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The investigators hypothesize that surgical release of the filum terminale (strand of fibrous tissue at the end of the spinal cord) is a more efficacious treatment option for symptomatic relief than medical management in subjects with Occult Tethered Cord Syndrome (OTCS) and that the risks do not outweigh the benefit profile.
This is a phase II pilot randomized-controlled, single-site trial to determine if surgical untethering of the filum terminale is more effective, preliminarily, than medical management as a treatment option for OTCS. Subjects will be randomized to one of two arms: surgical untethering or medical management only. Symptom improvement and adverse events will be assessed and recorded for 1 year from initiation of treatment. After a minimum of 1 year, subjects who were randomized to the medical management arm may cross over to the surgical arm if the PI deems it is in the subject's best interest to do so. The exploratory hypothesis is that surgery for OTCS is both safe and more effective than medical management at relieving the symptoms of OTCS.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Surgery | Active Comparator | Filum release |
|
| Observation | No Intervention | Medical Management only |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Release of filum terminale | Procedure | Surgery will be offered to section the filum terminale |
|
| Measure | Description | Time Frame |
|---|---|---|
| Change in symptoms related to tethered cord, as measured by the OCCULT Scale | Combination of neurologic, urologic, orthopedic, and cutaneous assessments. The OCCULT Scale is from 0-100, with 0 being none of the listed signs/symptoms present and 100 being all listed signs/symptoms present with maximum severity. | Baseline, 1 year |
| Measure | Description | Time Frame |
|---|---|---|
| Change in urologic incontinence score | Score is measured by the International Consultation on Incontinence Questionnaire Urinary Incontinence Short Form. The minimum score is 0 and the maximum score is 21. The higher the score, the more severe the urinary incontinence symptoms and/or effect of symptoms on quality of life. | Baseline, 1 year |
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Inclusion Criteria:
OCCULT Grading Scale (Score 0-100) Orthopedic Abnormality: 0-15; Central Nervous System Dysfunction: 0-25; Cutaneous Stigmata: 0-10; Urological or Bowel Dysfunction: 0-25; Lumbosacral Anatomy: 0-15; Tissue Integrity Disorder: 0-10.
Exclusion Criteria:
Subjects < 2 or > 80 years of age.
Radiographically identified tethered cord, as defined by any of the following:
A history of Meningocele manqué or Myelomeningocele.
Cutaneous markings of dermal sinus tract.
History of prior surgery on the lumbar spine.
History of prior surgery for spinal dysraphism.
History of prior infection or autoimmune condition of the central nervous system.
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| Name | Role | Phone | Extension | |
|---|---|---|---|---|
| Cynthia Nguyen | Contact | (212) 746-1788 | cyn4002@med.cornell.edu | |
| Jeffrey Greenfield, MD, PhD | Contact | (212) 746-2363 | jpgreenf@med.cornell.edu |
| Name | Affiliation | Role |
|---|---|---|
| Jeffrey Greenfield, MD, PhD | Weill Medical College of Cornell University | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| Weill Cornell Medicine | Recruiting | New York | New York | 10065 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 34268593 | Background | Michael MM, Garton ALA, Kuzan-Fischer CM, Uribe-Cardenas R, Greenfield JP. A critical analysis of surgery for occult tethered cord syndrome. Childs Nerv Syst. 2021 Oct;37(10):3003-3011. doi: 10.1007/s00381-021-05287-5. Epub 2021 Jul 15. |
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Subjects will be randomized to one of two arms: surgical untethering or medical management only. Symptom improvement and adverse events will be assessed and recorded for 1 year from initiation of treatment. After a minimum of 1 year, subjects who were randomized to the medical management arm may cross over to the surgical arm if the PI deems it is in the subject's best interest to do so.
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For a surgical vs non-surgical trial, the investigator can not be masked thus only the evaluators will be unaware of the arm.
| Change in fecal incontinence score |
Score is measured by the Rapid Assessment Faecal Incontinence Score. The minimum score is 0 and the maximum score is 20. The higher the score, the more severe the fecal incontinence symptoms and/or effect of symptoms on quality of life. |
| Baseline, 1 year |
| Number of patients who cross over | 1 year |
| Percent of patients with a decrease in anticholinergic medications at 1 year post-surgery | For patients who presented with urological symptoms | 1 year |
| Number of intra-operative findings that are discordant with MRI interpretations | To examine whether there is a limitation in MRI in identifying pathology that is identified at the time of surgery | Intraoperative |
| ID | Term |
|---|---|
| D013119 | Spinal Cord Injuries |
| D009436 | Neural Tube Defects |
| D016136 | Spina Bifida Occulta |
| ID | Term |
|---|---|
| D013118 | Spinal Cord Diseases |
| D002493 | Central Nervous System Diseases |
| D009422 | Nervous System Diseases |
| D020196 | Trauma, Nervous System |
| D014947 | Wounds and Injuries |
| D009421 | Nervous System Malformations |
| D000013 | Congenital Abnormalities |
| D009358 | Congenital, Hereditary, and Neonatal Diseases and Abnormalities |
| D016135 | Spinal Dysraphism |
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| ID | Term |
|---|---|
| D007796 | Laminectomy |
| ID | Term |
|---|---|
| D019637 | Orthopedic Procedures |
| D013812 | Therapeutics |
| D019299 | Decompression, Surgical |
| D013514 | Surgical Procedures, Operative |
| D019635 | Neurosurgical Procedures |
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