Predictors of surgical treatment in children with tethered fibrofatty filum terminale

OBJECTIVE Thickened or fatty filum terminale is an occult lesion that can cause tethered cord syndrome requiring surgical untethering. This study’s objectives were to estimate the incidence of tethered fibrofatty filum terminale (TFFT) in a large insured pediatric population, identify predictors of surgery among those TFFT patients, and assess a diagnostic algorithm. METHODS TFFT was defined according to the ICD-9-CM code for cord tethering (742.59), after excluding codes for diastematomyelia, lipomyelomeningocele, terminal myelocystocele, meningocele, and myelomeningocele. Utilizing the Optum Insight database for 2001–2014, the authors identified pediatric patients (< 21 years) in the US who were diagnosed with a tethered cord and estimated the TFFT incidence rates in that source population and the surgical untethering probability among TFFT patients over the 14-year period. Logistic regression was used to estimate the effects (adjusted OR and 95% CI) of age at diagnosis, sex, Charlson Comorbidity Index (CCI) score, diagnosis of Chiari malformation type I, diagnosis of syrinx, and the probability of surgery by US census region. Lastly, to evaluate their algorithm for identifying TFFT from ICD-9 codes, the authors estimated its positive predictive value (PPV) among 50 children who were diagnosed at their institution and met the ICD-9-CM criteria. RESULTS There were 3218 diagnoses of TFFT, with 482 of these pediatric patients undergoing tethered cord release during the study period. The estimated incidence rate was 12.0 per 100,000/year (95% CI 11.6–12.4 per 100,000/year). The incidence rate was slightly higher in females than in males (12.7 vs 11.4 per 100,000/year). The probability of surgery in the total pediatric TFFT population was 15.0% (95% CI 13.8%–16.2%) and was greater in children with a syrinx (OR 2.2, 95% CI 1.6–3.0), children 7–11 years of age at diagnosis versus < 1 year (OR 1.5, 95% CI 1.1–2.0), CCI score ≥ 3 versus 0 (OR 2.3, 95% CI 1.4–3.8), and residents of the Western vs Northeastern US (OR 2.3, 95% CI 1.6–3.5). In the authors’ own institution’s database, the PPV of TFFT was 35/50 (70.0%, 95% CI 57.3%–82.7%) for identifying tethered cord due to fibrofatty filum terminale among childhood positives. CONCLUSIONS Patients with comorbidities or an associated syrinx showed a higher risk of untethering procedures for TFFT. Also, surgery was appreciably more frequent in the Western US. These findings signify the need for a collaborative prospective cohort study of long-term outcomes for TFFT patients with and without surgery to determine which patients should have surgery.