Management of Tethered Cord Syndrome in a 22-Year-Old Female
Surgical untethering is recommended if this patient has progressive or new-onset symptoms (pain, neurological deficits, bladder/bowel dysfunction, or musculoskeletal deformities), while asymptomatic patients should undergo conservative management with close surveillance. 1, 2
Initial Diagnostic Assessment
Clinical Evaluation
- Pain assessment: Look specifically for pain radiating to the groin, genitals, or perianal region, which is characteristic in teenagers and adults 1
- Neurological examination: Document any sensory abnormalities, motor weakness, gait disturbances, muscle atrophy, or loss of reflexes in the lower extremities 1, 3
- Bladder/bowel function: Assess for urinary urgency, incontinence, urinary tract infections, fecal urgency, or constipation 1, 4
- Musculoskeletal evaluation: Check for scoliosis or progressive orthopedic deformities 5, 1
Required Diagnostic Studies
- MRI of the lumbar spine: Essential to confirm diagnosis, assess conus position (normal is above L1-L2), and evaluate filum terminale thickness (abnormal if >2mm) 1, 6
- Urologic function assessment: Perform comprehensive evaluation including detailed history, renal ultrasonography (looking for hydronephrosis, bladder wall thickening), and formal urodynamic testing 5, 1, 6
Treatment Algorithm
Indications for Surgical Intervention
Proceed with surgical untethering if any of the following are present:
- Progressive or new-onset pain 2, 4
- New or worsening neurological deficits (motor weakness, sensory changes) 2, 4
- Bladder or bowel dysfunction (new or worsening) 2, 4
- Progressive musculoskeletal deformities or scoliosis 2, 4
Surgical outcomes: Pain relief is achieved in almost all cases; realistic goals include pain resolution and stabilization of neurological function, with improvement often seen 4. Early operative intervention is associated with improved outcomes 4. Bladder function may improve, though sphincter dysfunction often remains a permanent problem 3.
Conservative Management Protocol
If the patient is asymptomatic or has stable, minimal symptoms:
- Continued urologic surveillance: Regular urodynamic studies are critical as they can detect deterioration before clinical symptoms manifest 1, 2, 6
- Serial MRI monitoring: Repeat lumbar spine MRI to assess for progression 1, 2
- Orthopedic follow-up: Monitor for development of scoliosis or other deformities 1, 2
- Multidisciplinary support: Consider physical and occupational therapy to maximize function 1, 2
Critical Management Pitfall
Given the potential for rapid deterioration with incomplete neurological recovery, even prophylactic surgery may be advisable in young adults with confirmed tethered cord on imaging. 3 The risk of permanent neurological deficits increases with delayed intervention, particularly for bladder dysfunction which often becomes irreversible 3, 6.
Special Consideration for This Age Group
At 22 years old, this patient falls into the teenager/young adult category where presentations typically include pain as the predominant symptom, along with urinary/fecal urgency and incontinence 1. Urodynamic studies are particularly valuable in this population as they identify subclinical deterioration that precedes overt clinical manifestations 6.