Advertisement

Child's Nervous System

, Volume 32, Issue 7, pp 1265–1272 | Cite as

Spinal lipoma of the filum terminale: review of 174 consecutive patients

  • Kenichi Usami
  • Pauline Lallemant
  • Thomas Roujeau
  • Syril James
  • Kevin Beccaria
  • Raphael Levy
  • Federico Di Rocco
  • Christian Sainte-Rose
  • Michel ZerahEmail author
Original Paper

Abstract

Purpose

Spinal lipoma of the filum terminale (LFT) is a congenital lumbosacral anomaly that can cause tethered cord syndrome. Purposes of this study are to clarify preoperative characteristics of LFT, to elucidate surgical effects, and to discuss the rationale of prophylactic surgery for LFT.

Methods

Medical data of 174 children (2008–2014) who underwent section of LFT were prospectively recorded for prevalence of symptoms, skin stigmas, and associated malformations, motivator of diagnosis, conus level, and surgical outcome. Mean age at surgery was 4.1 ± 4.2 years (37 days to 17.7 years).

Results

Ninety-four children (54.0 %) had skin stigmas and 60 (34.5 %) had certain perineal malformations. Seventy-nine children (45.4 %) were symptomatic. The most common motivator for diagnosis was skin stigmas (44.3 %), followed by associated malformations (33.3 %), and symptoms (20.1 %). The age at surgery was significantly older in symptomatic patients than in asymptomatic patients (p < 0.001). Surgery improved symptoms in 50 % of patients at 2.1-year follow-up period. Of 85 asymptomatic patients, all except one remained asymptomatic postoperatively and none of the symptomatic patients deteriorated. The presence of associated malformations and the conus level did not affect surgical outcome. Postoperative complications developed in nine patients (5.2 %): seven transient local problems, one definitive urological deterioration, and one transient respiratory problem.

Conclusions

Surgery for LFT was a simple and safe procedure. It improved half of symptomatic patients and stopped the deterioration of the others. Even if only one of the asymptomatic patients deteriorated at maximum follow-up, the role of prophylactic surgery remains a point of discussion.

Keywords

Occult spinal dysraphism Tethered cord syndrome Surgical outcome Prophylactic surgery 

Introduction

Spinal lipoma of the filum terminale (LFT) is the simplest type of occult spinal dysraphism. The infiltration of fatty tissue localized in the filum terminale thickens and loses its flexibility, which can provoke tethered cord syndrome (TCS). Although the embryology of LFT has been considered as a problem of secondary neurulation in the early fetal period [1], it is still to be elucidated. The prevalence of LFT has been reported ranging from 0.24 to 5 % [2, 3, 4].

Surgery for LFT has been considered as a low-risk procedure. There is little discussion about surgery for symptomatic LFT; meanwhile, prophylactic surgery for asymptomatic patients is still controversial. A possible reason of this conflict is that detailed characteristics of LFT, including motivators for diagnosis, cutaneous abnormalities, associated malformations, symptoms of TCS, conus levels, and surgical outcomes, remain unclear.

Purposes of this study are to clarify preoperative characteristics of LFT, to elucidate surgical effects, and to discuss the validity of prophylactic surgery for LFT. To achieve these objectives, we prospectively recorded medical data of patients with LFT who underwent surgical treatment in a single center.

Patients and methods

Children (less than 18 years old) who underwent section of LFT in the Department of Pediatric Neurosurgery, Necker-Enfants Malades Hospital, between September 2008 and December 2014, were prospectively followed. Exclusion criteria were as follows: (1) history of previous lumbosacral surgery, (2) simultaneous surgery for another dysraphism (i.e., diastematomyelia, dermal sinus, neurenteric cyst …), (3) simultaneous surgery for a lipoma of the conus, and (4) extra dural surgery.

