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";s:4:"text";s:29382:"Tethered Cord Syndrome (TCS) is a broad term that encompasses both congenital (primary) and acquired (secondary) pathologies that anchor, elongate and tension the spinal cord[1] The spinal cord fixation produces mechanical stretch, distortion, and ischemia with daily activities, growth, and development[2] This prevents the spinal cord from freely moving, which then increases . This can cause many different symptoms called tethered cord syndrome. Tethered cord syndrome (TCS) refers to a series of neurological dysfunction caused by the retraction of the conus medullaris related to a variety of reasons, which is manifested by both lower extremities orbicularis weakness, sensory abnormalities, defecation dysfunction, and so on.[1]. In adults, surgery to free the spinal cord can reduce the size and further development of cysts in the cord and may restore some function or alleviate other symptoms. There are different types of tethered cord. We conducted a retrospective multicenter study. Shiro Imagama, none Eleven patients underwent untethering surgery, and 3 patients underwent SSO surgery. Object: Although postsurgical neurological outcomes in patients with tethered cord syndrome (TCS) are well known, the rate and development of neurological improvement after first-time tethered cord release is incompletely understood. 12 Although the majority of affected patients with TCS are children and infants, several studies have shown that TCS also occurs in adults.1 When surgeons operate around the spinal cord, the area where the CSF lies is opened so they can untether the spinal cord. 10 After surgery, the lipoma was removed almost completely (Fig. PMC eCollection 2020 Mar. Posterior Vertebral Column Subtraction Osteotomy for Recurrent Tethered Cord Syndrome: A Multicenter, Retrospective Analysis. Thus, additional prospective randomized large-scale studies are needed to confirm our results. The mean estimated blood loss during surgery (300 ml in the open group vs 167 ml in the mini-open group, p = 0.313) and the mean length of stay (7 days in the open group vs 6.3 days in the mini-open group, p = 0.718) were similar between the 2 groups. These patients included those who had either tight terminal filum or secondary lesions that restricted the movement of the caudal spinal cord. Tethered cord, also called tethered spinal cord syndrome, occurs when the spinal cord abnormally attaches to tissue inside the spinal canal, usually at the base of the spine. Kokubun S, Ozawa H, Aizawa T, Ly N M, Tanaka Y. Spine-shortening osteotomy for patients with tethered cord syndrome caused by lipomyelomeningocele. Tokumi Kanemura, none Learn about the many ways you can get involved and support Mass General. A hairy patch overlying the spine in any area is almost always associated with an underlying splitting of the spinal cord by a band of fibrous tissue or bone (a diastematomyelia). sharing sensitive information, make sure youre on a federal Up to 6% of the normal population will be found to have fat within their filum terminale, 14 and many of these individuals will have symptoms of a tethered spinal cord ().The term filum terminale syndrome was coined in 1953 by Garceau, 15 who reported three patients with progressive spinal deformity and neurological dysfunction. Neurophysiologic intraoperative monitoring is when doctors place electrodes (wires with a sticker on one end) on your childs head, arms and legs. Fourteen patients (37.712.5 years) with TCS were enrolled at 6 hospitals. Get new journal Tables of Contents sent right to your email inbox, http://creativecommons.org/licenses/by/4.0, Surgical treatments on adult tethered cord syndrome: A retrospective study, Articles in Google Scholar by Jun Gao, MD, PhD, Other articles in this journal by Jun Gao, MD, PhD, The efficacy and safety of pre-emptive methoxamine infusion in preventing hypotension by in elderly patients receiving spinal anesthesia: A PRISMA-compliant protocol for systematic review and meta-analysis, Minimally invasive pedicle screw fixation, including the fractured vertebra, combined with percutaneous vertebroplasty for treatment of acute thoracolumbar osteoporotic compression fracture in middle-age and elderly individuals: A prospective clinical study, Three dimensional finite element analysis used to study the influence of the stress and strain of the operative and adjacent segments through different foraminnoplasty technique in the PELD: Study protocol clinical trial (SPIRIT Compliant), Risk Factors for Recurrent Lumbar Disc Herniation: A Systematic Review and Meta-Analysis, Privacy Policy (Updated December 15, 2022). Improvement in clinical features was compared in the untethering and SSO groups (Table 3). Unauthorized use of these marks is strictly prohibited. The