{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T11:05:39Z","timestamp":1785409539816,"version":"3.56.0"},"reference-count":22,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,7,5]],"date-time":"2026-07-05T00:00:00Z","timestamp":1783209600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100003710","name":"Korea Health Industry Development Institute","doi-asserted-by":"crossref","award":["RS-2025-25459885"],"award-info":[{"award-number":["RS-2025-25459885"]}],"id":[{"id":"10.13039\/501100003710","id-type":"DOI","asserted-by":"crossref"}]},{"award":["RS-2025-25459885"],"award-info":[{"award-number":["RS-2025-25459885"]}],"id":[{"id":"https:\/\/ror.org\/00fdzyk40","id-type":"ROR","asserted-by":"publisher"}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Brain Sciences"],"abstract":"<jats:p>Lipomyelomeningocele (LMMC) is one of the most common forms of occult spinal dysraphism, with an estimated incidence of 3\u20136 per 100,000 live births, and microsurgical untethering remains the cornerstone of management for symptomatic and selected at-risk children. The operation is technically demanding: reported rates of long-term symptomatic re-tethering after partial resection still reach 15\u201325%, and the surgeon must balance adequate untethering against preservation of the placode and lumbosacral nerve roots. In this technical note, we present a stepwise, illustrated description of our institutional 14-step microsurgical technique for pediatric LMMC. Each step is anchored to a defined anatomical landmark, beginning with a midline skin incision planned away from the anal verge and proceeding through subtotal subcutaneous lipoma resection, identification of the dural penetration site, a limited rostral laminectomy over normal anatomy, dural opening with circumferential dissection of lipoma\u2013dura\u2013cord adhesions, exploitation of the arachnoid\u2013dura plane, electrophysiologically guided debulking of the intradural lipoma, stimulation-controlled division of the fatty filum, pia-to-pia reconstruction of the placode with 8-0 monofilament suture, expansile duraplasty with an artificial dural substitute, and reinforced multilayered watertight closure. Technical pearls aimed at minimizing the risks of cord injury, cerebrospinal fluid leak, and postoperative re-tethering are highlighted at each stage, and the role of multimodal intraoperative neurophysiological monitoring is emphasized. This note is intended as a practical, image-anchored operative reference for pediatric neurosurgeons and trainees managing this challenging closed neural tube defect.<\/jats:p>","DOI":"10.3390\/brainsci16070720","type":"journal-article","created":{"date-parts":[[2026,7,6]],"date-time":"2026-07-06T14:01:08Z","timestamp":1783346468000},"page":"720","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Microsurgical Untethering of Pediatric Lipomyelomeningocele: A Stepwise, Photo-Illustrated Technical Note"],"prefix":"10.3390","volume":"16","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-4876-2380","authenticated-orcid":false,"given":"Chul Ou","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kwan-Sung","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3490-1064","authenticated-orcid":false,"given":"Seung Ho","family":"Yang","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Seoul St. Mary\u2019s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpodaero, Seocho-gu, Seoul 06591, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,5]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1007\/s00381-015-2839-7","article-title":"Symptomatic retethering of the spinal cord in postoperative lipomyelomeningocele patients: A meta-analysis","volume":"32","author":"Goodrich","year":"2016","journal-title":"Childs Nerv. Syst."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1633","DOI":"10.1007\/s00381-016-3288-7","article-title":"Unjoined primary and secondary neural tubes: Junctional neural tube defect, a new form of spinal dysraphism caused by disturbance of junctional neurulation","volume":"33","author":"Eibach","year":"2017","journal-title":"Childs Nerv. Syst."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"279","DOI":"10.3340\/jkns.2020.0024","article-title":"Surgical management of complex spinal cord lipomas: A new perspective","volume":"63","author":"Pang","year":"2020","journal-title":"J. Korean Neurosurg. Soc."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"428","DOI":"10.3171\/2016.10.PEDS16247","article-title":"New classification of spinal lipomas based on embryonic stage","volume":"19","author":"Morota","year":"2017","journal-title":"J. Neurosurg. Pediatr."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"327","DOI":"10.3340\/jkns.2020.0018","article-title":"Junctional neural tube defect","volume":"63","author":"Eibach","year":"2020","journal-title":"J. Korean Neurosurg. Soc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"348","DOI":"10.1186\/s13023-025-03856-4","article-title":"Revised Orphanet nomenclature and classification for spina bifida and other spinal dysraphisms (SBoD)","volume":"20","author":"Dhombres","year":"2025","journal-title":"Orphanet J. Rare Dis."