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The patient came to the clinic 21-June-2004 complaining of
micturition erection and defecation problems and LBP for 6
years. MRI done 23-May-2004 showing a huge lipoma of conus
medullaris with tethered cord. On examination: cauda equina syndrome
with weak dorsiflexion both feet and planterflexion left foot.
Hypalgesia and analgesia below S1 root. The patient was advised to
undergo surgery, which was performed elsewhere. The patient came
31-October-2004 after performing surgery 19-September-2004 with same
neurological status without improvement. He had no histological data
reflecting the nature of the mass. He was sent for MRI, which showed
the same picture as before without any changes. The patient was
advised for redo and he disappeared.
The patient then came 29-June-2005 telling that he performed
surgery elsewhere 15-January-2005. Decompression of the cystic
fluidy mass without histological verification. MRI performed
12-June-2005 showed small residual of the mass, which still at the
same level behind the L3 level. The patient telling that he regained
nothing from surgery and the neurological evaluation was the same.
The patient then came 27-August-2006 claiming that, he progressed
further deterioration and he was sent another time for MRI
investigation, which confirmed the presence of tethering and
persistence of the cystic component at the same level. Laminectomy
of L2-3 was noticed.
Laminectomy of L4 and 5 with uppermost of the sacrum was done
with refreshment of the dura over L2 and 3 levels. Using
electrophysiological monitoring, the tethered cord was identified
and separated from the running roots and bisected at the level of
the sacrum. Immediately the cord jumped 20 mm upward. The scarous
dura over the operated site was followed and opened from the left
border, reaching the normal spinal cord proximal to the lesion. The
adherent spinal cord to the dura was dissected sharp off the dura
and to my surprise no stitches were noted in the area of surgery.
After total myelolysis and neurolysis the spinal cord regained
relaxed position and inspection for presence of a mass was negative.
After retrospective analysis of the MRI data and the operative
field, it became clear that the cystic mass was just and adherent
neural structures stuck to the dura.
Water-tight closure of the dura and routine closure of the wound.
Comments:
1. Since tethering of the cord was his primary problem, it was
logical to resolve the problem from the start. About his
neurological recovery , time will give the answer and performing
this kind of surgery, without using electrophysiological monitoring
could lead to neurological deterioration. |
