Publication: Primer gergin omurilik sendromlu hastalarda kord serbestleştirilmesi ameliyatının üriner sistem semptomları ve ürodinami parametreleri üzerine etkisi
Abstract
AMAÇ: Gergin omurilik sendromu (GOS) konus medullarisin ucunun L1-L2 vertebra seviyesinde sonlanması gerekirken L1 vertebra seviyesinin altında anormal fiksasyonu olarak tanımlanır. Fiksasyon doğumsal olarak meydana gelirse primer GOS, herhangi bir intraspinal cerrahi sonrası skara bağlı olursa sekonder GOS olarak adlandırılır. Kordun normal fiksasyonunun olmamasının spinal kordda gerilmeye yol açtığı ve buna bağlı olarak da spinal kord ve sakral sinir köklerinde hipoksi ve iskemiye neden olduğu düŞünülmektedir. (2) Bu patofizyolojik süreç ürolojik, nörolojik, iskelet-kas sistemini ilgilendiren değiŞik semptom ve bulgular ile sonuçlanır. Gergin omurilik sendromunda idrar kaçırma, bozulmuŞ mesane duyumu, iŞeme bozuklukları, vezikoüreteral reflü ve hidronefroz üriner sistem sorunları olarak karŞımıza çıkmaktadır. Bu çalıŞmada, primer gergin omurilik sendromu tanısıyla kord serbestleŞtirilmesi ameliyatı yapılan hastalarda, cerrahinin üriner sistem semptomları ile ürodinami parametrelerine olan etkisini (mesane hacmi, iŞeme basıncı, maksimum detrüsör basıncı, mesane kompliyansı ve postmiksiyonel rezidüel idrar miktarı) ve üriner sistem semptomları ile ürodinami parametreleri arasındaki iliŞkiyi irdelemeyi amaçladık. Tüm bu bulguları ameliyat sonrası 3. ve 12. ayda değerlendirerek cerrahinin neden olduğu değiŞikliklere zamanın etkisini araŞtırdık. HASTALAR VE YÖNTEM: Bu çalıŞmaya Marmara Üniversitesi Tıp Fakültesi NöroŞirurji ile Kartal Eğitim ve AraŞtırma Hastanesi NöroŞirurji kliniklerinde, primer GOS tanısı konularak cerrahi planlanan hastalar dahil edildi. ÇalıŞmada yer alan 40 hastanın primer GOS tanısı, bu kliniklerce öykü, fizik muayene ve MRG sonuçları ile konuldu. Hastaların tanıları SEP ve ürodinamik inceleme ile de desteklendi. Tüm hastalara prospektif olarak ameliyat öncesi ve sonrası 3 ile 12. ayda ürolojik semptom sorgulaması ve ürodinamik inceleme yapılması planlandı. Ürodinamik çalıŞmada mesane kapasitesi, iŞeme basıncı, maksimum detrüsör basıncı, kompliyans ve postmiksiyonel rezidüel idrar olmak üzere 5 parametre değerlendirildi. Hastalar üriner sistem semptomlarının ameliyat öncesi ve sonrası olup olmamasına göre 4 gruba ayrıldı. Bunlar; 1. grup: ameliyat öncesi üriner semptomu var, ameliyat sonrasında yok olan hastalar, 2. grup: ameliyat öncesi üriner semptomu var, ameliyat sonrası var olan hastalar, 3. grup: ameliyat öncesi üriner semptomu yok, ameliyat sonrasında var olan hastalar, 4. grup: ameliyat öncesi üriner semptomu yok, ameliyat sonrası yok olan hastalardan oluŞturuldu. BULGULAR: Hastaların 25‟i (% 62,5) kız, 15‟i (% 37,5) erkek idi. YaŞ aralığı 1,5-16 yaŞ ( ortalama: 7,2 yaŞ ) arasında saptandı. Ortalama takip süresi 2,8 yıl (1-6,6 yıl ) idi. Ameliyat öncesi ve sonrası ürolojik semptomda iyileŞme olup olmamasına göre oluŞturulan gruplara baktığımızda, 1. grupta 13 hasta, 