| Part Ⅰ: Imaging features of split spinal cord malformation associated with scoliosis and its correlation with neurologic symptomsBackground data Neurologic deficit symptoms may be absent in some CS patients with a SSCM; however, controversy arises as to the treatment of these patients. It is generally believed that preventive excision of the bony septum or loosening of the membranous septum is necessary before scoliosis correction surgery for patients with or without neurologic deficits. Some scholars contend that preventive excision of the bony septum is unnecessary for patients having stable neurologic function without neurologic deficits. To settle this problem, we discussed the imaging features of a SSCM and the correlation with neurologic deficits. Based on the analysis of the causes of neurologic deficits, we can determine whether or not it is necessary to perform scoliosis correction surgery for CS patients with a SSCM.Objective To analyze the imaging features of congenital scoliosis(CS) associated with split spinal cord malformation(SSCM) and other intraspinal abnormalities, and to investigate the relationship to neurological symptoms.Methods 105 cases CS with SSCM were retrospectively studied. Analysis the imaging features of SSCM(including type of SSCM, location of SSCM, location and apical vertebrae, symmetry of divided cord) and other intraspinal abnormalities. To investigate the relationship of the factors and neurological symptoms using Chi-square test of one factor and multiple factors logistic regression analysis.Results 28 cases(26.7%) were formation failure, 33 cases(31.4%) were segmentation failure, and 44 cases(41.9%) were combination of 2 disorders. 41 cases had neurological symptoms, 64 cases were asymptomatic. The distribution of SSCM combined with spinal deformities: thoracic(11 cases), thoracolumbar(18 cases) and lumbar(20 cases) in type I SSCM, thoracic(31 cases), thoracolumbar(20 cases) and lumbar(5 cases) in type II, none was in cervical. The location of SSCM upper than apical vertebrae 29 cases, on apical vertebrae 25 cases, lower than apical vertebrae 51 cases. Spinal cord was splitted symmetric 27 cases and asymmetric 78 cases. 66 cases combined with other intraspinal abnormalities, lower conus 42 cases, syringomyelia 38 cases, meningocele 10 cases and sakrale zyste 5 cases. Associated with intraspinal abnormalities, the rate of neural symptoms was different. According to Chisquare test of one factor and multiple factors logistic regression analysis, lumbar SSCM, spinal cord asymmetric and lower conus were related with neurological symptoms.Conclusion The predilection spinal deformity of type I is combination, type II SSCM is segmentation failure. When SSCM patients associated with other intraspinal abnormalities, the incidence of neurologic symptoms is increased. The lumbar SSCM, hemicords asymmetry and lower lying conus have significant relationship with neurologic symptoms.Part Ⅱ: Treatment for split spinal cord malformation associated with low-lying conus of congenital scoliosisBackground data Split spinal cord malformation(SSCM) and low-lying conus are common intraspinal malformation, which has high incidence in congenital scoliosis. However, the co-occurred of both intraspinal malformation was less reported in congenital scoliosis. The mechanism of SSCM and low low-lying conus is still not clear. At present, in SSCM associated with congenital patients, the treatment of SSCM has been controversial before correction procedure. Whether should take the untethered surgery or not, before scoliosis correction procedure, which related research is very limited.Objective(1)To investigate the outcome of different surgical treatment toward Type Ⅰand Type Ⅱsplit spinal cord malformation(SSCM) associated with low-lying conus in congenital scoliosis;(2)To investigate the safety of spinal osteotomy for congenital scoliosis associated with SSCM and low-lying conus;(3)How to prevent the occurence of complication.Methods From June 2007 to December 2015, A total of 33 patients underwent spinal osteotomies for longitudinal SSCM associated with low-lying conus in our hospital. 6 of them were male, and 17 cases were female with an average age of 16.2 years(range, 7 to 27 years). 7 patients presented with lumbosacral pain, including 4 patients with only lumbosacral pain. 17 patients had neurological deficit. There were 15 patients with typeⅠSSCM and 18 patients with typeⅡSSCM. During surgery, bony spurs were resected in patients with type ⅠSSCM, while nothing was done for type ⅡSSCM; pedicle subtraction osteotomy(PSO) was performed in 8 patients and vertebral column resection(VCR) in 14; posterior fusion surgery was performed following the correction. The local of conus medullaris of all patients were below L2. Preoperative average coronal cobb angle were 77.9°±26.9°(35°-156°). All coronal Cobb angle and SBNS grade were measured before operation, after operation and at final follow-up.Results All patients were followed up for a minimum of 24 months after initial surgical treatment with an average follow-up of 44.7±26.2 months(range, 24-104 months). The average operation time was 484.2±145.8 min(range, 265-835min), and the average intraoperative blood loss was 2971.2±2372.2ml(range, 500-11500ml). Postoperative coronal Cobb angle ranged from 3 ° to 73 °(average, 31.2°±13.9 °). Compared with preoperative Cobb angle, postoperative Cobb angle showed significant difference(P < 0.05). The immediate postoperative correction rate was(58.0±16.1)%. At the final follow-up, the coronal Cobb angle ranged from 5 ° to 80 °(average, 34.9°±14.9°), with a correction loss 3.7°±2.9°. The final correction rate was(53.3±16.4)%, Compared with preoperation, these indexes showed significant differences(P < 0.05). There were no significant difference between TypeⅠ and TypeⅡ SSCM(P < 0.05).The neurological function was improved in 17 cases. 14 patients improved from preoperative SBNS grade Ⅱ to grade Ⅰ. 2 patients from preoperative SBNS grade Ⅲto grade Ⅱ. Although neurological function scores of the other 3 cases improved, SBNS grading remained unchanged. The coronal deformity and the local back pain relieved very well. The overall perioperative complications were noted in 5 cases. Postoperative unilateral lower limb neurological deterioration was noted in 2 cases, which recovered at 2 weeks and 3 months respectively. Cerebrospinal fluid leakage was noted in 1 case, pleural rupture in 1 case and urinary infection in 1 case. No infection surgical site, nonunion, pseudarthrosis, implant failure and permanent neurological deterioration were noted in all cases.Conclusions It is no necessary to take un-tethered surgery for congenital scoliosis co-exist SSCM and low-lying conus patients. For TypeⅠSSCM patients, it is need to remove the bony spur and scoliosis correction procedure. For Type SSCM, before correction step, spinal Ⅱosteotomy should be took to decrease the tension of filum terminale. The spinal osteotomy for SSCM associated with low-lying conus in congenital scoliosis is safety, effective and of well recovery of neurological function. |
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