In our cohort 130 patients underwent 182 SSCU. Only 56 interventions in 52 patients met the inclusion criteria. Gender distribution was equally (male: n=29; 51,8%; female: n=27; 48,2%). The median age at SSCU was 9,02 years (range 0,5 – 22,8 years). Closed spinal dysraphism was observed in 10,7% (n=6) of surgeries, a spina bifida aperta in 89,3% (n=50). Most interventions were performed on patients with a lumbar lesions (n=39; 69,6%), followed by sacral (n=13; 23,2 %) and thoracic (n=4; 7,1%) lesion levels. The reasons for SSCU were: BF (n=10; 17,9%), NOD (n=24; 42,9%), BF+NOD (n=17; 30,4%), and other indications (n=5; 8,9%) (Fig. 1C).
Benefit in bladder functional outcome in patients after SSCU.
Regarding AC, 9 out of 56 procedures (16.1%) were classified as stage 1 preoperatively, 26 (46.4%) as stage 2 and 21 (37.5%) as stage 3. After SSCU, the stage improved in 11 patients (19.6%), worsened in 11 (19.6%) patients and remained the same in 34 patients (60.7%) after intervention. As we considered stable bladder function as well as improved outcome after surgery to be a success of SSCU, we defined an improved stage and an unchanged stage after surgery as non-deterioration. This condition was observed in a total of 45 cases (80.4%) (Fig. 2A, chi²-test, p<0.001).
With regard to the MHS, 17 of 56 interventions (30,4%) were carried out with a score between 0 to 1 before surgery, 25 (44,6%) had a score of 2 to 4 and 14 interventions (25%) were performed with an initial score of 5 or more. The minimal score was 0, the maximum value was 7 points before the intervention and 6 points after. In nearly half of the cases (n=27, 48,2%) the score improved, as measured by a decrease in MHS, or remained unchanged in 12 patients (21.4%), 17 patients worsened (30.4%). Non-worsening in postoperative bladder functional outcome was demonstrated in 39 cases (69,6%) over all (Fig. 2B, chi²-test, p<0.005).
High risk for worsening of bladder functional outcome after SSCU due to the neuro-orthopedic indication (NOD).
When considering the postoperative deterioration of bladder outcome depending on the indication for SSCU, the NOD group dominates regardless of the chosen assessment score. (Fig. 3AB). Categorized with AC, 11 times a surgery lead to a worsened bladder functional outcome. In 7 of these 11 cases (63,6%) the indication for surgery were NOD, the remainder were BF and BF+NOD, twice each (18,2% respectively) (Fig. 3C). Referring to the MHS, 17 interventions resulted in worsening, 11 of them with NOD as indication (64,7%), one with BF (5,9%), 3 with BF+NOD (17,6%) and 2 times others (11,8%) (Fig. 3D). We further analyzed those 17 patients, listed details on pre and postoperative scores, intications for surgery and postoperatibe outcome (Table 1). Regardless of whether bladder function is categorized by AC or MHS, postoperative outcome worsened significantly when SSCU was performed due to increasing deterioration in motor function alone (chi²-test p<0.05).
Table 1
Details of the patients with worsening of the bladder function after untethering surgery.
