Tethered spinal cord ucsf benioff childrens hospital oakland. This case demonstrates radiological features of spina bifida at s3 level and tethered cord. Applying the word tethered to the lumbosacral spinal cord, one. We report a 63yearold man with suddenonset severe right chest and upper back pain, followed by. Prompt surgical treatment is often necessary to avoid permanent sequelae. Introduction to the tethered cord syndrome shokei yamada 1 1 the word tether means to restrain, an example of which is an animal held to the maximal range of motion by a rope.
We then positioned the patient prone and obtained the same sequences. Mr imaging of spinal dysraphism american journal of. Mr protocol for techs and physicians mr total spine chiaritethered cord wo protocol skip to main content skip to main navigation most ohsu services have returned to normal operations. Us spinal canal and contents tethered cord pediatric exam 76800 vascular other. Dr kula and dr bolognese at chiari neurological center. Cor t1 obl sacrum cor stir obl sacrum if contrast given. Prone position mri is a diagnostic imaging technique for the study of the position of the filum terminale with respect to nerve radicles inside the vertebral canal and more precisely within the meninges. Surgery for tethered cord surgery involves the following steps. Substitute axial t1 for t2 gre if hardware is present. Normally, the spinal cord hangs loose in the canal, freely bending and stretching and moving up. Diagnosis also includes looking for signs of a lowerthannormal spinal cord, which may be detected during an endoscopy.
Tethered cord syndrome is a clinical diagnosis based on neurologic deterioration involving the lower spinal cord 7. Prone lumbar mri in patients with occult tethered cord syndrome if the occult tethered cord syndrome otcs due to a tight filum terminale is occult, how is the diagnosis made. Mar 27, 2019 tethered spinal cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal column. Tethered cord syndrome tcs is an increasingly recognized clinical disorder, which is usually identified in childhood and is defined as a stretchinduced functional disorder of the spinal cord with its caudal part anchored by an inelastic structure. Pt can be brought back if deemed necessary by radiologist or if already on scanner you can. This scan is for the localisation of the spinal cord and to check the vertebral body level of any spinal cord pathologies.
Magnetic resonance imaging in the prone position and the. Spinal mr was found to be extremely useful in the evaluation of the suspected tethered spinal cord. In children, a tethered cord can force the spinal cord to stretch as they grow. The development of magnetic resonance imaging mri and other technological advances has given rise to abetter understanding of spinal fluid dynamics. Many people with open spina bifida have tethered spinal cords. The use of prone magnetic resonance imaging to rule out. If you dont areposition the paddle b change the amplitude c use sat bands to null any bright signal near your area of interest from stomach, fluid or fat dmake sure patient is holding breath. Radiologists work closely with ohsu mri techs in the art of creating optimal images from current technology. Tethered cord syndrome due to a tight filum terminale the nonoccult variety has been classically diagnosed by appropriate clinical signs and symptoms and radiographic.
Early in infancy ultrasound of the spine is a good screening tool. Tethered cord syndrome is a congenital childhood disease, which can also be seen in adults. The causes of the tethering were spinal lipomas 72%, tight. Schneider, md figure mri of a tethered spinal cord. Myelopathy due to lumbar disc herniation in the presence. Normal radiology in the presence of clinical features of cord tethering should. In some cases, symptoms may be present at birth congenital, while others may not experience symptoms until later in adulthood. This definition leads to the connotation the harder the pull on the rope, the tenser the rope. This unexpected finding may have diagnostic andor prognostic significance.
Subjects journals books book series working papers. It can affect children and adults, but the causes of tcs differ. The decision to detether the spinal cord is made based on presenting symptoms. This abnormal attachment is associated with progressive stretching and increased tension of the spinal cord as a child ages, potentially resulting in a variety of. Jan 14, 2015 tethered cord syndrome tcs represents a spectrum of congenital anomalies characterized by an abnormal caudal position and traction of the conus medullaris.
This approach requires the patient to be old enough to reliably convey whether the symptoms are. Tethered cord syndrome is a neurological disorder caused by tissue attachments that limit the movement of the spinal cord within the spinal canal. It is only suggested or recommended whenever the presenting symptoms of the child are unbearable and that signs of deterioration are noted. This test uses magnetic fields to give a very clear picture of the anatomy of the spine. Diagnosing tethered spinal cord diagnosing tethered spinal cord is done by performing an mri of the spine at childrens hospital oakland. If you have questions about ordering your patients mri, we encourage you to speak with a radiologist about the study and the need for contrast. Tethered cord syndrome with a tight filum terminale is a very rare. The severity of the condition and the associated signs and symptoms vary from person to person. In some institutions this may include a mri movie cine study to evauate spinal cord movement. A three plane localiser must be taken in the beginning to localise and plan the sequences.
