Treatment for Tethered Cord Syndrome

Surgical untethering is the definitive treatment for tethered cord syndrome in patients with progressive or new onset symptoms attributable to the condition. 1

Understanding Tethered Cord Syndrome

Tethered cord syndrome (TCS) is a clinical entity characterized by symptoms and signs caused by excessive tension on the spinal cord, resulting in:

Physical stretching of the spinal cord
Impaired blood flow
Diminished oxidative metabolism and glucose utilization
Metabolic failure at the mitochondrial respiratory chain level 2

The severity and reversibility of these metabolic disturbances correlate with the severity and chronicity of the tethering 2.

Clinical Presentation

Symptoms vary by age and underlying pathology:

In Infants:

Often asymptomatic, with malformations recognized solely by associated cutaneous abnormalities 2

In Children:

Pain (back and/or leg) that may be dull, sharp, lancinating, electrical, or dysesthetic in character 2
Sensorimotor disturbances of lower limbs 2
Difficulties with bladder and/or bowel control 2
Progressive musculoskeletal deformities and/or scoliosis 2
Muscle weakness and gait disturbances 2

In Teenagers/Adults:

Pain radiating into the groin, genitals, and/or perianal region 2
Sensory abnormalities starting distally in the leg and becoming more proximal 2
Urinary and fecal urgency/incontinence, urinary tract infections, incomplete bladder emptying 2
History of subtle abnormalities dating back to childhood (athletic difficulties, chronic constipation, late toilet training) 2

Diagnostic Evaluation

MRI of the lumbar spine is indicated in patients with:
- Bowel and bladder dysfunction
- Lower limb upper motor neuron signs
- Presence of a sacral dimple 2
Urologic function assessment through:
- History (incontinence, frequency, repeated urinary tract infections)
- Imaging (renal ultrasonography showing hydroureter/hydronephrosis)
- Formal urodynamic testing 2

Surgical Management

Indications for Surgery:

Progressive or new onset symptoms attributable to TCS 1
Pain, neurological deficits, or urologic dysfunction 3

Surgical Techniques:

Traditional Untethering:
- Microsurgical release of the tethered cord 4
- Sectioning of the filum terminale 5
- Cutting arachnoid and fibrous bands 5
- Protection of nerve rootlets 5
- Correction of associated malformations 5
Spinal Column Shortening (alternative approach):
- Pedicle subtraction osteotomy or vertebral column resection 6
- Most commonly performed at the L-1 level 6
- Fusion between T-12 and L-2 using pedicle screw-rod construct 6
- Avoids risks associated with direct cord manipulation 6

Surgical Outcomes:

Pain relief is accomplished in almost all cases 1, 3
Improvement in pain reported in 78-83% of patients 4, 3
Stabilization of neurological function in most patients 1
Improvement in bladder function in approximately 50% of patients 4
Overall neurological status improved or stabilized in 90% of patients 4
Spinal column shortening shows 71% improvement in preoperative symptoms 6

Potential Complications:

Cerebrospinal fluid leakage (most common) 4, 5
Wound infection 4
Meningitis 4
Urinary tract infection 4
Potential for neurological deterioration (rare) 4

Special Considerations

Early operative intervention is associated with improved outcomes 1
Long-standing or severe orthopedic deformities are unlikely to improve with surgery alone and may require subsequent orthopedic intervention 2
Patients who have undergone previous intradural detethering procedures generally have poorer outcomes 4
Realistic surgical goals include relief of pain and stabilization of neurological function, although improvement is often seen 1

Follow-up Care

Monitoring for retethering due to normal scar formation after surgery 6
Continued urologic assessment 2
Orthopedic follow-up for associated deformities 2
Physical, occupational, and speech therapies to maximize function when appropriate 2

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