2. grupta 11 hasta, 3. grupta 3 hasta ve 4. grupta 13 hasta olduğu saptandı. Hastaları ameliyat sonrası 3. ve 12. ayda üriner semptom açısından değerlendirdiğimizde, semptomatik açıdan 3. ile 12. ay arasında herhangi bir fark olmadığı görüldü. Ameliyat öncesi yapılan ürodinamik incelemede, hastaların yaŞlarına göre hesaplanan BMK‟nın % 0.5 oranında azalmıŞ olduğu görüldü. Ameliyat sonrası bakılan ilk ölçümde BMK‟nın % 2.6 oranında, ikinci ölçümde % 9.5 oranında artmıŞ olduğu saptandı. Ameliyat öncesi iŞeme basıncı 40 cmH2O‟nun üzeri (anormal) saptanan hasta sayısı 23 (% 62.2) kiŞi, ameliyat sonrası ilk ölçümde 22 (% 59.5) kiŞi, ameliyat sonrası ikinci ölçümde 16 (% 42.1) kiŞi olarak belirlendi. Ameliyat öncesi maksimum detrüsor basıncı 15 cmH2O‟nun üzeri (anormal) saptanan hasta sayısı 33 (% 82.5), ameliyat sonrası ilk ölçümde 31 (% 77.5), ameliyat sonrası ikinci ölçümde 21 (% 52.5) kiŞi olarak belirlendi. Ameliyat öncesinde, hastaların iŞeme sonrası ölçülen rezidüel idrar miktarı BMK‟nin %10‟undan daha fazla olan hastaların sayısı 20 (% 50) kiŞi olarak belirlendi. Ameliyat sonrası ilk ölçümde 17 (% 42.5), ikinci ölçümde 15 (%37.5) hastanın, iŞeme sonrası rezidüel idrar miktarı var olarak raporlandı. Kompliyans değerlendirilmesinde kompliyans (<10 ml/ cmH20) (anormal-hipokompliyan) olan hasta sayısı ameliyat öncesi 17 (% 42.5) kiŞi, ameliyat sonrası ilk ölçümde 18 (% 45) kiŞi, ikinci ölçümde 10 (% 25) kiŞi saptandı. Semptomu olan hastaların ürodinami parametrelerine baktığımızda; ameliyat öncesi 24 hastanın 10‟unda (% 41.6) iŞeme basıncı yüksekliği, 19‟unda (% 79.1) detrüsör overaktivitesi, 13‟ünde (% 54.1) PMR de artıŞ ve 10‟unda da (% 41.6) kompliyans düŞüklüğü saptanmıŞtır. Ameliyat sonrası semptomu olan 14 hastanın 8‟inde (% 57.1) iŞeme basıncı yüksekliği, 11‟inde (% 78.5) detrüsör overaktivitesi, 9‟unda (% 64.2) PMR de artıŞ ve 6‟sında da (% 42.8) kompliyansta düŞüklük izlenmiŞtir. Ameliyat öncesi üriner semptomu olmayan (Grup 3 ve Grup 4) 16 hastanın, 13‟ünde (% 81.2) iŞeme basıncı yüksekliği, 14‟ünde (% 87.5) detrüsör overaktivitesi, 7‟sinde de (% 43.7) hem kompliyans düŞüklüğü hem de PMR‟de artıŞ saptanmıŞtır. Ameliyat sonrası üriner semptomu olmayan (Grup 1 ve Grup 4) 26 hasta değerlendirildiğinde, 8‟inde (% 30.7) iŞeme basıncı yüksekliği, 10‟unda (% 38.4) detrüsör overaktivitesi, 6‟sında (% 23) PMR de artıŞ ve 4‟ünde de (% 15.3) kompliyans düŞüklüğü görülmüŞtür. SONUÇ: ÇalıŞmamız GOS‟lu hastalarda kord serbestleŞtirmesi ameliyatının hem üriner sistem semptomları hem de ürodinami parametreleri üzerine iyileŞtirici etkisi olduğunu göstermiŞtir. Ancak, üriner sistem bulguları ile ürodinami parametrelerinin düzelme oranları arasında bir korelasyon saptanmamıŞtır. Üriner sistem semptomlarının ve ürodinami parametrelerinin ameliyat sonrası 3. ve 12. aydaki sonuçları benzerlik göstermektedir. Ayrıca çalıŞmamız, bu hasta grubunda üriner sistem semptomları olmamasına rağmen, hem ameliyat öncesi hem de ameliyat sonrası ürodinami çalıŞmasının önemini vurgulamaktadır.
