In a 37-year-old woman with an asymptomatic tethered spinal cord who has not undergone detethering surgery, what management recommendations should be made?

Management of Asymptomatic Tethered Spinal Cord in a 37-Year-Old Woman

For a 37-year-old asymptomatic woman with tethered spinal cord who has not undergone surgery, we recommend conservative management with serial neurological surveillance rather than prophylactic surgical intervention. 1, 2

Rationale Against Prophylactic Surgery

Surgery is not indicated for asymptomatic tethered cord. The evidence consistently demonstrates that surgical untethering should be reserved for patients with progressive or new-onset symptoms attributable to tethered cord syndrome. 1

• Prophylactic surgery in asymptomatic patients carries surgical risks without proven benefit, as the benefits of surgery remain debated in this population. 1
• While tethered cord can eventually produce neurological deficit, not all patients with radiographic tethering develop symptoms, particularly those who have reached adulthood without manifestations. 3
• Surgical intervention in adults involves greater risk of neurological injury compared to children, making the risk-benefit calculation less favorable in asymptomatic cases. 2

Recommended Surveillance Strategy

Implement structured neurological monitoring every 3-6 months to detect early symptom development. 1, 2

Key Symptoms to Monitor:

• Pain: Lower back pain, leg pain, or radicular symptoms (most common presenting feature in adults). 2
• Motor dysfunction: Progressive weakness in lower extremities, gait disturbances, or foot deformities. 1, 2
• Sensory changes: Numbness, paresthesias, or sensory loss in lower extremities or perineal region. 2
• Bowel/bladder dysfunction: Urinary incontinence, retention, constipation, or fecal incontinence. 1, 2
• Orthopedic manifestations: Progressive scoliosis or foot deformities. 1

Cutaneous Examination:

• Check for skin markers over the lumbosacral spine including dermal sinus tracts, hairy patches, lipomas, or vascular malformations, which may indicate underlying dysraphism. 4

Advanced Monitoring Techniques

Consider phase-motion MRI studies to assess cervical cord motion, which may predict functional deterioration before clinical symptoms emerge. 3

• Symptomatic patients with progressive deficit demonstrate limited cervical cord motion that improves after surgical untethering. 3
• This technique shows promise in predicting neurological deficit from spinal cord tethering and could guide timing of intervention. 3

Indications for Surgical Intervention

Surgery becomes indicated only if the patient develops progressive or new-onset symptoms. 1, 2

Surgical Timing Considerations:

• Early operative intervention when symptoms first appear is associated with improved outcomes compared to delayed surgery. 1, 2
• Pain relief is accomplished in almost all surgical cases (22 of 27 patients in one series). 2
• Neurological improvement occurs in approximately 48% of patients with motor/sensory dysfunction and 61% with bowel/bladder disturbance. 2
• Critical caveat: Neurological deficits, particularly bowel and bladder dysfunction, are generally irreversible once established, making early detection of symptom onset crucial. 2, 5

Expected Surgical Outcomes if Symptoms Develop

If surgery becomes necessary, realistic expectations include:

• Pain relief: Achieved in nearly all cases. 1
• Neurological stabilization: Primary goal is halting progression rather than complete reversal. 1
• Functional improvement: Often seen but not guaranteed, with 79% of adult patients rating surgery as a long-term success. 2
• Return to work: 86% of employed patients return to work postoperatively. 2
• Scoliosis: Cord untethering can halt progression of associated scoliosis. 1

Common Pitfalls to Avoid

• Do not operate based solely on radiographic findings without clinical correlation, as MR imaging almost always shows cord tethering even in asymptomatic or improved patients. 3
• Do not delay surgery once symptoms develop, as neurological deficits become increasingly irreversible with time, particularly bladder and bowel dysfunction. 2, 5
• Do not dismiss subtle symptoms such as mild pain or minor gait changes, as these may herald progressive deterioration requiring intervention. 1, 2