In principle, a single-level laminectomy at L5 or S1 was performed. The filum terminale was identified by visual inspection, liberated from surrounding nerves, and divided (Fig 1a, ab). No neurophysiological monitoring was used during surgery.
Fig 1

Typical images on sagittal view of lumbosacral MRI. Filum terminale (yellow arrow) is strained preoperatively (a) and is unstrained postoperatively (b). Presacral meningocele (red arrow) in Currarino syndrome is shown on T1-weighted image (c) and on T2-weighted image (d)

Data collection and analysis

Preoperative characteristics including motivators of diagnosis, associated syndromes or malformations, clinical symptoms, skin stigmas, and conus level were evaluated. When the patient had one or some associated malformations (dysraphism or locoregional syndrome (VACTERL, Currarino triad)), it was defined as “syndromic” (Fig 1c, 1d). Patient out of “syndromic” was defined as “isolated.” Conus levels were determined on sagittal images on MRI. The last vertebra with a rectangular shape was considered as L5, and each level was determined by counting from it [5]. Postoperative parameters were analyzed in patients with more than 1 month of follow-up after surgery.

All statistical analyses were performed with JMP Pro 9 ® software (version 9.0.0; SAS Institute Inc., Cary, NC). The non-parametric Wilcoxon signed-rank test or the chi-square test was used to compare data between groups. Differences among more than two groups were evaluated by analysis of variance (ANOVA). A significant level of p < 0.05 was considered for all analysis.

Result

Preoperative characteristics (Table 1)

Candidates who fulfilled the criteria for this study were 174 children (82 boys and 92 girls) during the designated period. The most common motivator of diagnosis was skin stigma (n = 77, 44.3 %), followed by syndromic (n = 58, 33.3 %), symptom (n = 35, 20.1 %), and incidental detection by MRI for another reason (n = 4, 2.3 %). Mean age at surgery was 4.1 ± 4.2 years (37 days to 17.7 years). Regarding motivators, mean age at surgery was 1.6 ± 1.6 years in patients with skin stigma, 4.8 ± 3.9 years in syndromic patients, and 8.7 ± 4.3 years in symptomatic patients. There were significant differences between every pairs of mean age at surgery (p < 0.001 in every pairs) and among these three motivators (p < 0.001).
Table 1

Population of characteristics and principal motivator of diagnosis

 

Prevalence

Motivator

Age at surgery (years)

Skin stigma

94

54.0 %

77

44.3 %

1.6 ± 1.6

Syndrome

60

34.5 %

58

33.3 %

4.8 ± 3.9

Symptom

79

45.4 %

35

20.1 %

8.3 ± 4.7

Incidental

  

4

2.3 %

6.6 ± 5.0

Total

174

100.0 %

174

100.0 %

4.1 ± 4.2

Syndromes (Table 2)

Sixty patients (34.5 %) were syndromic. Among the patients with syndrome, two were initially undiagnosed and have had a delayed diagnosis in relation with the appearance of a new symptom. The most common syndrome was Currarino syndrome (n = 25, 41.7 %), followed by VACTERL syndrome (n = 18, 30.0 %). Other malformative complexes (n = 17, 28.3 %) which were not diagnosed as certain syndrome but had one or several malformations as perineal anomaly, sacral agenesis, upper gastrointestinal atresia, and renal or cardiac anomalies were also found out.
Table 2

Type of associated malformations

Type of syndrome

 

Percentage

Currarino syndrome

25

41.7

VACTERL syndrome

18

30.0

Other malformative complexes

17

28.3

Total

60

100.0

Symptoms (Table 3(a))

Seventy-nine patients (45.4 %) had one or some symptoms. The most common symptom was sphincter dysfunction (n = 62, 35.6 %) including dysuria (n = 41, 23.6 %), repetitive urinary tract infection (UTI) (n = 17, 9.8 %), and constipation (n = 27, 15.5 %). Neuro-orthopedic disorders were found in 29 patients (16.7 %), including motor weakness in lower extremities (LEs) (n = 7, 4.0 %), gait disturbance (n = 12, 6.9 %), deformity of LEs (n = 13, 7.5 %), and atrophy in LEs (n = 3, 1.7 %). Sensory disturbances were found in 11 patients (6.3 %), including pain in lower back or LEs (n = 11, 6.3 %) and dysesthesia in LEs (n = 3, 1.7 %). Patients with symptom were found more frequently in syndromic patients than in isolated patients (p = 0.01) (Fig. 2a). However, difference of type of symptoms between isolated and syndromic patients was not significant. The age at surgery was significantly older in symptomatic patients than in asymptomatic patients (6.3 ± 4.7 vs 2.3 ± 2.7 years, p < 0.001) (Fig. 2b). Regarding symptoms, sensory disturbance was correlated with the age at surgery (p = 0.003).
Table 3