ÖZET (ABSTRACT) AIM: While the spinal cord should end at the level of the L1-2 vertebra, tethered cord syndrome (TCS) is defined as the abnormal fixation of the conus medullaris below the level of L1. Primary TCS is the congenital abnormal fixation of the spinal cord while secondary TCS is due to scarring after any intraspinal surgery. It is thought that the abnormal fixation leads to stretching of the spinal cord which leads to hypoxia and ischemia of the spinal cord and the sacral nevre root. This pathophysiological process leads to urological, neurological and musculo-skeletal system signs and symptoms. TCS can present with urinary system problems such as incontinance, impaired bladder sensation, vesicoureteral reflux and hydronephrosis. In this study we evaluated the surgical urinary symptom scores and its effect on urodynamic parameters (bladder volume, voiding pressure, maximum detrussor pressure, bladder compliance and postvoiding residue) and compared urinary system symptoms with urodynamic parameters in patients had spinal cord release surgery due to TCS. All patients were evaluated at 3rd and 12th postoperative months to determine the effect of surgery over time. PATIENTS AND METHOD: Patients operated on due to primary TCS at the Neurosurgery clinics of Marmara University School of Medicine and Kartal Education and Research Hospital were included in this study. The 40 patients‟ TCS diagnosis was made with clinical history, physical examination and MRI results. Diagnosis was supported by SEP and urodynamic findings. All patients were prospectively followed and urological symptom questioning and urodynamic studies were planned for 3rd and 12th postoperative months. Five parameters – bladder capacity, voiding pressure, maximum detrussor pressure, compliance and postvoiding residual urine, were evaluated on urodynamic studies. Patients were seperated into 4 groups according to the presence of urinary symptoms before and after surgery. (Group 1: preop urinary symptoms positive, postop urinary symptoms negative; Group 2: preop urinary symptoms pozitive, postop urinary symptoms positive; Group 3: preop urinary symptoms negative, postop urinary symptoms positive; Group 4: preop urinary symptoms negative, postop urinary symptoms negative.) RESULTS: Twenty-five females (62,5%) and 15 males (37.5%) were included in the study. The average age was 7.2 years (range 1.5 – 16 years.) The average follow up time was 2.8 years (1 - 6.6 years.) There were 13 patients in group 1, 11 in group 2, 3 in group 3 and 13 in group 4. When compared at 3rd and 12th postoperative months we found no difference in urinary symptoms. Preoperative urodynamic studies showed that the bladder capacity was 0.5% lower than the expected capacity calculated by age. The bladder capacity was found to be 2.6% and 9.5% more than the expected capacity at the 3rd and 12th postoperative months, respectfully. Voiding pressure over 40 cmH2O (abnormal) was found in 23 (62.2%) patients preoperatively and this rate decreased to 59.5% (n=22) and 42.1% (n=16) at the 3rd and 12th postoperative months. There were 33 patients (82.5%) with a maximum detrussor pressure above 15 cmH2O (abnormal) preoperatively. At the postoperative 3rd and 12th months, this rate decreased to 77.5% (n=31) and 52.5% (n=21) respectfully. There were 20 patients (50%) with residual urine that was measured to be 10% more than their expected bladder capacity. At the postoperative 3rd and 12th months, the rate decreased to 42.5% (n=17) and 37.5% (n=15) respectfully. When compliance was evaluated, an abnormal complience was noted (<10 ml/ cmH20 – hypocompliant) in 17 patients (42.5%) preoperatively, 18 patients (45%) at postoperative 3rd month and 10 patients (25%) at the postoperative 12th month. When urodynamic parameters of 24 patients with symptoms were compared preoperatively, 10 (42.6%) had high voiding pressure, 19 (79.1%) had detrussor overactivity, 13 (54.1%) had increase in PVR and 10 (41.6%) had decreased compliance. Of 14 patients with syptoms after surgery, 8 (57.1%) had high voiding pressure, 11 (78.5%) had detrussor hyperactivity, 9 (64.2%) had increase in PVR and 6 (42.8%) had decreased compliance. Of 16 patients without urinary symptoms preoperatively (groups 3-4) 13 (81.2%) had high voiding pressure, 14 (87.5%) had detrussor hyperactivity, 7 (43.7%) had increase in PVR and decreased compliance. Of 26 patients with urinary symptoms preoperatively (groups 1-2) 8 (30.7%) had high voiding pressure, 10 (38.4%) had detrussor hyperactivity, 6 (23%) had increase in PVR and 4 (15.3%) had decreased compliance. Our study shows that untethering in TCS has a beneficial effect on urinary system symptoms and urodynamic parameters of these patients. However, we found no correlation between improvement of urinary system symptoms and urodynamic findings. Urinary system symptoms and urodynamic parameters show similarity at 3rd and 12th postoperative months. Our study also demonstrates the significance of both preoperative and postoperative urodynamic studies even if patients have no urinary system symptoms.
