenic bladder into four types. Relevant consequences and management are also described. In accordance with the sites of dysfunction, four subtypes can be identified. A : Both sphincter and detrusor are underactive. B : The sphincter is overactive and detrusor is also overactive. C : Both sphincter and detrusor are underactive. D : Sphincter is underactive but detrusor is overactive. Adopted from Verpoorten and Buyse [9]. DSD : detrusor sphincter dyssynergia, CIC : clean intermittent catheterization.

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  Fig. 2. Follow-up protocol applied to patients after initial untethering to adults. Due to various manifestations and time courses, there is no “one size fits all” follow-up scheme and evaluation process should be tailored according to the conditions. For rationale and detailed scheme, please refer to the manuscript. PVR : postvoid residual urine, UFM : uroflowmetry, USG : ultrasonography of kidney and bladder, UDS : urodynamic study, FVC : frequency volume chart, KUB : simple radiography of kidney, ureter and bladder.

Reference

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