Tethered cord in children: a clinical classification with urodynamic correlation

Tethered cord was classified based on clinical presentation and correlated with urodynamic and uroradiographic findings.

A total of 54 children underwent cord untethering from 1993 through 2000. Preoperative magnetic resonance imaging, fluorourodynamics and renal ultrasound were performed in all cases, and postoperative (mean 16 months) fluorourodynamics was done in 33. The conus was at L-2 or lower, with or without a thickened filum in 51 patients and 3 older children with voiding dysfunction had normal cords.

Children were classified into group 1-19 with orthopedic deformities (scoliosis or lower limb abnormalities, group 2-16 with cutaneous back lesions, group 3-13 with voiding dysfunction (VD) or urinary tract infection without cutaneous lesions and group 4-6 with associated syndromes. In group 1, 3 patients (16%) had preoperative hyperreflexia (HR) which improved postoperatively in 2, HR developed in 1, none had hydronephrosis or reflux (VUR), 5 (26%) had voiding dysfunction (VD) and 4 improved postoperatively. In group 2, 4 patients (25%) had preoperative HR and all improved postoperatively, and 5 (31%) had VUR and 2 improved postoperatively. In group 3, 11 patients (85%) had HR and 2 (15%) were areflexic preoperatively and 6 (areflexic 1, HR 5) improved postoperatively, 3 (23%) had VUR and 2 improved postoperatively, and 7 (54%) had improved VD but 5 (71%) were on anticholinergics. All 3 patients with VD/normal cords had preoperative HR, and 1 improved, 1 had preoperative VUR which resolved and 1 clinically improved but was on anticholinergics. In group 4, 5 patients (83%) had HR and 2 improved, 2 (33%) had VUR and both improved, and 3 (50%) had VD and 1 improved.

Older children who present with orthopedic problems have rare neurourological abnormalities many of which resolve after surgery. Similarly, infants who are diagnosed early with a cutaneous back lesion can have urodynamic abnormalities, which also have a high rate of resolution. Older children who present with VD have the highest incidence of urodynamic abnormalities. While many seem improved clinically after surgery, they require anticholinergics. All patients with VATER's syndrome should be evaluated prospectively for tethered cord.