ÖZET (ABSTRACT) AIM: While the spinal cord should end at the level of the L1-2 vertebra, tethered cord syndrome (TCS) is defined as the abnormal fixation of the conus medullaris below the level of L1. Primary TCS is the congenital abnormal fixation of the spinal cord while secondary TCS is due to scarring after any intraspinal surgery. It is thought that the abnormal fixation leads to stretching of the spinal cord which leads to hypoxia and ischemia of the spinal cord and the sacral nevre root. This pathophysiological process leads to urological, neurological and musculo-skeletal system signs and symptoms. TCS can present with urinary system problems such as incontinance, impaired bladder sensation, vesicoureteral reflux and hydronephrosis. In this study we evaluated the surgical urinary symptom scores and its effect on urodynamic parameters (bladder volume, voiding pressure, maximum detrussor pressure, bladder compliance and postvoiding residue) and compared urinary system symptoms with urodynamic parameters in patients had spinal cord release surgery due to TCS. All patients were evaluated at 3rd and 12th postoperative months to determine the effect of surgery over time. PATIENTS AND METHOD: Patients operated on due to primary TCS at the Neurosurgery clinics of Marmara University School of Medicine and Kartal Education and Research Hospital were included in this study. The 40 patients‟ TCS diagnosis was made with clinical history, physical examination and MRI results. Diagnosis was supported by SEP and urodynamic findings. All patients were prospectively followed and urological symptom questioning and urodynamic studies were planned for 3rd and 12th postoperative months. Five parameters – bladder capacity, voiding pressure, maximum detrussor pressure, compliance and postvoiding residual urine, were evaluated on urodynamic studies. Patients were seperated into 4 groups according to the presence of urinary symptoms before and after surgery. (Group 1: preop urinary symptoms positive, postop urinary symptoms negative; Group 2: preop urinary symptoms pozitive, postop urinary symptoms positive; Group 3: preop urinary symptoms negative, postop urinary symptoms positive; Group 4: preop urinary symptoms negative, postop urinary symptoms negative.) RESULTS: Twenty-five females (62,5%) and 15 males (37.5%) were included in the study. The average age was 7.2 years (range 1.5 – 16 years.) The average follow up time was 2.8 years (1 - 6.6 years.) There were 13 patients in group 1, 11 in group 2, 3 in group 3 and 13 in group 4. When compared at 3rd and 12th postoperative months we found no difference in urinary symptoms. Preoperative urodynamic studies showed that the bladder capacity was 0.5% lower than the expected capacity calculated by age. The bladder capacity was found to be 2.6% and 9.5% more than the expected capacity at the 3rd and 12th postoperative months, respectfully. Voiding pressure over 40 cmH2O (abnormal) was found in 23 (62.2%) patients preoperatively and this rate decreased to 59.5% (n=22) and 42.1% (n=16) at the 3rd and 12th postoperative months. There were 33 patients (82.5%) with a maximum detrussor pressure above 15 cmH2O (abnormal) preoperatively. At the postoperative 3rd and 12th months, this rate decreased to 77.5% (n=31) and 52.5% (n=21) respectfully. There were 20 patients (50%) with residual urine that was measured to be 10% more than their expected bladder capacity. At the postoperative 3rd and 12th months, the rate decreased to 42.5% (n=17) and 37.5% (n=15) respectfully. When compliance was evaluated, an abnormal complience was noted (<10 ml/ cmH20 – hypocompliant) in 17 patients (42.5%) preoperatively, 18 patients (45%) at postoperative 3rd month and 10 patients (25%) at the postoperative 12th month. When urodynamic parameters of 24 patients with symptoms were compared preoperatively, 10 (42.6%) had high voiding pressure, 19 (79.1%) had detrussor overactivity, 13 (54.1%) had increase in PVR and 10 (41.6%) had decreased compliance. Of 14 patients with syptoms after surgery, 8 (57.1%) had high voiding pressure, 11 (78.5%) had detrussor hyperactivity, 9 (64.2%) had increase in PVR and 6 (42.8%) had decreased compliance. Of 16 patients without urinary symptoms preoperatively (groups 3-4) 13 (81.2%) had high voiding pressure, 14 (87.5%) had detrussor hyperactivity, 7 (43.7%) had increase in PVR and decreased compliance. Of 26 patients with urinary symptoms preoperatively (groups 1-2) 8 (30.7%) had high voiding pressure, 10 (38.4%) had detrussor hyperactivity, 6 (23%) had increase in PVR and 4 (15.3%) had decreased compliance. Our study shows that untethering in TCS has a beneficial effect on urinary system symptoms and urodynamic parameters of these patients. However, we found no correlation between improvement of urinary system symptoms and urodynamic findings. Urinary system symptoms and urodynamic parameters show similarity at 3rd and 12th postoperative months. Our study also demonstrates the significance of both preoperative and postoperative urodynamic studies even if patients have no urinary system symptoms.