What is the recommended treatment for tethered cord syndrome?

Treatment of Tethered Cord Syndrome

Surgical untethering is the definitive treatment for patients with tethered cord syndrome who have progressive or new-onset symptoms, while asymptomatic patients should be managed conservatively with close surveillance. 1

Surgical Indications

Operate on patients who demonstrate:

• Progressive pain (back, leg, gluteal, perianal, or pelvic regions) 1, 2
• New or worsening neurological deficits including motor weakness, sensory abnormalities, or reflex changes 1, 3
• Bladder or bowel dysfunction including new-onset incontinence, urinary retention, urgency, or recurrent urinary tract infections 1, 4
• Progressive musculoskeletal deformities such as scoliosis or lower extremity orthopedic abnormalities 1, 4

Pain responds best to surgical intervention, with 78% improvement in back pain and 83% improvement in leg pain at long-term follow-up 3. Motor function improves or stabilizes in 90% of surgically treated patients 3.

Conservative Management Protocol

For asymptomatic or minimally symptomatic patients, implement:

• Serial MRI of the lumbar spine to monitor for progression 1, 5
• Urologic assessment including history, renal ultrasonography, and formal urodynamic testing when indicated 1, 5, 4
• Orthopedic follow-up for associated deformities and scoliosis monitoring 1, 5

Conservative management is appropriate for adults without neurological deficits, with 79% remaining clinically stable over 10 years 2. However, when surgery is recommended but declined, clinical deterioration occurs in 47% within 5 years 2.

Surgical Technique Considerations

Microsurgical release with intraoperative neurophysiological monitoring is the standard approach 3. The procedure involves:

• Laminectomy (open or minimally invasive) to access the thecal sac 6
• Sectioning of the filum terminale or release of tethering lesions 3
• Exploration and treatment of associated anomalies like diastematomyelia or lipomas 3

Minimally invasive approaches achieve similar outcomes with smaller incisions but may have comparable complication rates 6. The most common complication is cerebrospinal fluid leakage (15% of cases), typically managed with reinforcement sutures or temporary drainage 3.

Special Population: Myelomeningocele Patients

Children with prenatal or postnatal myelomeningocele closure require heightened surveillance as they develop tethered cord syndrome at equal or higher rates than the general population 4, 1. Key considerations include:

• Earlier age of presentation in infants with prenatal closure 4
• Increased risk of inclusion cysts with in utero closure 4
• Continued surveillance is mandatory regardless of closure timing (Level II recommendation) 4

Critical Pitfalls to Avoid

Do not perform revision surgery liberally in patients with complex dysraphic lesions (lipomas, dermoid/epidermoid cysts), as all such patients experience clinical deterioration within 10 years despite reoperation 2. First-time surgery achieves 89% 10-year neurological stabilization for simple tethering versus 81% for complex lesions 2.

Do not delay surgery in symptomatic patients expecting spontaneous improvement, as long-standing orthopedic deformities are unlikely to improve even after successful untethering 4. Bladder dysfunction often remains permanent despite surgery, with only 50% experiencing subjective improvement 3.

Prophylactic surgery in asymptomatic patients is not routinely recommended except in specific circumstances where rapid deterioration is anticipated 7.

Multidisciplinary Support Requirements

Coordinate care with:

• Urology for ongoing bladder function assessment and management 1, 5
• Orthopedics for scoliosis and musculoskeletal deformity management 1, 5
• Physical and occupational therapy to maximize functional outcomes 1, 5

This comprehensive approach addresses the metabolic failure at the mitochondrial level caused by physical stretching of the spinal cord, which impairs blood flow and oxidative metabolism 5. The severity and reversibility of these metabolic disturbances correlate directly with the chronicity of tethering 5.