The patients were divided into two groups, one with a diagnosis of occult tethered cord in chiari malformation i or with llct descent of the tonsils from 1 to 4 mm so as not to configure the presence of chiari malformation i and a group with the diagnosis occult tethered cord is not associated with other diseases of the nervous system. This 6yearold girl was referred to physical therapy for baseline evaluation in the spina bifida clinic and for assessment of neurogenic bowel and bladder dysfunction. Tethered spinal cord syndrome causes, diagnosis and treatments. However, mri has largely replaced ultrasound in the diagnostic evaluation of pediatric spinal dysraphism due to its superior ability to visualize and differentiate lesions involving the spinal canal and surrounding soft tissues. Followup examination revealed release of the cord, and only a small amount of residual lipoma was seen. Mri lumbar supine, no contrast urodynamic testing report ruling out neurogenic bladder. A diagnostic test that, using powerful magnets and computer technology, produces threedimensional images of body structures. Tethered cord syndrome is a stretchinduced functional disorder associated with the fixation tethering effect of inelastic tissue on the caudal spinal cord, limiting its movement. In babies and children, tcs is nearly always congenital, meaning the child was born with his or her spinal cord attached to the spinal column or to the skin. All forms involve the pulling of the spinal cord at the base of the spinal canal, literally a tethered cord. Tethered cord syndrome symptoms, surgery, treatment, causes. Needles are inserted into the lower body to monitor nerve function even as the child is asleep. See more ideas about cord, spinal cord and chiari malformation.
Various forms include tight filum terminale, lipomeningomyelocele, split cord malformations diastematomyelia, dermal sinus tracts, and dermoids. Interestingly, cavitary lesionsmyelomalacia of the conus or the cord adjacent to the tethering lesion were seen with appropriate images in nine of 20 patients. Tethering of the spinal cord is a condition in which the spinal cord becomes attached to the spinal column via surrounding structures. Oldfield, 1994 has proposed the piston theory, whereby the cerebellar tonsils are thought to act as miniature pistons driving fluid from the space surrounding the spinal cord into the spinal. Diagnosing and treating a tethered spinal cord pediatric. Adult tethered cord syndrome atcs is a rare entity that usually presents with multiple neurological symptoms, including lower extremity pain, backache, lower extremity muscle weakness, and bowelbladder disturbances. Aug 06, 2016 the spinal cord normally exhibits anteroposterior and craniocaudal movement when the patient has changed from the supine to the prone position, whereas the tethered spinal cord exhibits decreased or no movement.
A tethered cord syndrome is caused by a stretchinduced dysfunction of the caudal spinal cord and conus, that often associated with spinal dysraphism. Outcome of ultrasonographic imaging in infants with sacral. The filum terminale appears separate to the mass, and can be traced as it descends in the thecal sac anterior to the fatty mass. Tethered cord see pacsp7 tethered cord evaluation of suspected occult and nonoccult dysraphism see pacsp6. What is prone position magnetic resonance imaging mri. Cortical bone has few mobile protons and is dark on all sequences. Tethered cord syndrome tcs is rare, but no one knows exactly how prevalent it is because it commonly goes undiagnosed. On imaging, it manifests as a low conus medullaris below l2 and thickened filum terminale 2 mm. Supine mri is the imaging modality of choice, but prone mri and cine mri can demonstrate cord movement. Tethered spinal cord surgery childrens hospital colorado. No contrast reference sheet headneck body part reason for exam procedure to precert cpt.
The decision to perform surgery to untether the cord requires clinical judgment. Comparison of standard, prone and cine mri in the evaluation. Patients may present with any combination of the following 4. Get the cdroms of the mris from the radiology place. Tethered cord syndrome nord national organization for rare. The first five chapters of the book introduce the reader to the basics of mr imaging, including the relaxation concept, mr pulse sequences, and mr imaging parameters and options. Tethered cord syndrome associated with a thickened filum. Magnetic resonance imaging mri exam to order symptomsconcerns cpt code.
Giving a chance to untether the cord before progressive and permanent damage occurs. Surgical cord release usually stops neurological deterioration. Symptomatic protocols for adult tethered cord syndrome. An unusual presentation of adult tethered cord syndrome. Mr imaging in the tethered spinal cord syndrome ajr.
Because the patient must be still for the entire study, your child will have the test with anesthesia. If a tethered cord is suspected, one or more tests may be necessary to confirm the diagnosis. A spinal mri is obtained to confirm the diagnosis of tethered cord. Normally, the bottom of the spinal cord floats around freely in the spinal canal. An mri of the low back is the most definitive test for spinal cord tethering, and often the only test needed. An incision is made in the skin over the lower back. Followup examination revealed release of the cord, and only a. An mri scan, which offers a closer look at soft tissues, can usually determine if the issue is an abnormal placement of the spinal cord rather than nerve compression. The most definitive diagnostic test is the mri scan. Localisers are normally less than 25 seconds long and are t1 weighted low resolution scans. The spinal cord normally hangs loose in the canal, free to move up and down with growth, and with bending and stretching. Lowlying conus medullaris, tethered cord syndrome, intradural lipoma.