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"737","DOI":"10.1007\/s10143-016-0796-6","article-title":"Conservative and surgical treatment of pediatric asymptomatic lumbosacral lipoma: A meta-analysis","volume":"41","author":"Yang","year":"2018","journal-title":"Neurosurg. Rev."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1007\/s00381-023-06203-9","article-title":"Lumbosacral lipoma in childhood, how strong is the evidence base? A systematic review","volume":"40","author":"Perera","year":"2024","journal-title":"Childs Nerv. Syst."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1038\/s41393-019-0385-y","article-title":"Long-term urological outcomes of spinal lipoma after prophylactic untethering in infancy: Real-world outcomes by lipoma anatomy","volume":"58","author":"Hayashi","year":"2020","journal-title":"Spinal Cord"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2025","DOI":"10.1007\/s00381-021-05081-3","article-title":"Does conus morphology have implications for outcome in lumbosacral lipoma?","volume":"37","author":"Thompson","year":"2021","journal-title":"Childs Nerv. Syst."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"537","DOI":"10.3171\/2019.2.PEDS18390","article-title":"Surgical management of complex spinal cord lipomas: How, why, and when to operate. A review","volume":"23","author":"Pang","year":"2019","journal-title":"J. Neurosurg. Pediatr."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"143","DOI":"10.3340\/jkns.2020.0124","article-title":"Intraoperative neurophysiology monitoring for spinal dysraphism","volume":"64","author":"Kim","year":"2021","journal-title":"J. Korean Neurosurg. Soc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"2289","DOI":"10.1007\/s00381-021-05128-5","article-title":"Feasibility and diagnostic accuracy of intra-operative monitoring of motor evoked potentials in children <2 years of age undergoing tethered cord surgery: Results in 100 children","volume":"37","author":"Nair","year":"2021","journal-title":"Childs Nerv. Syst."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1623","DOI":"10.1007\/s00381-020-05000-y","article-title":"Early- and long-term surgical outcomes in 109 children with lipomyelomeningocele","volume":"37","author":"Vora","year":"2021","journal-title":"Childs Nerv. Syst."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"2847","DOI":"10.1007\/s00381-023-06024-w","article-title":"Surgery for spina bifida occulta: Spinal lipoma and tethered spinal cord","volume":"39","author":"Morota","year":"2023","journal-title":"Childs Nerv. Syst."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"e207221","DOI":"10.1001\/jamanetworkopen.2020.7221","article-title":"Incidence of occult spinal dysraphism among infants with cutaneous stigmata and proportion managed with neurosurgery: A systematic review and meta-analysis","volume":"3","author":"Choi","year":"2020","journal-title":"JAMA Netw. Open"},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"349","DOI":"10.3171\/2022.6.PEDS2286","article-title":"Characterizing syringomyelia and its clinical significance in 140 patients with lipomyelomeningocele","volume":"30","author":"Abraham","year":"2022","journal-title":"J. Neurosurg. Pediatr."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"257","DOI":"10.1097\/WNP.0000000000001096","article-title":"Intraoperative neurophysiological monitoring in tethered cord syndrome surgery: Predictive values and clinical outcome","volume":"42","author":"Squintani","year":"2025","journal-title":"J. Clin. Neurophysiol."},{"key":"ref_19","first-page":"1739","article-title":"Filum terminale transection in pediatric tethered cord syndrome: A single center, population-based, cohort study of 95 cases","volume":"164","author":"Sandvik","year":"2022","journal-title":"Acta Neurochir."},{"key":"ref_20","first-page":"e1646","article-title":"Massive lumbosacral subcutaneous exudate after surgical treatment of a large lipomyelocele: Case report and literature review","volume":"94","author":"Cao","year":"2015","journal-title":"Medicine"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1007\/s00381-025-06867-5","article-title":"Effectiveness of conus lipoma surgery\u2014A case series","volume":"41","author":"Spazzapan","year":"2025","journal-title":"Childs Nerv. Syst."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"587","DOI":"10.1007\/s00381-021-05404-4","article-title":"Risk factors for pre-operative functional deterioration in children with lipomyelomeningocele","volume":"38","author":"Sarkar","year":"2022","journal-title":"Childs Nerv. Syst."}],"container-title":["Brain Sciences"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2076-3425\/16\/7\/720\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,7]],"date-time":"2026-07-07T05:02:58Z","timestamp":1783400578000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2076-3425\/16\/7\/720"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,5]]},"references-count":22,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["brainsci16070720"],"URL":"https:\/\/doi.org\/10.3390\/brainsci16070720","relation":{},"ISSN":["2076-3425"],"issn-type":[{"value":"2076-3425","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,5]]}}}