Abstract General Information

Title

CHANGES OF URODYNAMICS AND PSYCHOLOGICAL-BEHAVIORAL PROFILE BEFORE AND POST DETETHERED PROCEDURES IN CHILDREN WITH TETHERED CORD SYNDROME

Introduction and objective

Tethered cord syndrome (TCS) is presumed to be a diverse clinical entity characterized by the increased tension of the conus medullaris or cauda equina due to a comparatively low-lying level. Overstrain of the spinal cord could lead to “traction” ischemia and impaired oxidative metabolism, thus manifesting a constellation of tension-induced cord dysfunction symptoms and signs. Surgical untethering is the modality most extensively utilized to treat TCS. The aim is to halt the progression of TCS as much as possible on the basis of maximum protection of neurological function. It is pretty important to undertake timely surgery for patients with progressive neuro-urological findings and avoid unnecessary surgery for those not at risk of deterioration. Disappointingly, some patients without bladder impairment present a deterioration of bladder function after surgery, which critically influenced the health-related quality of life. Thus, we investigated the effect of untethering on bladder function and provided preliminary surgical indications about bladder function in children with TCS by comparing variations of urodynamic parameters. Moreover, psychological behavior modification in patients was quantitatively evaluated by questionnaires to investigate whether surgery can alleviate the misery endured by patients.

Method

A total of 55 children diagnosed with TCS from January 2019 to October 2022 were reviewed in the study. Each case underwent meticulous history questioning and whole-body physical examination. Detailed history information should pay attention to surgical history, medications, family history, voiding habits, and whether the patient ever experienced lower urinary tract symptoms (LUTS). Physical examination includes the dorsal spine, cutaneous stigmata, and the lower extremity motor and sensory function. Sensory assessment should cover pinprick, tactility, and proprioception. Evaluation for defecation and surgical scars is also imperative.
Patients were examined by urodynamics before and after untethering and the examinations are performed by a specially trained practitioner. We compare urodynamic parameters before and after untethering. Maximum cystometric bladder capacity, bladder compliance, detrusor activity, and bladder detrusor sphincter synergy were graded and summed up to obtain the urodynamic score. Additionally, the psychological-behavioral profile of individuals was assessed according to the parent version of the Strengths and Difficulties Questionnaire (SDQ) before pre- and postoperative follow-up.
Subsequently, the children with TCS were divided into two groups according to the preoperative urodynamic parameters and LUTS: the normal bladder function group (Normal group) and the abnormal bladder function group (Abnormal group). The postoperative urinary system of the children in the two groups was analyzed according to the alterations of the postoperative UDS parameters and LUTS. Normal bladder function was defined as urodynamic score ≤4 with no clinical manifestations of LUTS, and improved bladder dysfunction was described as a decreased urodynamic score and reduction in LUTS. According to preoperative symptoms and postoperative clinical outcomes, lower extremity pain and motor dysfunction and intestinal tract dysfunction were classified as improvement (symptoms improved), stability (no change in symptoms but no progression), ineffectiveness (failure to control the disease and continued progression), and aggravation (symptoms worsened) with improvement and stability as effective treatment and ineffectiveness and aggravation as ineffective treatment.

Results

43 children were eligible for inclusion in this study and the Mean ± SD age at surgery was 9.19 ± 2.61 years. The urodynamics before and after untethering showed statistically significant differences in bladder detrusor sphincter synergy (Z = 2.374, P = 0.018) and urodynamic score (Z = 2.500, P = 0.012), and no statistically significant differences in the maximum flow rate (Qmax), post-void residual volume (PVR), maximum cystometric bladder capacity, bladder compliance, and detrusor activity (P >0.05). There was no statistically significant difference before and after untethering in emotional problems, conduct problems, hyperactive attention inability, peer interaction problems, pro-social behavior, and the detection rate of abnormalities in the total score of SDQ difficulties (All P > 0.05 and Table 1). Nevertheless, the detection rate of each psychological behavior abnormality in children with TCS was higher compared with that of normal children, both preoperatively and postoperatively.

24 cases (55.8%) in the Normal group and 19 cases (44.2%) in the Abnormal group; the differences between the two groups in the proportion of male and female gender, lower extremity pain and motor dysfunction, and intestinal tract dysfunction after surgery were not statistically significant (All P > 0.05 and Table 2); the proportion of bladder dysfunction that improved or did not worsen after surgery was higher in the Abnormal group (73.7%, 14/19) than in the Normal group (33.3%, 8/24) (χ2 = 6.910, P = 0.009).

Conclusion

In the era of individualized medicine, the clinical management of each patient should be thoughtfully considered. The overall risk profile of procedure should be carefully considered before untethering to avoid unnecessary harm. In terms of bladder function, for children with TCS who present abnormal or progressive bladder function, surgery is advocated only if the risk of observation exceeds the benefit of surgical intervention. Children with TCS exhibiting normal or non-progressive bladder function could be treated conservatively with close observation. And psychological counseling and health education for children with TCS should be strengthened, both preoperatively and postoperatively.