categories of tethering lesions were tight terminal filum in 1 patient, lipoma in 5 patients, and lipomyelomeningocele in 8 patients. Perioperative complications are another concern in adult TCS. 5 The patient was followed up for 2 years without local recurrence. smoke city char bar los angeles; youth sports referee jobs; que pasa cuando los dos amantes son casados; margot robbie samara weaving and jaime pressly However, to use this type of procedure for spinal cord tethering is new and extremely rare, says Theodore . WebRecovery from the surgery is one to two weeks of very limited activity to ensure proper healing of the surgical site and to prevent leaking of any cerebrospinal fluid. neurologic recovery with regard to pain and He presented with symptoms of lower back pain and legs pain. A total of 32 consecutive adult patients underwent untethering surgery for secondary tethered cord syndrome in our department from January 2008 until December 2018. . The lower half of the T12 lamina, the bilateral lower articular processes at T12, and the bilateral L1 superior articular processes were resected, and the bilateral L1 pedicles and bilateral transverse processes were then removed. 10 10 Phi J H, Lee D Y, Jahng T A, Chung C K, Kim H J. Tethered cord syndrome in adulthood: reconsidering the prognosis. Log in now and start [2] The tumor compression of the cone and the tail is one of the main causes for the tethered cord. Tethered cord, also called tethered spinal cord syndrome, occurs when the spinal cord has abnormal attachments inside the spinal canal, usually at the base of the spine. Would you like email updates of new search results? Primary is typically a form of OSD while secondary usually occurs following a myelomeningocele repair or other type of spinal cord surgery History and Exam Tethered spinal cord is most commonly diagnosed in infancy by the discovery of a abnormality noticed on the skin of the back. Romagna A, Suchorska B, Schwartz C, Tonn J C, Zausinger S. Detethering of a congenital tethered cord in adult patients: an outcome analysis. Over time, the term ''tethered cord'' has been . 9 Patients with such complex pathologies have been found to have a 9 to 50% chance of worsening pain and sensorimotor deficits after untethering.7 Unlike pediatric patients, adults experience degenerative changes that further complicate treatment.5 government site. This causes extra stress on the nerves and can cause a range of symptoms known as tethered cord syndrome. Surgical management of tethered spinal cord in adults: report of 54 cases. (C) Postoperative lateral radiograph 3 years after surgery shows complete bone union and significant spine shortening. . 12 The causes of tethering, preoperative duration of symptoms, and completeness of untethering could cause the outcomes to vary. [3,4] Adult onset cases are rare compared to that in children. Major or serious complications are uncommon during this surgery. 11/2021. WebWhat happens after tethered spinal cord surgery? For this procedure, the patient is placed under general anesthesia. Reduction of caudal traction force using dural sac opening rather than spinal cord detethering for tethered cord syndrome caused by lipomyelomeningocele: a case report. Surgery may be difficult, and is always accompanied by One patient showed worsening of sensory function and another patient complained of a new lower back pain in the SSO group. Now, to catluvr's post. The end of the spinal cord normally hangs and moves freely inside the spinal column. The mean age at onset of symptoms and diagnosis was 30 years and 37 years, respectively. Tethered cord syndrome in adults: experience of 56 patients. Yamada and Lonse[18] divided 70 cases of adult TCS patients into 2 groups, who underwent surgical treatment and followed by comparative analysis, patients with longer course of disease were found to show limited relief of motor sensory dysfunction and bladder dysfunction; pain in the lumbosacral portion and both lower extremities was relieved 3 months after surgical relaxation of the tethered cords; and in patients with shorter disease duration following surgical lysis, motor sensory dysfunction and bladder dysfunction were improved significantly, pain symptoms also alleviated rapidly. Highlight selected keywords in the article text. Revision surgery in patients with complex dysraphic lesions should be performed in exceptional cases only. 11 You will have many questions about the disorder, and we are here to answer them. The mean age of the patients was 46 13 years (range 23-74 . Suite F4300. JG, XK, and ZL have contributed equally to the article. Their clinical charts, operative records, and follow-up data were reviewed. Syringomyelia is a disorder in which a fluid-filled cyst (called a syrinx) forms within the spinal cord. sharing sensitive