Type of symptoms and postoperative evolution

Type of symptom

(a) Preoperative characteristics

(b) Postoperative evolution

Over all (n = 79)

Isolated (n = 44)

Syndromic (n = 35)

Improvement of symptoms

Sphincter dysfunction

62

35.6 %

34

19.5 %

28

16.1 %

33

53.2 %

 Dysuria

41

23.6 %

23

13.2 %

18

10.3 %

 Repetitive UTI

17

9.8 %

12

6.9 %

5

2.9 %

 Constipation

27

15.5 %

14

8.0 %

13

7.5 %

Neuro-orthopedic disorder

29

16.7 %

16

9.2 %

13

7.5 %

29

48.3 %

 Motor weakness

7

4.0 %

3

1.7 %

4

2.3 %

 Gait disturbance

12

6.9 %

9

5.2 %

3

1.7 %

 Deformity of LEs

13

7.5 %

7

4.0 %

6

3.4 %

 Atrophy of lower LEs

3

1.7 %

2

1.1 %

1

0.6 %

Sensory disturbance

11

6.3 %

6

3.4 %

5

2.9 %

3

27.3 %

 Pain

11

6.3 %

6

3.4 %

5

2.9 %

 Dysesthesia

3

1.7 %

2

1.1 %

1

0.6 %

UTI urinary tract infection, LEs lower extremities

Fig 2

Comparison between asymptomatic and symptomatic patients. Symptomatic patients were found more frequently in syndromic patients than in isolated patients (a) (p = 0.01). Age at surgery was older in symptomatic patients than in asymptomatic patients (b) (p < 0.001)

Skin stigmas (Table 4)

Skin stigmas were found in 94 patients (54.0 %). The most common finding was a fossette in lumbosacral area (n = 46, 26.4 %); intergluteal fold deviation was found in 33 (19.0 %), dermal sinus in 26 (14.9 %), cutaneous angioma in 24 (13.8 %), cutaneous aplasia in nine (5.2 %), hypertrichosis in six (3.4 %), subcutaneous lump in two (1.1 %), caudal appendix in two (1.1 %), and patchy hair in two (1.1 %). Patients with more than one stigma were found in 44 (25.3 %). Among patients with skin stigmas, surgery was performed significantly later in symptomatic patients than in asymptomatic patients (1.7 ± 2.0 vs 4.4 ± 4.1 years, p = 0.013).
Table 4

Type of skin stigmas

Type of skin stigma

 

Percentage

Fossette

46

26.4

Intergluteal fold deviation

33

19.0

Dermal sinus

26

14.9

Angioma

24

13.8

Cutaneous aplasia

9

5.2

Hypertrichosis

6

3.4

Subcutaneous lamp

2

1.1

Caudal appendix

2

1.1

Patchy hair

2

1.1

Unknown

4

2.3

More than 1 stigma

44

25.3

Neuroradiological findings

Preoperative conus levels were evaluated in 153 patients with available MRI. Table 5(a) shows preoperative conus level locations. The most common conus level was L2, followed by L1 and L3. There was no significant relationship between the conus level and the existence of symptoms. Syrinx was found in 34 patients (22.2 %), diastematomyelia in six (3.9 %), arachnoid cyst in four (2.6 %), and benign tumors (dermoid cyst and sacral teratoma) in two (1.3 %). Only surgery for arachnoid cysts and tumors was performed Table 6.
Table 5

Distribution of patients in conus level and postoperative evolution

Conus level

(a) Preoperative characteristics

(b) Postoperative evolution

Overall patients

Symptomatic patients

Improved patients/ (incomplete f/u)

