The clinical manifestations of spinal

cord fixation syndromes are believed to result from an ischemic event, usually caused by stretching of the spinal cord, with early Selleck CDK inhibitor surgical release allowing the best chance for neurologic recovery.53 The incidence of retethering in the myelomeningocele population has been estimated at 15% to 20%.54 Its diagnosis is primarily clinical, with patients presenting with progressive or subtle loss of function, and it is usually detected by Inhibitors,research,lifescience,medical careful and regular evaluations. It is important for urologists to recognize the presence of a tethered cord because it may present as new-onset or a pattern change of voiding dysfunction in this population. Numerous reports have shown urodynamic improvements in some patients after surgical release of the fixed spinal cord.55–62 Inhibitors,research,lifescience,medical Screening for a tethered cord. Patients at risk for a tethered cord include those with cloacal exstrophy, imperforate anus, VATER syndrome, and cutaneous stigmata of occult dysraphism (focal hirsutism, midline dermal sinus above the gluteal crease, subcutaneous lipoma, capillary hemangioma,

midline appendages, dermal dysplasia resembling a “cigarette burn”), among others (Tables 3 and ​and4).4). It is recognized that up to 10% to 50% of patients with surgically significant occult spinal dysraphism will have normal skin; therefore, Inhibitors,research,lifescience,medical screening for intradural pathology only on the basis of skin inspection is a poor method of detection.63 Table 4 Conditions Requiring Screening for Spinal Dysraphism The majority of myelomeningocele patients have radiographic evidence of a tethered cord on MRI. Therefore, radiographic evidence alone is not a justification for operation. Patients Inhibitors,research,lifescience,medical with symptoms referable to the area, particularly if the problems are progressive, should be considered candidates for operative detethering. Symptoms may be subtle and may simply be a change in the continence pattern

or a worsening in scoliosis. Children with voiding dysfunction are a mainstay of urologic practice. Evaluation of all of them by MRI looking Endonuclease for a neurologic Inhibitors,research,lifescience,medical cause is inappropriate and costly. There are some criteria that will enhance the yield. Any patient with cutaneous stigmata of occult dysraphism should be imaged, whether symptomatic or not. This implies that the skin of the back should be examined. Any child with neurologic deficit or back or leg pain should also be imaged. Those with a neurogenic pattern to their urodynamic study or significant bony dysmorphism should be considered. Appropriate imaging of the intradural anatomy can be accomplished in a child up to 4 to 6 months of age by ultrasonograpy.64,65 Premature children should not be screened until they reach full-term gestational age because of the naturally low position of the conus. After 6 months of age, MRI is the most appropriate imaging study.