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Unformed Conus Medullaris in Children With Spinal Lipoma Is a Risk Factor Requiring Clean Intermittent
Shinako Takeda1,2, Naoki Kawamorita2, Tsubasa Shironomae1
1Department of Urology, Miyagi Children's Hospital, Sendai, Japan.
Insights
Children with spinal lipoma requiring clean intermittent catheterization (CIC) often have an unformed conus medullaris. Early identification of risk factors like detrusor overactivity and detrusor-sphincter dyssynergia is crucial for managing neurogenic lower urinary tract dysfunction.
Area of Science:
- Pediatric Urology
- Neuroscience
- Developmental Biology
Background:
- Spina bifida is a leading cause of neurogenic lower urinary tract dysfunction (NLUTD) in children.
- Spinal lipoma, a type of spina bifida occulta, presents unpredictable outcomes and can delay urinary management.
- Clean intermittent catheterization (CIC) significantly impacts the quality of life for affected children and their caregivers.
Purpose of the Study:
- To identify risk factors associated with the need for CIC in pediatric patients with spinal lipoma.
- To investigate predictors of NLUTD requiring CIC in this specific patient population.
Main Methods:
- A retrospective observational study of 116 pediatric patients (≤18 years) treated between 2007 and 2022.
- Evaluation included videourodynamics (VUDS), imaging (MRI, CT), and clinical data.
- Exclusion criteria included other congenital anomalies like anorectal malformations.
Main Results:
- 41% of patients required CIC, with a median introduction age of 43.7 months.
- Unformed conus medullaris (HR 11.5), detrusor overactivity (DO) (HR 2.23), and detrusor-sphincter dyssynergia (DSD) (HR 2.34) were significant predictors for CIC requirement.
- No filar type spinal lipomas required CIC.
Conclusions:
- Unformed conus medullaris is a high-risk factor for NLUTD requiring CIC in spinal lipoma patients.
- DO and DSD on VUDS suggest congenital neural dysgenesis, linking spinal cord development abnormalities to NLUTD.
- Close monitoring of patients with unformed conus medullaris is recommended.
Background:
Spina bifida is the most common cause of neurogenic lower urinary tract dysfunction (NLUTD) in children. Spinal lipoma, a form of occult spina bifida, exhibits variable functional outcomes and unpredictable progression, which may delay timely urinary management. The requirement for clean intermittent catheterization (CIC) also imposes a substantial and lasting impact on the social lives of affected children and their caregivers. Consequently, identifying the predictors of NLUTD necessitating CIC is of significant clinical interest. This study aimed to identify the risk factors associated with the need for CIC in patients with spinal lipoma.
Methods:
A retrospective observational study was conducted on 116 patients aged ≤ 18 years who underwent videourodynamics (VUDS) and received treatment at Miyagi Children's Hospital between April 2007 and April 2022. We excluded patients with other complications, such as anorectal malformations. The study evaluated the necessity for CIC using magnetic resonance and computed tomography imaging, VUDS bladder function, and clinical data, including medication details, duration, and timing of untethering procedures.
Results:
Among the 116 patients analyzed (50 boys and 66 girls), 47 (41%) required CIC at the time of assessment, with a median introduction age of 43.7 months. Patients were categorized into five subtypes of the Arai's classification: 33 with dorsal type, 21 with transitional type, 30 with lipomyelomeningocele (LMMC), 28 with caudal type, and four with filar type. CIC was required in 5 dorsal type, 14 transitional type, 18 LMMC, and 10 caudal type patients, whereas no filar type patients required CIC. Unformed conus medullaris was present in 73 patients (62.9%), and sacral agenesis in 50 patients (43.1%). Proportional hazard model analysis identified unformed conus medullaris (HR 11.5; 95% CI 3.53-37.7; p < 0.0001), detrusor overactivity (DO) (HR 2.23; 95% CI 1.07-4.62; p = 0.0307), and detrusor-sphincter dyssynergia (DSD) (HR 2.34; 95% CI 1.01-5.41; p = 0.0465) on initial VUDS as significant risk factors for the requirement of CIC.
Conclusion:
Patients with an unformed conus medullaris are at a high risk of NLUTD requiring CIC and warrant close monitoring. The presence of DO and DSD on VUDS likely reflects underlying congenital neural tissue dysgenesis, indicating that abnormalities during the junctional neurulation stage of spinal cord development are strongly associated with NLUTD.