Th12

6

3.9 %

3

50.0 %

2/(1)

66.7 %

L1

38

24.8 %

20

52.6 %

12/(1)

63.2 %

L2

52

34.0 %

23

44.2 %

7/(2)

33.3 %

L3

24

15.7 %

10

41.7 %

4/(1)

44.4 %

L4

14

9.2 %

7

50.0 %

3/(2)

60.0 %

L5

11

7.2 %

3

27.3 %

1/(0)

33.3 %

S1

6

3.9 %

4

66.7 %

1/(3)

100.0 %

S2

2

1.3 %

1

50.0 %

1/(0)

100.0 %

Total

153

100.0 %

71

46.4 %

31/(10)

50.0 %

The number of incomplete follow-up patients is indicated in parentheses

Table 6

Postoperative complications

Type of complication

 

Percentage

Re-operation

5

2.9

 Wound infection

1

0.6

 CSF leak

3

1.7

 Pseudomeningocele

1

0.6

Pseudomeningocele

1

0.6

Subcutaneous CSF collection

1

0.6

New neurological symptom

1

0.6

Respiratory impairment

1

0.6

CSF cerebrospinal fluid

Postoperative evolutions

Postoperative data with sufficient follow-up periods were obtained in 153 patients, including 68 patients with symptom and 85 patients without symptom preoperatively. Mean follow-up period was 2.1 ± 1.7 years after surgery. Fifty-one patients were followed up for more than 3 years and 11 for more than 5 years. Of 68 symptomatic patients, symptoms improved in 34 patients (50 %) and remained stable in 34 (50 %). There was no significant difference in the age at surgery between improved and stable patients (7.3 ± 4.7 vs 5.5 ± 4.4 years, n.s.). Concerning the type of symptom (Table 3(b)), sphincter dysfunction improved in 33 of 62 (53.2 %), neuro-orthopedic disorders in 14 of 29 (48.3 %), and sensory disturbance in three of 11 (27.3 %). Preoperative conus level did not affect the improvement of symptoms (Table 5(b)). Of 85 patients without preoperative symptom, worsening occurred in one patient. He underwent surgery at 3.6 years old; thereafter, new dysuria necessitating a catheterization occurred immediately postoperatively.

Group analysis (Fig 3)

We classified patients into three groups depending on characteristics as follows: (1) isolated patients with skin stigmas (n = 90), defined as “group 1,” (2) isolated patients without skin stigma (n = 24), defined as “group 2,” and (3) syndromic patients (n = 60) defined as “group 3.” Only four patients (6.7 %) with skin stigma were found in group 3 (p < 0.001). The age at surgery was 2.3 ± 2.9 years in group 1, 8.8 ± 4.5 years in group 2, and 5.0 ± 4.0 years in group 3. There were significant differences of the age at surgery both among the three groups (p < 0.001) and between every pairs of groups (p < 0.001). Considering the symptoms, the age at surgery was older in symptomatic patients than in asymptomatic patients. (Group 1, 4.4 ± 4.1 vs 1.7 ± 2.0, p = 0.013; group 2, 9.4 ± 4.3 vs 2.8 ± 0.9, p = 0.041; group 3 (without stigmas) 5.8 ± 4.3 vs 4.4 ± 3.5; n.s.) The prevalence of symptomatic patients significantly differed also (24.4 vs 91.7 vs 58.3 %) among on the total series (p < 0.001) and between each groups (p < 0.001). On the other hand, in terms of the improvement of symptoms, there were no significant differences among the three groups (n.s.).
Fig 3

Tree of intergroup analysis. Patients were classified by syndrome, skin stigmas, symptom and surgical outcome. There were significant differences of the age at surgery (AS) both among the three groups (p < 0.001) and between every pairs of groups (p < 0.001). The number of incomplete follow-up patients is indicated in brackets. There was no significant difference in improvement of symptoms among groups

Complications

Surgical complications developed in nine patients (5.2 %). Among them, five patients needed additional surgery, including one wound infection, three cerebrospinal fluid (CSF) leaks, and one pseudomeningocele. Meanwhile, one pseudomeningocele and one subcutaneous CSF collection improved without surgery. Postoperative new symptom occurred in one patient described previously. One transient respiratory problem occurred.

