Application and outcomes of a standardized, evidence based institutional approachto tethered cord management in pediatric urology
Background:Tethered cord syndrome (TCS) is a common diagnosis seen in pediatric urology, which often presents with bladder dysfunction. There are significant findings in the literature regarding the definition and evaluation of simple tethered cord (sTC). However, the management of sTC with surgery remains controversial. In this study, we hypothesized that we could develop an algorithm for management of tethered cord and use this algorithm to determine suitable candidates for tethered cord release surgery in collaboration with neurosurgery.
Methods:Based on an EBM analysis of 93 papers from PubMed, an institutional standard for TC management was established with neurosurgery. After IRB approval, a prospective study was performed on all patients seen for sTC and managed using the surgical indications created during the year 2019. Demographic, clinical, diagnostic, consultative and outcome data was collected for each patient. A multidisciplinary team of neurosurgery, urology, gastroenterology, general surgery and/or orthopedics were involved in the evaluation of each patient. Patients who underwent surgical intervention were seen at 6 weeks and 6 months for follow-up. Post-operative outcomes were recorded on a four-point ordinal scale (worse, same, better, resolved) for analysis and cross-referenced among the different specialties. Statistical analysis was performed using Wilcoxon Signed-Rank Test and a linear regression model. Results:729 patients were evaluated for possible TC in the year of 2019. Of those, 151 underwent surgery based on the institutional algorithm. Two minor complications occurred (surgical wound breakdown and upper extremity DVT). All patients who underwent surgery were clinically symptomatic pre-operatively, 76% of whom had 3 or more symptoms of sTC. The most common presenting symptom was bladder dysfunction. 65% of patients were seen by 3 or more subspecialties before surgery; neurosurgery and urology were the two most common specialties involved. Significant improvement of symptomatic TC was seen across all symptoms (bladder bowel, back pain, leg pain, gait, headache, tone) in most patients. For bladder symptoms, all patients who underwent surgery had significant improvement in symptoms over time (six weeks vs six months, p<0.05).
Conclusion:Surgical intervention for TC patients has low morbidity with significant improvement in symptoms post-operatively when managed via our institutional EBM algorithm. A standardized set of operative indications driven by a multidisciplinary, evidence-based algorithm for sTC was found to have high accuracy in identifying patients who benefit from surgery based on displayed symptom improvements.