information, make sure youre on a federal Call Today. Tethered cord syndrome is a stretch-induced functional disorder associated with the fixation (tethering) effect of inelastic tissue on the caudal spinal cord, limiting its movement. Methods: In contrast, sensory deficits were less likely to improve; numbness and paresthesias remained unchanged in 55% of the patients. Yasutsugu Yukawa, none 12 Therefore, it is necessary to remove contents within the cyst and to reduce the size of the cyst as far as possible, followed by free cystic wall, and then to minimize the stretching of the nerve tissue. In addition and preoperatively, there were 68 cases (83%) of varying degrees of pain in the lumbosacral portion and lower extremity, 58 cases (71%) of motor dysfunction of the lower extremity, 44 cases (54%) with abnormal sensation, and 50 cases (61%) of defecation dysfunction. 7 Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. 9. 5 For more information about these cookies and the data
The variations of tethering lesions were tight terminal filum (present in 1 patient), lipoma (5 patients), and lipomyelomeningocele (8 patients). The care team will review your childs symptoms and how tethered cord syndrome is affecting their quality of life. Iskandar B J, Fulmer B B, Hadley M N, Oakes W J. Congenital tethered spinal cord syndrome in adults. J Neurosurg Spine. SSO was performed at the level of T12 or L1 (Fig. 2018 Apr-Jun;13(2):264-270. doi: 10.4103/1793-5482.228566. HHS Vulnerability Disclosure, Help Federal government websites often end in .gov or .mil. Surgeries were performed under continuous electrophysiologic neuromonitoring with somatosensory-evoked potentials, combined with motor-evoked potentials, and electromyography with direct nerve root stimulation. To be included, patients (1) had to be>18 years old at the time of surgery and (2) had to have undergone spinal surgery for TCS. Note: Results are the number of patients with improvement/the number of patients with each symptom preoperatively. A retrospective analysis of 82 adult patients (17 male cases, 82% and 24 female cases, 59%) with TCS treated by surgery was conducted between March, 2005 and December, 2015, with an average age of 31.6 years and average disease course of 6.7 years. http://creativecommons.org/licenses/by/4.0, Received in revised form October 19, 2016. The General Hospital Corporation. . Hiroki Matsui, none Hoffman HJ, Hendrick EB, Humphreys RP. Doctor en Historia Econmica por la Universidad de Barcelona y Economista por la Universidad de la Repblica (Uruguay). This causes stretching of the spinal cord as your child grows, leading to extra stress on nerves. bDepartment of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Harvard University, Boston, MA. It is essential to make surgical corrections on time and prevent irreversible damage to nerve tissue and consequent neurological deficits. Horrion J, Houbart MA, Georgiopoulos A, et al. All patients received general anesthesia and took their prone position, neural electrophysiological monitoring electrode were then placed, followed by the acquisition and collection of muscle electromyography signals from the anal sphincter, bilateral musculus vastus lateralis, gastrocnemius and mesothenar. Webtom kenny rick and morty characters. dispersed camping roosevelt national forest, approach to pancytopenia in pediatrics ppt, cedar ridge high school basketball roster, private landlords in garfield heights ohio, que pasa cuando los dos amantes son casados, margot robbie samara weaving and jaime pressly, how to broadcast party chat on twitch xbox one, illinois state law on medication administration, purpose of short service line in badminton. 2 eCollection 2020. Next, the T12 and L2 vertebrae were compressed gradually by using a pedicle screwrod construct with somatosensory-evoked potentials and motor-evoked potentials monitoring. This can lead to infection if the incision is on the low back. Back pain: 14% better; 14% worse; leg pain: 11% better; 11% worse, Back pain: 78% better; 3% worse; leg pain: 83% better; 7% worse, Back pain: 77% better; leg pain: 47% better, 2% extradural hematoma/paraparesis; 5% revision CSF; 2% permanent neurologic worsening, 3% neurologic deterioration; 3% reoperation. This keeps the spinal cord from moving freely. There were 10 cases of lumbosacral intraspinal canal lipoma (12%), 32 cases of (39%) dermoid cyst and epidermoid cyst, and 40 cases (49%) without occupying lesions of tethered spinal cord. Symptoms often stabilize or improve after surgery; 6 however, retethering (along with renewed symptoms) may reoccur especially during rapid Prompt untethering after diagnosis leads to improved . Tethered cord is often a birth defect, though . Please enable it to take advantage of the complete set of features! 