Discussion

The present study of 174 consecutive pediatric patients with LFT clarified some characteristics of LFT and favorable surgical outcome with minimal complications. Surgery for LFT improved symptoms in a half of symptomatic patients and stabilized in the other half, regardless of the level of conus, the age at surgery, and the presence of syndrome. For asymptomatic patients, none deteriorates but one, after surgery at the maximum of follow-up.

Comparison with series in the literature

Associated perineal malformations

Several studies concerning the correlation between TCS and perineal malformations have been conducted. In Currarino syndrome, occult spinal dysraphism (OSD) was found in approximately 60 %, and the risk of symptomatic TCS was higher in patients with lipomas than in those with other spinal lesions [6]. In VACTERL syndrome, TCS requiring surgery was found in 17–39 % and LFT accounted for 7–24 % [7, 8]. In the present study, one third of patients had one or several perineal malformations. In most of the series, surgery for perineal malformations is preferentially performed prior to surgery for LFT, even if the patients are symptomatic. Nevertheless, our study demonstrated that surgery improved symptoms regardless of the presence of associated malformations and could be proposed as a first option to symptomatic syndromic patient (group 3). As some authors [8, 9, 10], we advocate that MRI should be routinely performed in patients with perineal malformations to detect spinal lesions involving TCS.

Skin stigmas

OSD is diagnosed by skin lesions in more than 50 % [11]. In all types of diagnosed spinal lipomas, skin stigmas appear in 86–90 %, and the most common lesion is a subcutaneous mass [12, 13]. The incidence of asymptomatic dysraphism without skin stigma remains unknown in the general population. Nevertheless, the presence of skin stigmas in LFT seems to be lower than in other spinal lipomas [12, 14]. Our study demonstrated that subcutaneous mass was rarely found in patients with LFT while lumbosacral fossette was the most frequent stigma. In our study, skin stigma was the most common motivator of diagnosis, and patients with skin stigmas underwent surgery in significantly younger age than those without skin stigmas. Particularly, patients without skin stigmas or syndrome could not be diagnosed except incidental detection. For such reason, skin stigmas play an important role to make an early diagnosis in LFT.

Symptoms

In previous reports of LFT series, sphincter dysfunction was found in 43–59 %, neuro-orthopedic disorder in 24–50 %, and sensory disturbance in 16–32 % [13, 15, 16]. In our study, the prevalence of each symptom was in the range of these previous reports. Considering that it is difficult to detect neurological symptoms in young infant particularly subclinical sphincter dysfunction [13], severe bladder dysfunction is found more frequently after 3 years [17]. Urodynamic studies should be useful to detect subclinical symptom at the early phase in infants [18].

Conus level

Some authors advocated that lower conus position was liable to involve symptoms [15, 19], whereas others suggested that the conus level does not affect the presence of symptom [20, 21, 22]. In the present study, there was no consistent correlation between the incidence of symptoms and the conus level. In case of LFT, the absence of low-lying conus cannot exclude TCS.

Intergroup analysis

Characteristics of LFT raise a question whether the clinical entity differed between patients with and without syndrome, because of the difference in the incidence of skin stigmas. Patients with skin stigmas were found in 79 % in isolated patients, in contrast to 6.7 % in syndromic patients (p < 0.001). It is natural to consider that syndromic LFT and isolated one are different conditions. If we hypothecate that these two conditions are the same, the prevalence of LFT is identical in all patients. Since syndromic patients without skin stigmas in whom LFT was normally diagnosed shortly after birth were found in 56 in 60 patients (93.3 %), isolated patients without skin stigmas (group 2) should be found in 1350 patients. Nevertheless, in fact, patients in group 2 were found in 24 patients (1.7 % for 1350) in the present study. This low prevalence indicates the difficulty of diagnosis in isolated patients without skin stigmas, and it may suggest the actual prevalence of LFT in the normal population. Further investigations are necessary to determine the difference between isolated and syndromic LFT.

