Filum Section for Urinary Incontinence in Children with Occult Tethered Cord Syndrome: A Randomized, Controlled Pilot Study
Filum Section for Urinary Incontinence in Children with Occult Tethered Cord Syndrome: A Randomized, Controlled Pilot Study
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DOI：
10.1016/j.juro.2015.09.082
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发表时间：
2016-04-01
影响因子：
6.6
通讯作者：
Pugh, Jeffery
中科院分区：
文献类型：
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作者：
Steinbok, Paul;MacNeily, Andrew E.;Pugh, Jeffery
目的：隐匿性脊髓栓系综合征是有争议的，尽管临床和尿动力学证据显示神经性膀胱行为，但神经解剖学成像正常。几个不受控制的系列描述了终丝部分后膀胱功能的改善。我们进行了一项试点随机对照研究，比较了隐匿性脊髓栓系综合征儿童的药物治疗与手术切除加药物治疗的情况。材料和方法：对标准药物治疗无效一年或以上、磁共振成像圆锥位置正常且尿动力学异常的儿童进行随机分组。排除标准包括任何神经系统疾病、脊柱闭合不全、膀胱出口梗阻和膀胱失张力。患者在随机分组中接受评估，一年后使用标准化尿动力学评分、经过验证的 PEMQOL（小儿遗尿生活质量模块 (TM)）量表以及经过验证的肠和膀胱功能障碍评分进行评估。结果：8 年后，我们招募了 21 名患者。手术组和内科组的肠道和膀胱功能障碍评分有所改善（20% 和 24%），尿动力学评分略有改善（分别为 6% 和 4%）。两组的 PEMQOL 儿童和家庭影响量表均略有改善。所有差异均不显着。中期分析表明，根据我们的初步数据，每组需要超过 700 名患者来证明尿动力学评分存在统计学差异。结论：对于隐匿性脊髓栓系综合征患者，在医疗治疗加或减细丝切除之间，泌尿外科结果似乎没有客观差异。这些数据挑战了隐匿性脊髓栓系综合征概念的存在，其中肠和膀胱功能障碍评分归因于丝的栓系，尽管圆锥位于正常位置。
Purpose: Occult tethered cord syndrome, in which there is normal neuroanatomic imaging despite clinical and urodynamic evidence of neuropathic bladder behavior, is controversial. Several uncontrolled series describe improvement in bladder function following section of the filum terminale. We performed a pilot randomized, controlled study comparing medical treatment to surgical section of the filum plus medical treatment in children with occult tethered cord syndrome.Materials and Methods: Children refractory to standard medical management for 1 year or more with normal conus position on magnetic resonance imaging and abnormal urodynamics were randomized. Exclusion criteria included any neurological conditions, spinal dysraphism, bladder outlet obstruction and an atonic bladder. Patients were assessed at randomization and 1 year later with a standardized urodynamic score, the validated PEMQOL (Pediatric Enuresis Module on Quality of Life (TM)) scale, and a validated bowel and bladder dysfunction score.Results: After 8 years we accrued 21 patients. The bowel and bladder dysfunction score improved in the surgical and medical arms (20% and 24%) and the urodynamic score improved slightly (6% and 4%, respectively). The PEMQOL Child and Family Impact Scales improved modestly in both groups. All differences were nonsignificant. Interim analysis indicated that more than 700 patients in each arm would be required to demonstrate a statistical difference with respect to urodynamic score based on our preliminary data.Conclusions: There appears to be no objective difference in urological outcome between medical management plus or minus filum section for patients with occult tethered cord syndrome. These data challenge the existence of the concept of occult tethered cord syndrome, in which bowel and bladder dysfunction score is attributed to tethering by the filum despite a normally located conus.