2011 Jun 15;36(14):E944-9. The purpose of this study was thus to fill in this knowledge gap by comparing the surgical results of untethering surgery and SSO for treating TCS in adults. For instance, if a traditional fusion surgery is performed, recovery time will be longer and thus differ from a less invasive, motion preserving spine procedure. "The best age to perform a detethering is 6 months to 1 year old, but it is still very treatable in older children. You may be trying to access this site from a secured browser on the server. government site. As a result, the spinal cord can't move freely within the spinal canal. (B) Preoperative sagittal T2-weighted magnetic resonance imaging (MRI) scan shows a low-placed conus medullaris and terminal filum connected with a subcutaneous lipomyelomeningocele at the S1S2 level. Comparative Study of Untethering and Spine-Shortening Surgery for Tethered Cord Syndrome in Adults. Keyword Highlighting
1994 Oct;81(4):513-9. doi: 10.3171/jns.1994.81.4.0513. This study compared clinical outcomes and perioperative complications resulting from untethering and SSO surgery performed on patients with adult TCS. 5 Recovery involves a period of immobility where the . 7 As the child grows taller, the spinal cord is stretched. Garceau theorized that tension on the . Fatty Filum Terminale. In surgically treated patients, pain relief can often be achieved, and long-term neurological stabilization tends to persist more often than it does in conservatively treated patients. The result may be nerve damage and severe pain. Post-operative radiotherapy for recurrent dermoid cysts of the spine: a report of 3 cases. The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. As first-line treatment, patients presenting with TCS typically undergo direct spinal cord untethering, often as young children or infants. If re-tethering does occur, your child may need another surgery to fix it. Tethered Cord Syndrome can be difficult to diagnose in babies and children since the symptoms may be subtle and insidious over time. Accessibility Because neurological deficits are generally irreversible, early surgery is recommended. The care team uses neurophysiologic intraoperative monitoring during the entire surgery to ensure your childs spinal cord still works properly. Surgical treatment was indicated for patients with radiologically proven tethering of the spinal cord who consistently showed progressive neurologic deficits, back/lower limb pain, or sphincter dysfunction. Funding/support: This study was supported by Peking Union Medical College Youth Research Funds (2016) (project no. [] This entity was first described by Garceau (1953) and By clinical analysis of 611 cases of patients with lipoma-oriented TCS, Cui et al[19] proved that patients with no symptoms and mild symptoms obtained satisfactory postoperative curative effects, according to Hoffman grading evaluation of preoperative and postoperative changes of symptoms, whereas the curative effect was relatively poor in patients showing severe symptoms after operation, early surgical treatment was therefore recommended to obtain better curative effect. The tethered spinal cord is developed by the following ways: A . The next day, your child sit up and the care team will check whether your child has a headache. After surgery, the lipoma was removed almost completely (B). The patient with symptoms following resection of a lipomyelomeningocele: do increases in the lumbosacral angle indicate a tethered spinal cord? 5 The .gov means its official. August 2017. Klekamp[14] advocated that for small lipoma and cone did not show obvious compression, the symptom is mainly caused by tethered, simply releasing of the tethered is suitable to prevent postoperative adhesion and not to destroy lipoma; and for larger lipoma compressed the conus medullaris, decreasing the volume of lipoma from internal, retaining the capsule, and sewing up the incision will be more effective to reduce the possibility of adhesion. 6 13 On the other hand, even when the neurologic deficits are not severe at the time of presentation,9 sensory deficits and urologic dysfunction are more likely to remain static.1 Second, a standardized surgical protocol was not used, and the surgical approach was left to the discretion of the attending surgeon. 