Efficacy of surgery for symptomatic LFT

In the series of spinal lipomas reported by Pierre-Kahn and colleagues [13], eight of 17 patients (47 %) with symptomatic LFT cured or improved their symptoms and nine (53 %) remained stable postoperatively. In the study of 22 patients with symptomatic tight filum terminale [23], symptoms improved in 16 (73 %) and remained stable in four (19 %) irrespective of conus level, volume of fatty filum, or the presence of syrinx. In the large series of LFT detected by MRI, of 21 symptomatic patients who underwent sectioning filum terminal, symptom improved in 12 (57 %) and remained stable in nine (43 %) [15]. In our study, symptoms improved in 34 patients (50 %) and remained stable in 34 (50 %) postoperatively. In addition, there was no correlation between the age at surgery and the ratio of improved patients. Considering these results, surgery for LFT can improve symptoms in about half of patients and stabilizes them in the other half, regardless of the age at surgery, syndrome, and conus level.

In the previous reports of LFT surgery, postoperative complications develop in 0–12.1 % [13, 24]. In our series, surgical complications developed in nine patients (5.2 %). Among them, permanent neurological deficit occurred in only one patient (0.6 %), which may be acceptable considering previous series of LFT surgery.

Postoperative retethering

Retethering after section of LFT occurred 1.9–8.6 % [16, 24, 25]. In the present study, no retethering occurred after surgery. In case of LFT, surgical procedures are normally performed at only the lowest part of the spinal canal where there is a large space around the filum terminale. This is the reason why retethering rarely occurs in LFT. In any cases of LFT, the incidence of retethering is relatively low; thus, for us, it cannot be an adverse opinion for surgery.

Validity of prophylactic surgery for asymptomatic LFT

In any type of lipomas, surgery for symptomatic patients should be performed without hesitation to prevent the progression of symptom [13, 26, 27]. Meanwhile, the prophylactic surgery for asymptomatic spinal lipomas is still controversial [26, 28]. Proponents of prophylactic surgery for LFT have alleged the safeness and favorable surgical outcomes [13, 27, 29]. In the series of La Marca and colleagues, all of 28 asymptomatic LFT remained asymptomatic postoperatively with 3.4-year follow-up [27]. In the series of Pierre-Kahn and colleagues, new symptom occurred postoperatively in one of 38 asymptomatic LFT [13].

Opponents of prophylactic surgery for LFT have questioned the surgical outcome [12, 15, 30]. Certain patients may not present any symptom without prophylactic surgery. Cools et al. reported a natural history of LFT of all age groups [15]. One of 94 pediatric patients of asymptomatic LFT presented sphincter trouble 1.5 years after diagnosed. Other children did not present any new symptom in 3.5 years of follow-up period. This follow-up was too short to verify the absence of symptom because, in our study, mean age at surgery in symptomatic patients was 8.2 years old. Longer follow-up period may be necessary to elucidate the natural history of LFT. As long as the natural history of LFT is not concluded and considering the innocuity of the surgery, asymptomatic LFT should be prophylactically treated at this time.

To determine the validity of the prophylactic surgery for LFT, the direct comparison between surgery and natural course with long follow-up periods, ideally randomized controlled trial may be desirable.

Conclusion

There seems to be three groups that have different clinical entities, characterized by skin stigmas, associated perineal symptoms, and clinical symptoms. The presence of skin stigmas or associated malformations is essential for early diagnosis. Surgery for LFT improved symptoms in half of patients regardless of the age at surgery, the preoperative conus level, and the presence of associated malformations with minimal complications. Definitive indication of prophylactic surgery for LFT is to be determined.

Notes

Compliance with ethical standards

Conflict of interest

No conflict of interest for any author.

