The complex treatment paradigms for concomitant tethered cord and scoliosis: illustrative case

Rose Fluss Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

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Riana Lo Bu Dominik Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx, New York; and

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Andrew J Kobets Department of Neurological Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

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Jaime A Gomez Department of Orthopedic Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York

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BACKGROUND

Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections.

OBSERVATIONS

A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3–4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved.

LESSONS

Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

ABBREVIATIONS

HV = hemivertebra; LE = lower extremity; MEP = motor evoked potential; VCR = vertebral column resection

BACKGROUND

Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections.

OBSERVATIONS

A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3–4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved.

LESSONS

Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

ABBREVIATIONS

HV = hemivertebra; LE = lower extremity; MEP = motor evoked potential; VCR = vertebral column resection

Tethered cord syndrome is a complex clinical entity in which progressive tension on the spinal cord can compromise neurological function and can result in progressive spinal deformity. Tethered cord syndrome occurs in 12%–17% of patients with scoliosis and results from the tether itself restricting spinal cord perfusion.1–5 It is a constellation of motor and sensory neuron dysfunction attributable to abnormally increased tension on the spinal cord.1,6 However, radiographic evidence of a tethered cord must be supported by a clinical diagnosis.7 The clinical presentation varies by age and etiology. In neonates and infants, cutaneous manifestations include nevi, lipomas, tufts of hair, hemangiomas, and dermal sinuses.8 Urinary dribbling, extremity deformity, or scoliosis can also be seen. Toddlers and adolescents present with motor and sensory dysfunction, such as difficulties with gait or running; progression of scoliosis; development of foot deformities; bladder regression or, less frequently, bowel control; and low-back or leg pain.8,9 Management is complex and requires expertise in preserving neurological function and addressing concurrent pathologies, because a tethered spinal cord can increase the chance of neurological injury.7 Excessive traction during reduction maneuvers makes this pathology one of the most challenging spinal deformities to manage.10 The degree and reversibility of cord dysfunction correlate with both the magnitude and duration of the traction.7 The aim of the present report is to describe the complex treatment paradigms that exist when attempting to manage tethered cord syndrome associated with scoliosis. This unique case involving a kyphotic deformity in addition to a tethered cord syndrome and scoliosis demonstrates the complexity and nuance of determining the optimal surgical approach for this clinical syndrome.

Illustrative Case

History and Examination

A 10-year-old female presented with congenital kyphoscoliosis, worsening curve progression, and tethered spinal cord. The scoliosis had first been identified when the patient was age 8, originally with a 25° scoliosis and 40° thoracolumbar kyphosis identified on scoliosis radiographs (Fig. 1), which progressed over 2 years to a 26° coronal curve and 55° thoracolumbar kyphosis. She had a history of enuresis. On physical examination, she had bilateral cavovarus foot deformity, short stature, toe walking, and mild hyperreflexia but was graded 5/5 on motor examination. Given her neurological findings and the complex spinal pathology, she underwent preoperative magnetic resonance imaging, which showed a large kyphotic deformity at L1 and a tethered cord between the levels of L3–4 in the setting of a low-lying conus medullaris (Fig. 2). Because she already had significant neurological pathology likely resulting from her spinal deformities, concomitant spinal cord detethering and scoliosis correction were scheduled to avoid a worsening of neurological symptoms, minimize the morbidity of multiple operations, and complete management all at once.

FIG. 1
FIG. 1

Anteroposterior (left) and lateral (right) scoliosis radiographs showing a 25° scoliosis and a 40° thoracolumbar kyphosis.

FIG. 2
FIG. 2

Sagittal (left) and axial (right) magnetic resonance imaging depicting focal kyphosis at the thoracolumbar junction, resulting in severe spinal canal stenosis and impingement of the cord. Note the segmentation anomaly including a dominant L1 HV with focal angular kyphosis at the thoracic lumbar junction and low-lying conus medullaris abutting the posterior sac at L3–4.

Surgery

The operative plan involved 1) pedicle screw placement and L1 laminectomy to first correct the kyphoscoliosis. This decision was made to minimize the chance of neurological injury by relieving pressure on the spinal cord at the kyphosis apex first. Surgery also involved 2) lateral decompression via hemivertebrae (HVs) excision of the collapsed L1 vertebral body, 3) intradural detethering after a laminectomy at L4, and 4) completion of the T11–L2 fusion. Leads were placed for intraoperative neuromonitoring, and preflip motor evoked potentials (MEPs) and somatosensory evoked potentials were induced, recorded, and present. Sequential compression devices were placed on the legs, and appropriate intravenous antibiotics were administered. A longitudinal incision was made from the lower thoracic spine to L5. The Stealth array was placed on the spinous process of T11 to help with placement of the polyaxial pedicle screws bilaterally at T12 and L2. Fluoroscopy was used to confirm accurate pedicle screw placement.

An L1 laminectomy was then completed without any contact with the cord, after which MEPs were run and a bilateral lower-extremity MEP drop was found. A neuromonitoring loss protocol was initiated, and a senior anesthesiologist and neurologist were called into the room. The patient was administered red blood cells, her mean arterial pressure was kept >80 mm Hg, and dosed steroids were administered. Accurate screw placement was confirmed with radiography.

