Most children with lower urinary tract symptoms have an overactive bladder but a small number will have a neurogenic bladder due to spinal dysraphism. It is crucial to identify such patients to both optimise their management and to minimise the chance of irreversible upper tract damage. Following symptoms review and examination, urology specialist nurses and consultants in our centre refer selected patients to the neurosurgical team to screen for possible closed spinal dysraphism, which is diagnosed by Magnetic Resonance Imaging (MRI). We hypothesised that through review of these patients we would identify one or more symptoms / signs that should trigger routine neurosurgical referral. The aim was to assess the symptoms and signs of all patients referred to the neurosurgery service and to analyse them for any association between symptoms and signs and a significant spinal anomaly.

A master list of patients seen in both neurosurgery and urology clinics between 2018 and 2020 was used to identify patients. Patients were included in the study if they were age 16 or younger at the time of referral and if they were referred from the urology service to neurosurgery to consider a diagnosis of closed spinal dysraphism. The neurosurgical team made the decision whether MRI of the spine was indicated or not. Patients with a diagnosis of an obvious spinal diagnosis such as open myelomeningocele, lipomyelomeningocele or sacral agenesis were excluded.  Data collected included demographics and presence or absence of the following lower urinary tract symptoms:
-        Daytime incontinence 
-        Night-time enuresis 
-        Urinary urgency 
-        Urinary frequency 
-        Urinary tract infection 
-        Post void residual 

Non-urological symptoms or examination findings (signs) detected by the urology team were also noted including:              
-        Constipation
-        Dimple in the sacro-coccygeal area 
-        Lumbar hairy patch 
-        Asymmetrical natal cleft   
-        Back pain 
-        Lower limb symptoms 

The data was collated and reviewed in Google Sheets for Chrome Version 1.2. Statistical analysis was undertaken using ‘Wizard’ [https://apps.apple.com/us/app/wizard/id495152161?ls=1&mt=12]. Categorical data was analysed by Chi squared test, p<0.05 was considered to be significant.

58 patients were referred to the neurosurgery service for assessment during the specified timeframe, 37 were female (64%). The median age was 10 years (IQR 8-13).  The commonest symptoms were daytime incontinence (n=48, 83%), nocturnal enuresis (n=44, 76%) and urgency (n=42, 72%). The commonest potential neurological sign was presence of a dimple, recorded in 45 (78%) patients (Figure 1).  40 (69%) patients underwent MRI of the spine, the distribution of symptoms and signs between those who did and those who did not is shown in Figure 2.

Nine (23%) MRI scans were reported to be abnormal though only 3 identified distal spinal cord lesions and only 1 patient required surgery (1.7% of the entire cohort, 2.5% of all those undergoing MRI). The abnormalities detected included: 1x cervical syrinx + hydromyelia, 1x vertebral fusion anomaly, 1x increased CSF at foramen magnum, 1x cervical syringomyelia, 1x narrowed foramen, 1x Chiari malformation, 1x tethered cord and 2x fatty filum.  The patient with a tethered spinal cord presented with every one of the lower urinary tract symptoms, a palpable bladder, constipation and abnormal knee reflexes. The patient had a neurogenic bladder confirmed on urodynamics and underwent spinal cord untethering.

Analysis of which patients did and did not undergo MRI shows that notable differences were seen in the number of patients with recurrent UTI (28% who did not have MRI vs. 48% who did), lower limb symptoms (such as leg pain/weakness, abnormal knee jerk, abnormal foot position, 33% vs 6%), gait abnormality (10% vs. 0%) and asymmetrical natal cleft (38% vs. 17%). Presence of a dimple was the commonest non-urological sign (33% vs. 23%) but was not predictive of whether an MRI was requested or not (p=0.5). It is likely that pathological dimples are detected early in life and those detected in this cohort are likely to be normal anatomical variants.  However, the presence of lower limb symptoms was significantly associated with undergoing an MRI (13/14 patients with lower limb symptoms did get an MRI vs. 27/44 without did not, p=0.027). 

Analysis of individual symptoms found that nocturnal enuresis and urinary frequency were significantly associated with having any MRI abnormality (p=0.048 and 0.050 respectively) but these were no longer significant when examined by logistic regression analysis. No individual symptoms or signs predicted those who were found to have a distal spinal cord lesion.

In this cohort only a single patient with multiple symptoms and signs had a significant occult spinal cord abnormality. It was hypothesised that one or more symptoms or signs could be identified that should trigger referral for neurosurgical review. The hypothesis was not proven: many urological  and non urological symptoms and signs are ubiquitous so do not help identify higher risk patients.

Venkataramana, N., 2011. Spinal dysraphism. Journal of Pediatric Neurosciences, 6(3), p.31.
Copp, A., Adzick, N., Chitty, L., Fletcher, J., Holmbeck, G. and Shaw, G., 2015. Spina bifida. Nature Reviews Disease Primers, 1(1).
Amarante, M., Shrensel, J., Tomei, K., Carmel, P. and Gandhi, C., 2012. Management of urological dysfunction in pediatric patients with spinal dysraphism: review of the literature. Neurosurgical Focus, 33(4), p.E4.