References

  1. 1.
    Tortori-Donati P, Rossi A, Cama A (2000) Spinal dysraphism: a review of neuroradiological features with embryological correlations and proposal for a new classification. Neuroradiology 42:471–491CrossRefPubMedGoogle Scholar
  2. 2.
    Brown E, Matthes JC, Bazan C 3rd, Jinkins JR (1994) Prevalence of incidental intraspinal lipoma of the lumbosacral spine as determined by MRI. Spine 19:833–836CrossRefPubMedGoogle Scholar
  3. 3.
    Uchino A, Mori T, Ohno M (1991) Thickened fatty filum terminale: MR imaging. Neuroradiology 33:331–333CrossRefPubMedGoogle Scholar
  4. 4.
    Okumura R, Minami S, Asato R, Konishi J (1990) Fatty filum terminale: assessment with MR imaging. J Comput Assist Tomogr 14:571–573CrossRefPubMedGoogle Scholar
  5. 5.
    Paik NC, Lim CS, Jang HS (2013) Numeric and morphological verification of lumbosacral segments in 8280 consecutive patients. Spine 38:E573–E578CrossRefPubMedGoogle Scholar
  6. 6.
    Kole MJ, Fridley JS, Jea A, Bollo RJ (2014) Currarino syndrome and spinal dysraphism. J Neurosurg Pediatr 13:685–689CrossRefPubMedGoogle Scholar
  7. 7.
    O’Neill BR, Yu AK, Tyler-Kabara EC (2010) Prevalence of tethered spinal cord in infants with VACTERL. J Neurosurg Pediatr 6:177–182CrossRefPubMedGoogle Scholar
  8. 8.
    Kuo MF, Tsai Y, Hsu WM, Chen RS, Tu YK, Wang HS (2007) Tethered spinal cord and VACTERL association. J Neurosurg 106:201–204PubMedGoogle Scholar
  9. 9.
    Golonka NR, Haga LJ, Keating RP, Eichelberger MR, Gilbert JC, Hartman GE, Powell DM, Vezina G, Newman KD (2002) Routine MRI evaluation of low imperforate anus reveals unexpected high incidence of tethered spinal cord. J Pediatr Surg 37:966–969 discussion 966-969CrossRefPubMedGoogle Scholar
  10. 10.
    Tuuha SE, Aziz D, Drake J, Wales P, Kim PC (2004) Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients? J Pediatr Surg 39:773–777CrossRefPubMedGoogle Scholar
  11. 11.
    Kumar A, Kanojia RK, Saili A (2014) Skin dimples. Int J Dermatol 53:789–797CrossRefPubMedGoogle Scholar
  12. 12.
    Finn MA, Walker ML (2007) Spinal lipomas: clinical spectrum, embryology, and treatment. Neurosurg Focus 23:E10CrossRefPubMedGoogle Scholar
  13. 13.
    Pierre-Kahn A, Zerah M, Renier D, Cinalli G, Sainte-Rose C, Lellouch-Tubiana A, Brunelle F, Le Merrer M, Giudicelli Y, Pichon J, Kleinknecht B, Nataf F (1997) Congenital lumbosacral lipomas. Child Nerv Syst: ChNS: Off J Int Soc Pediatr Neurosurg 13:298–334 discussion 335CrossRefGoogle Scholar
  14. 14.
    McLendon RE, Oakes WJ, Heinz ER, Yeates AE, Burger PC (1988) Adipose tissue in the filum terminale: a computed tomographic finding that may indicate tethering of the spinal cord. Neurosurg 22:873–876CrossRefGoogle Scholar
  15. 15.
    Cools MJ, Al-Holou WN, Stetler WR Jr, Wilson TJ, Muraszko KM, Ibrahim M, La Marca F, Garton HJ, Maher CO (2014) Filum terminale lipomas: imaging prevalence, natural history, and conus position. J Neurosurg Pediatr 13:559–567CrossRefPubMedGoogle Scholar
  16. 16.
    Yong RL, Habrock-Bach T, Vaughan M, Kestle JR, Steinbok P (2011) Symptomatic retethering of the spinal cord after section of a tight filum terminale. Neurosurg 68:1594–1601 discussion 1601-1592CrossRefGoogle Scholar
  17. 17.
    Dorward NL, Scatliff JH, Hayward RD (2002) Congenital lumbosacral lipomas: pitfalls in analysing the results of prophylactic surgery. Child Nerv Syst: ChNS: Off J Int Soc Pediatr Neurosurg 18:326–332CrossRefGoogle Scholar