1). Yamada S, Lonser RR. In addition, telephone interviews were obtained after a period of 8.6 years. Nakashima H, Imagama S, Matsui H, Yukawa Y, Sato K, Kanemura T, Kamiya M, Ito K, Matsuyama Y, Ishiguro N, Kato F. Global Spine J. 7 The authors reviewed their experience of newly diagnosed adult TCS patients to identify and explore TCS misdiagnosis, recognition, subtype pathology . Please try again soon. The diagnosis of TCS is made with a high degree of clinical suspicion. SSO provided better clinical improvement than untethering surgery (p=0.003). Tubbs RS, Bui CJ, Loukas M, Shoja MM, Oakes WJ. The term occult spinal dysraphism (OSD) encompasses a group of abnormalities that occur during the development of a human embryo, beginning in the third week of gestation. Web Spinal cord tethering may be either primary or secondary. All the 82 cases of patients received nerve electrophysiology monitoring assisted microsurgery. This way, the care team can best assess your childs condition at their first appointment. A retrospective analysis of 82 adult patients with TCS treated by surgery was conducted between March 2005 and December 2015 in Peking Union Medical College Hospital. Only 5 of the conservatively treated patients experienced clinical deterioration over time; in 4 of these individuals with deterioration, surgery had been recommended but was refused by the patient. 3. 8 [13] The growth of body weight and the use of hormones may cause the increase of lipoma and increased symptoms of TCS. According to Hoffman grading system, the neurologic symptoms were improved in 22 patients (27%) and stabilized in 60 patients (73%). Tethered spinal cord syndrome in adults is an uncommon entity that can become symptomatic. and transmitted securely. Published by Wolters Kluwer Health, Inc. UNDERSTANDING TETHERED SPINAL CORD SURGERY AFTER THE SURGERY THE FIRST 24-48 HOURS CONTROLLING YOUR CHILD'S PAIN THE SURGICAL WOUND GOING HOME For the first 12-48 hours after surgery, your child must remain flat in bed. This causes extra stress on the nerves and can cause a range of symptoms known as tethered cord syndrome. Abstract. It is not a substitute for medical advice and should not be used to treatment of any medical conditions. As for the postoperative complications, there were 4 cases (5%) of spinal fluid leakage, and the 2 patients were cured following vacuum aspiration and pressurized dressing; there were 6 cases (7%) showing delayed wound healing, mainly caused by spinal fluid leakage or fat liquefaction. If no imaging has been done, your child may need a magnetic resonance imaging (MRI) test of their spine before the appointment. A nurse will call you for your childs anesthesia screening 1-2 days before their scheduled surgical date. Since 1991, data obtained in 2515 patients with spinal cord pathologies were entered into the spinal cord database, and prospective follow-up was performed through outpatient visits and questionnaires. 11 12 Treatment of TCS in adults is challenging because these malformations are rare, and adults may present with degenerative changes.9 Moreover, many adults with TCS have undergone previous surgery for myelomeningocele repair or untethering in childhood, which further complicates treatment.7, Untethering surgery has been commonly performed in the management of TCS in adults and children.7 However, neurologic recovery with regard to pain and neurologic deficit shows great variation, with improvement rates ranging from 0 to 100%.1 Clinical improvement 1 year after surgery in our study showed back pain improvement in 60% of children and 75% of adults, parathesia improved in 60% of 9 Results. WebThe dysfunction of nervous system in Cases 1, 2, and 4 disappeared within 3 weeks. Tethered cord syndrome: an updated review. Klekamp J. Tethered cord syndrome in adults. Based on this small retrospective case series, SSO appears to provide clinical improvement at least comparable to that of the untethering procedure, especially in more challenging cases (complex malformations or revision surgery). The patient was a 36-year-old man who had undergone myelomeningocele repair during infancy. Two groups were distinguished based on the absence (Group A, 43 patients) or presence (Group B, 42 patients) of an associated lipoma or dysraphic cyst (that is, dermoid, epidermoid, or neurenteric cyst). 2 Bristow RG, Laperriere NJ, Tator C, et al. Federal government websites often end in .gov or .mil. You may search for similar articles that contain these same keywords or you may
Symptoms in patients with combined and lipomyelomeningocele TCS was relatively heavier, fat surrounded multiple bundle of cauda equina, dissociating of the cauda equina was therefore more difficult, and it was difficult to be completely removed, also accompanied with subsidiary-injury recurrence of TCS, finally resulting in poor prognosis and none significant improvement of symptoms.[17]. Tethering can happen before or after birth in children and adults; and most often occurs in the lower (lumbar) level of the spine. The percentage of patients with prior surgery was higher in the SSO group than in the untethering group, although the difference was insignificant. Four patients (29%) underwent prior surgery for myelomeningocele repair during infancy, 2 (18.2%) in the untethering group and 2 (66.7%) in the SSO group; 1 of these 4 patients underwent untethering surgery at 7 years of age. Epub 2018 Mar 8. The benefit of secondary operations in Group B was limited, with eventual clinical deterioration occurring in all patients within 10 years. The site is secure. J Neurosurg. 