The following protocols are an updated list of the neuroradiology mri protocols for all of the mri sites at which tra medical imaging is responsible for the administration, quality and interpretation of neuroradiology mri examinations. If not, follow the adult protocol, but make changes to the slice, gap, and fov as needed. In 21 patients 84%, the level of the tip of the conus was below the mid l2 vertebral. A tethered spinal cord is attached to the spinal canal. Since she needs anesthesia, i was advised not to feed her 6 hours before the mri, which im already anticipating to be very hard to do. Were always available to answer questions and address any concerns you may have. Tethered cord syndrome nord national organization for. Tethered cord tc obtain tests have your treating physician ordering for you the following tests since you are not yet our patient at that point of the process, we cannot order them for you. The imaging protocol included sagittal, transverse, and dorsal plane. Tethered cord syndrome radiology reference article.
Mri exams contrast vs noncontrast guide these suggestions are general guidelines that apply to the use of contrast for mri exams provided at oregon imaging centers. Mr total spine chiaritethered cord wo protocol ohsu. This method was recently described in the 20 publication by colleagues at the university of hiroshima in the scientific journal j. Although mri is certainly sensitive and is considered the method of choice for the detection of a tethered spinal cord,1 diagnosis of the tethered cord syndrome tcs is a complicated one. When this happens, the spinal cord stretches as a person grows, which can permanently damage the spinal nerves. Nov 23, 2015 tethered cord syndrome is a rare neurological condition. Neuroradiology protocols currently applied in our mri section. A normal conus medullaris lies at the level figure 14 mri of a diastematomyelia showing the split spinal cord and tethering. The pediatric radiologists will usually protocol specific sequences they need in ris. Tethered spinal cord syndrome information page national. Mri of spine is also useful for evaluation of the cord lesions, diseases of foramen magnum, syringohydromyelia, etc. Tethered cord syndrome tcs is defined by abnormal traction on the spinal cord that confines its movement. A tethered cord, however, is held taut at the end or at some point in the spinal canal. If the patient has predominantly back pain and mild weakness, a course of physical therapy may provide tethered cord treatment.
These attachments cause an abnormal stretching of the spinal cord. Attachments may occur congenitally at the base of the spinal cord conus medullaris or they may develop near the site of an injury to the spinal cord. Prone lumbar mri in patients with occult tethered cord. The area of low signal intensity is a small amount of cartilage contained within the mass. It is recommended that all patients in which there is suspicion of a tethered spinal cord should have imaging.
At birth, this patient was diagnosed with sacral dysgenesis along with tethered cord and a lipoma within the sacral spinal canal. The variation of position of the conus medullaris in an adult population. The untethering of the cord is the most ideal treatment for tethered cord syndrome. Most people with spina bifida will have a tethered cord on the mri. Tethered cord syndrome tcs is a complex of neurologic symptoms that include pain, incontinence, musculoskeletal deformities, motor weakness, and sensory abnormalities resulting from abnormal stretch placed on the distal spinal cord by congenital or acquired factors. Tethered spinal cord in children treatments boston. Tethered cord syndrome tcs refers to a group of neurological disorders that relate to malformations of the spinal cord. Dynamic lumbosacral magnetic resonance imaging in a.
The diagnosis of a tethered spinal cord is made by obtaining a magnetic resonance imaging or mri of the spine. Mri of the lumbar spine demonstrates a low lying conus terminating at l4 associated with spina bifida of l5 and s1. Tethered cord see pacsp7 tethered cord evaluation of suspected occult and nonoccult dysraphism see pacsp6 spinal dysraphism evaluation of spinal cord tumors, vascular malformations, and cases of birthrelated trauma o in general, additional imaging studies of the spine are not indicated in. Our experts in the boston childrens hospital tethered spinal cord program have years of experience treating these disorders, using minimally invasive techniques whenever possible. In the defect is a fatty mass attached to the dorsal aspect of the cord. Tethered cord syndrome tcs represents a spectrum of congenital anomalies characterized by an abnormal caudal position and traction of the conus medullaris. In 21 patients 84%, the level of the tip of the conus was below the mid l2 vertebral body. Note that the spinal cord elements are not involved within the fatty mass, just tethered.
Im hoping this is the right place to post this question. Ecr 2019 c1766 diagnostic dilemma in mr imaging of spinal. The aim of this study was to describe magnetic resonance imaging findings of 17 adult patients with tethered cord syndrome and correlate the magnetic resonance images with intraoperative findings. To present a case of lumbar disc herniation causing compression of a tethered cord that was successfully treated with lumbar decompression and fusion.
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