Patient
|
Indication
|
Score pre OP
|
Score post OP
|
Neuro-orthopedic clinical situation before surgery
|
Situation post OP
|
Positive neuro-orthopedic outcome
|
1
|
NOD
|
0
|
1
|
Increase in deformity of joints and loss of muscle strength in legs
|
Deterioration stopped
|
yes
|
2
|
NOD
|
1
|
2
|
Increase in foot deformity and loss of muscle strength of the left leg
|
Deterioration stopped
|
yes
|
3
|
BF+NOD
|
2
|
3
|
Increase in contractures and spasticity of the left leg, so that walking in the orthoses used up to that point was difficult
|
Activity in the right leg worse than before the operation; still walking with difficulty
|
no
|
4
|
Other
|
0
|
1
|
Due to progressive scoliosis, the use of walking orthoses was no longer possible. Goal: by tethered cord with large spinal lipoma as preparation before scoliosis surgery
|
No deterioration of the neuro-orthopedic clinic; in the course successful scoliosis surgery
|
yes
|
5
|
NOD
|
0
|
5
|
Increasing back pain and pain in the scar area, increasing scoliosis
|
No more pain
|
yes
|
6
|
NOD
|
2
|
3
|
Back pain after about 30 minutes of walking
|
No more pain
|
yes
|
7
|
NOD
|
1
|
2
|
Back pain and pain in the scar area
|
No more pain
|
yes
|
8
|
NOD
|
1
|
4
|
Increase in deformity of joints and loss of muscle strength in legs; myoclonia in toes in right foot
|
Muscle strength returned, no more myoclonia
|
yes
|
9
|
NOD
|
1
|
6
|
Back pain and hypersensitivity with pain in the scar area, myoclonia in legs
|
No more pain, no more myoclonia, normal sensitivity in the scar area
|
yes
|
10
|
NOD
|
0
|
1
|
Due to progressive scoliosis, the use of walking orthoses was no longer possible. Goal: by tethered cord as preparation before scoliosis surgery
|
No deterioration of the neuro-orthoaedic clinic, in the course successful scoliosis surgery
|
yes
|
11
|
BF
|
3
|
6
|
No deterioration
|
No deterioration
|
no
|
12
|
NOD
|
1
|
2
|
Loss of muscle strength in legs, increasing problems with walking
|
Walking improved, Walking distance improved, muscle strength returned
|
yes
|
13
|
BF+NOD
|
5
|
6
|
Loss of muscle strength in legs, increasing problems with walking
|
Walking improved, walking distance improved, muscle strength returned
|
yes
|
14
|
NOD
|
0
|
1
|
Increase in deformity of joints and loss of muscle strength in legs
|
Muscle strength returned, walking distance improved.
|
yes
|
15
|
NOD
|
0
|
2
|
Increase in deformity of joints and loss of muscle strength in legs, increased spasticity
|
Muscle strength returned, walking distance improved, spasticity returned.
|
yes
|
16
|
Other
|
1
|
2
|
Due to progressive scoliosis, the use of walking orthoses was no longer possible. Goal: by tethered cord as preparation before scoliosis surgery
|
No deterioration of the neuro-orthopedic clinic, in the course successful scoliosis surgery
|
yes
|
17
|
BF+NOD
|
3
|
5
|
Loss of muscle strength in legs, increased spasticity
|
Spasticity returned, walking improved.
|
yes
|
SSCU surgery carried out with a good preoperative bladder situation have a significantly higher risk for a worsening of postoperative bladder functional outcome.
No matter if categorized with AC or MHS we saw a similar development in the postoperative bladder functional outcome after intervention.
The preoperative bladder situation was considered good with the AC=1 (n=9 of 56; 16,1%) or a MHS of 0 to 1 (n=17 of 56; 30,4%). The postoperative trend showed that 7 of 9 patients with an AC=1 (77,8%) worsened and only 2 (22,8%) did not change (Fig. 3.E, chi²-test, p<0,001). Concerning the MHS, 12 of 17 patients with a score of 0-1 points (70,6%) deteriorated while 2 (11,8%) stayed the same and 3 (17,6%) improved (Fig. 3.F, chi²-test, p<0,01).
Patients undergoing SSCU because of NOD benefit from surgery concerning the neuro-orthopedic outcome.
After investigating bladder function in patients with NOD as an indication, we asked how SSCU affected motor function. Since the development of NOD in spina bifida patients is a dynamic and progressive process, an unchanged neuro-orthopedic status over time after surgery can be considered a success.
In total only 8 of 56 (14,3%) had a worsened neuro-orthopedic outcome after surgery, the majority improved (n=23; 41,1%) or stayed identical (n=25; 44,6%) (Fig. 4A, chi²test, p<0.05). Of the 24 cases with NOD as indication, 22 (91,7%) had an unchanged (n=10; 41,7%) or improved (n=12; 50,0%), meaning positive neuro-orthopedic outcome, only 2 (8,3%) deteriorated (Fig. 4B, chi²-test; p<0,001). Therefore, SSCU delivers a notable benefit concerning the neuro-orthopedic outcome.