8 Epub 2015 Nov 26. After the tumor was removed, the dura mater spinalis with low tonus was closed by water, and the dura mater spinalis with high tonus was formed by the autogenous fascia. An umbilical hernia repair is a relatively routine surgery and takes about 20 to 30 minutes. Postoperative Orders . Laurent D, Bardhi O, Gregory J, Yachnis A, Governale LS. A tethered cord release reduces or removes the . 13 general health condition is usually good, so SSO could be an appropriate procedure for adults with TCS. [4] In 1953, Garceau described the filum terminal syndrome, suspected that the tensive filum terminal pulled the spinal cord might cause defecation dysfunction and other symptoms. Definition. 2007;23(2):E11. Safe Care CommitmentGet the latest news on COVID-19, the vaccine and care at Mass General.Learn more. collected, please refer to our Privacy Policy. The .gov means its official. The laminae and transverse processes of the vertebrae at T12 and L2 were resected, and the pedicle screws were placed bilaterally at these vertebrae. 6 It may not be possible for the syrinx to be fully removed, so the goal of surgery may be . Object: In some children who have tethered cord syndrome, they may lose control of their bladder or bowels. HOB, positioning, activity, bathing: The patient is kept flat on bed rest for 3 days to allow for dural healing and to put as little CSF pressure on the dura as possible during this time. Get the latest news on COVID-19, the vaccine and care at Mass General. One of the most common complications related to this surgery is wound infection, especially if the incision (cut into the skin) is made around the low back. Neurosurg Focus. Because the incision is lower on the back around a part of the spine that does 6 WebPatients were examined by the same neurologist in a standardized fashion before and after surgery, and most were followed for at least 2 years postoperatively. A tethered spinal cord occurs when the inelastic tissue on the caudal spinal cord is abnormally attached to a structure instead of free floating. Nineteen (86%) of 22 employed patients returned to work after surgery. Pathway Background and Objectives. J Neurosurg. Twenty-eight patients remained in stable clinical condition. WebAdult spinal deformity, which can result from disk degeneration, spinal arthritis, and prior surgeries that fail to align the spine, is an increasing problem among aging Americans. Most people have physical or occupational therapy to help regain function after surgery. Given radiographic findings of tethered cord syndrome and clinical symptoms of pain, UTIs, urinary retention requiring catheterization, and constipation, it was recommended that the patient undergo untethering of the spinal cord via sectioning of the fatty filum terminale. Adult intradural lipoma with tethered spinal cord syndrome. It is pulled tightly at the end, reducing blood ow to spinal nerves and causing damage to the spinal cord from both the stretching and the decreased blood supply. [10] Of course, if the relief of tethered parts of the cauda equina obtained a relatively satisfactory outcome during the surgery, most occupying lesions and diseased filum terminale were removed, postoperative symptoms improved at different degrees, further recovery of the nerve function could thus be observed in the long-term follow-up period. But in Case 3, the paraesthesia and weakness of lower extremities were persistent, and there Based on this small retrospective case series, SSO appears to provide clinical improvement at least comparable to the untethering procedure, especially in more challenging cases. Conclusions: Moreover, complications, such as cerebrospinal fluid (CSF) leakage and neurologic deterioration, have been frequently reported.1 In 1891, Jones [14] described what probably is Adult tethered cord syndrome (ATCS) is a rare entity that usually presents with multiple neurological symptoms, including lower extremity pain, backache, lower extremity muscle weakness, and bowel/bladder disturbances. Tethered cord syndrome is a rare neurological condition in which the spinal cord is attached (tethered) to the surrounding tissues of the spine. 8 The authors studied the hospital records of 34 consecutive patients who presented in adulthood with tethered cord syndrome and conducted follow-up phone interviews with 28 of them. Surgical effects were evaluated by observing improvement of symptoms of each patient postoperatively. ";s:7:"keyword";s:45:"tethered cord surgery in adults recovery time";s:5:"links";s:565:"Pro Bono Family Lawyers Seattle,
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