Can meningeal tethering after anterior cervical disc (ACD) decompression surgery cause strange paresthesias in the long post-operative period?

Meningeal Tethering and Long-Term Paresthesias After Anterior Cervical Disc Decompression

Yes, meningeal tethering can produce strange paresthesias in the long post-operative period after anterior cervical disc decompression surgery, though this is an extremely rare complication. This occurs when cerebrospinal fluid leakage during surgery leads to arachnoid adhesions and mechanical tethering of the spinal cord 1.

Mechanism of Meningeal Tethering

The pathophysiology involves a specific sequence of events:

• CSF leakage during the initial surgery creates the substrate for tethering through mechanical deformation and subsequent scar formation at the dural defect site 1.
• Arachnoid bands form between the spinal cord and surrounding structures, creating abnormal mechanical tension on neural tissue 1.
• This mechanical tethering produces neuropathic pain and neurological deficits that manifest months to years after the index procedure, typically presenting 2 years or more postoperatively 1.

Clinical Presentation

The presentation differs from typical immediate post-operative complications:

• Delayed onset of symptoms occurring months to years after surgery, not in the immediate perioperative period 1.
• Neuropathic pain quality that is often refractory to conservative management 1.
• Progressive myelopathic changes including reflex abnormalities and motor weakness that develop gradually 1.
• Symptoms may include unusual paresthesias that don't follow typical dermatomal patterns due to the mechanical distortion of the cord 1.

Differential Diagnosis for Late Post-Operative Symptoms

When evaluating strange paresthesias in the long post-operative period, consider these alternative diagnoses:

• Parsonage-Turner syndrome (neuralgic amyotrophy) can occur after cervical decompression, presenting with severe pain followed by weakness, typically affecting the C5 distribution but can involve other nerve roots 2.
• C5 palsy may develop without intraoperative monitoring changes and can present with delayed symptoms, though typically manifests within days to weeks rather than years 3, 4.
• Adjacent segment disease causing new compression at levels above or below the fusion 3.
• White cord syndrome from reperfusion injury, though this presents acutely in the immediate post-operative period, not years later 5.

Diagnostic Approach

Obtain urgent MRI with and without contrast to evaluate for:

• Arachnoid adhesions or tethering bands visible as abnormal tissue strands connecting the cord to surrounding structures 1.
• Cord signal changes indicating chronic mechanical stress or myelomalacia 1.
• Absence of new compression from hardware, hematoma, or adjacent segment disease 6.
• CSF flow studies may demonstrate abnormal flow patterns if tethering is significant 1.

Management Algorithm

For confirmed meningeal tethering with progressive symptoms:

1. Surgical detethering is the definitive treatment when conservative management fails and imaging confirms mechanical tethering 1.
2. Approach involves anterior corpectomy with dural opening to directly visualize and release the tethering bands 1.
3. Expect improvement in motor and reflex changes but neuropathic pain may persist despite successful detethering 1.
4. Reconstruction with fusion and plating is necessary after corpectomy to maintain stability 1.

For Parsonage-Turner syndrome (if diagnosed instead):

• Conservative management with pain control and physical therapy achieves resolution in the majority of cases (4 of 6 patients in one series) 2.
• Surgical nerve releases or reconstruction reserved for select cases not responding to conservative treatment 2.
• Recovery typically occurs over months with eventual resolution of pain and motor strength 2.

Critical Caveats

The most important pitfall is attributing late neurological symptoms to "normal post-operative changes" when they actually represent a treatable mechanical problem 1. Key warning signs include:

• Progressive rather than improving symptoms beyond 3-4 months postoperatively 3.
• New onset of symptoms years after surgery rather than persistent symptoms from the initial surgery 1.
• Neuropathic pain quality that is disproportionate to imaging findings of simple adjacent segment disease 1.

History of CSF leak during the index procedure is the critical risk factor that should raise suspicion for tethering when late symptoms develop 1. Without documented CSF leak, tethering is extremely unlikely and alternative diagnoses should be pursued more aggressively 1.

Delayed epidural hematoma, though rare, can present up to 5 days postoperatively and requires emergency decompression, so this must be excluded in any patient with acute neurological deterioration 7. However, this presents acutely, not in the "long post-operative period" as described in your question 7.