tethered cord syndrome ( tcs ) is a stretch - induced disorder of the spinal cord . it could be primary as in the case of spinal dysraphism , or secondary , following repair of the myelomeningocele . in the primary case
, tethering may result from an inelastic structure anchoring the caudal end of the cord as a short and thick filum terminale , while secondary tethering is produced by a scar in the area of the dysraphism resulting from postpartum surgical closure of the lesion , which in turn does not permit normal cranial migration of the conus within the vertebral canal , and leads to axonal anoxia resulting in neural dysfunction .
clinically , this syndrome manifests itself by progressive neurological , urological , and orthopedic signs and symptoms .
many studies have reported an improvement of urodynamic , and clinical variables after the untethering procedure.[379 ] however , other studies have raised suspicion about the usefulness of such a treatment in adults .
improvement of preoperative urological symptoms such as incontinence or abnormal urodynamic findings have been previously reported to be 38 and 100% , respectively , in two different studies .
the impact of untethering of the cord on fecal incontinence has not gained much attention .
the current study is designed to assess the urodynamic abnormalities and urinary symptoms in patients with myelomeningocele , who have undergone detethering of the spinal cord , as compared to those who have not undergone detethering .
this is a retrospective analysis of the data of 37 patients , post repair of myelomeningocele , who presented to the urodynamic unit between january 1998 and june 2008 .
the patients were divided into two groups : ( 1 ) those who underwent detethering of the cord , and ( 2 ) those who had primary repair only .
retrograde cystogram was also performed using a water soluble contrast and a small caliber nelaton tube ( 8 f. ) up to the sensation of maximum filling .
filling was conducted at room temperature ( 26c).the fill rate was 10% of the expected bladder capacity for age per minute(10 - 20 ml / min ) .
the end point of the filling phase was determined by a sensation of fullness or uretheral leak .
thirty - seven patients were enrolled in this study . there were 23 girls and 14 boys .
mean age at presentation was 10.1  4 and 10.8  7 years in groups 1 and 2 , respectively ( p 0.7 ) .
nocturnal and diurnal enuresis was found in 45% of group 1 and 69% of group 2 .
urinary tract infections ( utis ) were comparable in both groups ( 12.5 and 13.6% , respectively ) .
( cic was carried out with 8 f nelaton catheter every 4 hours per day time and once before bed time ) .
vesicoureteral reflux was noticed in 22.7% of group 2 , and none of group 1 had vesicoureteral reflux .
mean bladder capacity was 210  125 cc and 199  120 cc for groups 1 and 2 , respectively ( p 0.8 ) .
delta det lpp ( the difference between detrosur pressure at leakage and basal detrosur pressure ) was lower in group 1 ( 35  19 cm h2o ) than in group 2 ( 46  40 cm h2o ) .
uninhibited detrusor contractions were noted in nine patients ( 82% ) of group 1 and 21 patients ( 81% ) of group 2 .
tethered cord is a terminology commonly used in literature , which refers to a short , thickened , and tight filum terminale , as well as any pathology , which prevents the spinal cord from ascent .
secondary tethering of spinal cord after prior myelomeningocele closure has been found in about 30% of the cases .
although mri is certainly sensitive and is considered the method of choice for the detection of a tethered spinal cord , diagnosis of the tethered cord syndrome ( tcs ) is a complicated one , because data on the anatomical malformation are not adequate for this task .
recent studies have shown that a combination of an elongated cord and a thick filum terminale , demonstrated by mri , is no longer an essential feature for the diagnosis of tcs . moreover ,
the value of mri imaging is limited in patients with post repair of myelomeningocele , because most of these patients will show a pattern of tethering .
thus , for tcs diagnosis , emphasis should rather be on its characteristic symptomatology , accentuated by postural changes , since tcs is a functional disorder of the lumbosacral spinal cord .
surgical untethering of the cord is recommended by many authors.[1379 ] however , while patients with lipomyelomeningocele have the most favorable prognosis , secondary tethering of the cord have a worse prognosis , and it becomes even worse with surgical treatment , as reported by grass et al . in our study ,
untethered patients showed better outcome in terms of nocturnal and diurnal enuresis after detethering , as compared to those who did not undergo detethering ( 45% versus 69% ) .
this compares favorably to previous reports , in which improvement of urological symptoms has been described .
however , none of them , in our study or in the previous studies , became urologically normal . this could be explained by the fact that during complex microsurgery performed in those patients , the conus medullaris and the roots that innervate the lower limbs , bladder , and bowel were inevitably exposed to some degree of damage .
another possibility was the permanent reduction of bladder contractility and increased rigidity in patients with end - stage myelomeningocele . in pursuing the ideal management of such a malady
seeking an optimum approach of patient management , bladder management must be considered in adjunction to bowel management .
however , little attention has been paid to fecal incontinence , which is also common in patients with tethered spinal cord .
, reported ( 46% ) improvement of bowel function after meticulous spinal surgery , another report mentioned an improvement in up to 90% of the cases .
our results show less fecal soiling problems in patients who underwent detethering of the spinal cord ( 18% ) in comparison to those who did not ( 38% ) .
urodynamic testing is an integral part of the initial evaluation and subsequent management of a newborn with myelomeningocele .
based on the mcguire observations , deterioration of the upper urinary tract occurs when intravesical pressure during filling at time of leakage exceeds 40 cm h2o .
consequently , the accurate measurement of det lpp has evolved to critical importance in the treatment of such patients .
our results have shown an improvement in reduction of det lpp in group 1 , as well as more bladder stability after detethering of the spinal cord .
thus , detethering of the cord may prevent deterioration of upper urinary tract in those patients .
detethering of the spinal cord has a positive impact on patients with myelomeningocele in terms of lowering of det lpp and accordingly in decreasing the risk of upper tract deterioration .
 aim of work : to study the effect of detethering of the cord on urodynamic changes in patients with myelomeningocele.materials and methods : we retrospectively reviewed the urodynamic data of 37 patients . in all of them 
 myelomeningocele primary repair was carried out . 
 the patients were divided into two groups : ( 1 ) those who underwent detethering of the cord and ( 2 ) those who did not . 
 neurourological examination , filling cystometry , assessment of bladder management , and fecal continence were studied in all patients.results:eleven ( 29.7% ) out of 37 patients underwent detethering of the cord . the mean age at presentation was 10.1  4 and 10.8  7 years in groups 1 and 2 , respectively ( p 0.7 ) . 
 nocturnal and diurnal enuresis was found in 45% of group 1 , while it was found in 69% of group 2 . 
 fecal soiling was detected in 18% in group 1 and in 38.5% in group 2 . 
 mean bladder capacity was 210  125 cc and 199  120 cc for groups 1 and 2 , respectively ( p 0.8 ) . 
 uninhibited detrusor contractions were noticed in nine patients ( 82% ) of group 1 and in 21 patients ( 81% ) of group 2 . 
 delta det lpp was lower in group 1 ( 35  19 cm h2o ) than in group 2 ( 46  40 cm h20).conclusion : detethering of the cord had a positive impact on patients with myelomeningocele in terms of lowering of det lpp and accordingly decreasing the risk of upper tract deterioration . 
Introduction
Materials and Methods
Results
Discussion
Conclusion