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Filum terminale lipomas—the role of intraoperative neuromonitoring

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Abstract

Background

Filum terminale lipomas (FTL) represent a sub-type of spinal lipomas, where there is fatty infiltration of the filum. It becomes a surgical entity when it manifests as clinical or radiological tethered cord syndrome. Intraoperative neuromonitoring (IONM) has been suggested as a valuable tool in children for tethered cord surgeries. FTL is distinct and cannot be compared with complex tethered cord syndrome (TCS). Untethering an FTL is a relatively straightforward microsurgical exercise, usually based on anatomical findings. Neurological morbidity in FTL untethering is extremely low. The necessity of IONM in FTL has not been evaluated. The objective of this study was to identify the role of IONM in untethering an FTL

Methods

Available electronic data and case files were interrogated to identify children (0–18 years) who underwent an untethering of FTL between 2008 and 2019. We had a shift in our policy and tried to use IONM as often as possible in all tethered cord surgery from 2014. All children were categorised under ‘IONM implemented’ or ‘no IONM’ group. Outcomes analysed were as follows: (1) Clinical status on short-term and long-term follow-up, (2) alteration of surgical course by IONM and (3) complications specifically associated with IONM

Results

Among 80 children included in this study, IONM was implemented in 37 children and 43 children underwent untethering without IONM. 32.5% of children were ‘syndromic’. Seventy-five percent of children were under age 3 years during surgery. Both groups (No IONM vs. IONM implemented) were well matched in most variables. Majority of ‘no IONM’ surgeries were performed prior to 2014. There was no neurological morbidity in the entire cohort. Mean duration of follow-up was 49.10 (± 33.67) months. Short-term and long-term clinical status remained stable in both cohorts. In 16 children, the filum was stimulated. Based on our protocol, majority had a negative response. One child showed a positive response, contradicted by thorough microscopic inspection. Despite a positive response, the filum was untethered. IONM was not associated with any complication in this study.

Conclusion

FTL untethering is an inherently low-risk microsurgery in experienced hands with rarely reported neurological morbidity. IONM may not be required for all FTL and may be used more judiciously.

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Abbreviations

FTL:

Filum terminale lipoma

TCS:

Tethered cord syndrome

IONM:

Intraoperative neuromonitoring

MEP:

Motor evoked potential

SSEP:

Somato-sensory evoked potentials

EMG:

Electromyography

CMAP:

Compound muscle action potential

TIVA:

Total intravenous anaesthesia

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Acknowledgement

We thank Dr Swetha Kumar for editorial assistance.

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Authors and Affiliations

  1. Paediatric Neurosurgery Department, Dana-Dwek Children’s Hospital, Tel Aviv Sourasky Medical Centre, Tel Aviv University, Tel Aviv, Israel

    Harishchandra Lalgudi Srinivasan, Pablo Valdes-Barrera, Ariel Agur, Jehuda Soleman, Akiva Korn, Jonathan Roth & Shlomi Constantini

  2. Department of Neurosurgery, Division of Paediatric Neurosurgery, University Hospital and Children’s Hospital of Basel, Basel, Switzerland

    Jehuda Soleman

  3. Faculty of Medicine, University of Basel, Basel, Switzerland

    Jehuda Soleman

  4. Division of Anaesthesiology, Intensive Care, and Pain Medicine, Tel-Aviv Medical Center affiliated with the Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel

    Margaret Ekstein

  5. Intraoperative Neurophysiology Service, Tel Aviv Sourasky Medical Centre, Tel Aviv, Israel

    Akiva Korn & Irina Vendrov

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  1. Harishchandra Lalgudi Srinivasan
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Correspondence to Shlomi Constantini.

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Lalgudi Srinivasan, H., Valdes-Barrera, P., Agur, A. et al. Filum terminale lipomas—the role of intraoperative neuromonitoring. Childs Nerv Syst 37, 931–939 (2021). https://doi.org/10.1007/s00381-020-04856-4

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