  18. 18.
    Vernet O, Farmer JP, Houle AM, Montes JL (1996) Impact of urodynamic studies on the surgical management of spinal cord tethering. J Neurosurg 85:555–559CrossRefPubMedGoogle Scholar
  19. 19.
    Koyanagi I, Iwasaki Y, Hida K, Abe H, Isu T, Akino M, Aida T (2000) Factors in neurological deterioration and role of surgical treatment in lumbosacral spinal lipoma. Child Nerv Syst: ChNS: Off J Int Soc Pediatr Neurosurg 16:143–149CrossRefGoogle Scholar
  20. 20.
    Bulsara KR, Zomorodi AR, Enterline DS, George TM (2004) The value of magnetic resonance imaging in the evaluation of fatty filum terminale. Neurosurg 54:375–379 discussion 379-380CrossRefGoogle Scholar
  21. 21.
    Warder DE, Oakes WJ (1993) Tethered cord syndrome and the conus in a normal position. Neurosurgery 33:374–378CrossRefPubMedGoogle Scholar
  22. 22.
    Steinbok P, Kariyattil R, MacNeily AE (2007) Comparison of section of filum terminale and non-neurosurgical management for urinary incontinence in patients with normal conus position and possible occult tethered cord syndrome. Neurosurg 61:550–555 discussion 555-556CrossRefGoogle Scholar
  23. 23.
    Fabiano AJ, Khan MF, Rozzelle CJ, Li V (2009) Preoperative predictors for improvement after surgical untethering in occult tight filum terminale syndrome. Pediatr Neurosurg 45:256–261CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Ostling LR, Bierbrauer KS, Kuntz C (2012) Outcome, reoperation, and complications in 99 consecutive children operated for tight or fatty filum. World neurosurgery 77:187–191CrossRefPubMedGoogle Scholar
  25. 25.
    Ogiwara H, Lyszczarz A, Alden TD, Bowman RM, McLone DG, Tomita T (2011) Retethering of transected fatty filum terminales. J Neurosurg Pediatr 7:42–46CrossRefPubMedGoogle Scholar
  26. 26.
    Pang D, Zovickian J, Oviedo A (2010) Long-term outcome of total and near-total resection of spinal cord lipomas and radical reconstruction of the neural placode, part II: outcome analysis and preoperative profiling. Neurosurg 66:253–272 discussion 272-253CrossRefGoogle Scholar
  27. 27.
    La Marca F, Grant JA, Tomita T, McLone DG (1997) Spinal lipomas in children: outcome of 270 procedures. Pediatr Neurosurg 26:8–16CrossRefPubMedGoogle Scholar
  28. 28.
    Kulkarni AV, Pierre-Kahn A, Zerah M (2004) Conservative management of asymptomatic spinal lipomas of the conus. Neurosurg 54:868–873 discussion 873-865CrossRefGoogle Scholar
  29. 29.
    Hoffman HJ, Hendrick EB, Humphreys RP (1976) The tethered spinal cord: its protean manifestations, diagnosis and surgical correction. Childs Brain 2:145–155PubMedGoogle Scholar
  30. 30.
    Drake JM (2006) Occult tethered cord syndrome: not an indication for surgery. J Neurosurg 104:305–308CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Kenichi Usami
    • 1
  • Pauline Lallemant
    • 2
  • Thomas Roujeau
    • 1
  • Syril James
    • 1
  • Kevin Beccaria
    • 1
  • Raphael Levy
    • 3
  • Federico Di Rocco
    • 1
  • Christian Sainte-Rose
    • 1
  • Michel Zerah
    • 1
    Email author
  1. 1.Department of Pediatric NeurosurgeryNecker-Enfants Malades Hospital, Assistance Publique Hopitaux de Paris, Paris V UniversityParisFrance
  2. 2.Department of Pediatric RehabilitationTrousseau HospitalParisFrance
  3. 3.Department of Pediatric RadiologyNecker-Enfants Malades HospitalParisFrance

Personalised recommendations