Given the known kyphosis and possible compression of the cord from the HVs, the decision was made to continue with decompression via an HV excision to alleviate any stress on the cord. Temporary rods were placed, and emergent compression was performed. The cord appeared movable and not under extreme tension. Motor signals in the lower extremities (LEs) were flat. A complete HV excision was performed. The left L1 pedicle was also removed, and a complete 360° osteotomy was performed. At this point, the bony spine was compressed and shortened, and the cord was under decreased tension. Motor signals were still absent in the bilateral LEs, but sphincter MEPs and bulbocavernosus reflex returned. The vertebral column resection (VCR) was done in 30 minutes. Excellent correction was obtained, as confirmed by radiography. D waves were present above and below the kyphosis with a difference in latency consistent with cord function.

The decision whether to proceed with the detethering despite MEP loss in the LEs was discussed in detail. All involved teams agreed that the MEP loss may have been unavoidable from decompression; therefore, the decision was made to proceed with the detethering. An L4 laminectomy was first completed through a separate facial incision but the same skin incision. Then the filum was isolated after dissecting off any attached nerve roots without tissue. To confirm that there were no associated roots to the filum, direct bipolar stimulation with 2 mA was used, and no signal transduction occurred. The filum was then cauterized and cut, with movement of the cranial end up 1–2 spinal levels, demonstrating a true detethering. After irrigation with antibiotic saline and dural closure, a Valsalva maneuver was performed to demonstrate no leakage.

Instrumentation and stabilization of the spine then followed, with completion of the T11–L2 fusion. Autograft and allograft bone were placed over the decorticated posterior elements. Drain placement and then complete wound closure were completed. The patient was awakened from anesthesia, after which she moved her toes in both legs on command and her LE MEPs returned. She was taken back to the pediatric intensive care unit in stable condition.

Postoperative Course

After surgery, she experienced LE weakness (muscle strength 4/5), which resolved 2 months postoperatively (muscle strength 5/5). Her LE weakness improved remarkably from baseline but has required continued acute physical therapy intervention to address her impairments. Postoperative anteroposterior and lateral scoliosis radiographs showed that the hardware remained intact and in excellent coronal and sagittal alignment (Fig. 3). The disc heights were maintained. No evidence of proximal junctional kyphosis, adjacent segment disease, or vertebral abnormalities were noticed.

FIG. 3
FIG. 3

Postoperative anteroposterior (left) and lateral (right) scoliosis radiographs showing successful scoliosis correction.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Observations

We describe a case of a 10-year-old female with congenital kyphoscoliosis who had worsening curve progression with a concomitant tethered cord. Although a preoperative decision was made to detether her spinal cord after laminectomy and hemivertebrectomy in the hope of reducing the risk of pressure on the spinal cord at the kyphosis apex, the patient experienced neurological changes picked up by intraoperative neuromonitoring.

Traditionally, the management of tethered cord syndrome associated with scoliosis consists of a prophylactic detethering procedure staged with deformity correction 3–6 months later.11 Sometimes, in a small scoliotic curve with tethering, surgical release of the filum can halt curve progression entirely as a stand-alone treatment.12 However, when curves are large at presentation or progress despite initial detethering, a staged corrective fusion has been the standard of care.1,12,13 But given the higher complication rate of performing a second surgery, such as a repeated risk of cerebrospinal fluid leakage, excessive intraoperative bleeding, or surgical site infection, newer reports have advocated for a combined curve correction and detethering in a single procedure.14–18

Jallo et al.16 described 15 consecutive cases of concurrent detethering and deformity correction compared with 21 staged procedures. The concurrent surgeries were safe and effective and had a decreased complication rate, with corrective and neurological outcomes as robust as those of the staged cohort. The two-stage cohort experienced a longer cumulative operative time (11.2 versus 8.6 hours, p < 0.05); greater total blood loss (1534 versus 1266 mL, p < 0.05); more total days of hospitalization (14.8 versus 10.1 days, p < 0.05); and a greater incidence of dural tear (9.5% versus 0%), wound infection (26% versus 0%), and retethering (9.5% versus 0%). The mean Cobb angles preoperatively were similarly 55.4° ± 21.0°, which decreased to 40° postoperatively. No new neurological complications occurred in the single surgeries.16

Even in patients with severe scoliotic curvature, detethering and fusion can be performed safely and concurrently. In a 2017 review of 13 articles, for Cobb angles <35°, detethering was sufficient to halt scoliosis progression; those >35° required fusion and detethering, confirming the Jallo data.11 For large or progressive curves in symptomatic patients, “simultaneous tethered cord release and curve correction can be undertaken safely,” reducing the need for subsequent procedures and the risks associated with them.11 In a 2022 database review of a multicenter registry in which 66% of patients underwent staged surgeries and 34% underwent simultaneous surgeries, the conclusions regarding the safety of concurrent procedures were upheld.19

Kokubun first advocated a novel spine-shortening osteotomy for a tethered cord and scoliosis in 1995, with several refinements to date.20,21 Generally, a laminectomy is first performed at the apical vertebra with the facets completely excised, followed by the pedicles, then an osteotomy of the vertebral body. Screws are placed several levels above and below, with temporary rods placed prior to lateral wall resection. Bone-to-bone contact of the posterior cortex is achieved by compression of the precontoured temporary rods alternately. After reduction, the temporary rods are changed to final rods and shaped to the normal sagittal and coronal curvature.22 According to one report, the average column shortening is 23.4 ± 2.7 mm.23

In the largest reported series of spine-shortening osteotomy, 80% of patients were cured or improved, whereas 20% did not experience any neurological change.23 Spine-shortening osteotomy not only corrects the spinal deformity but also simultaneously releases the tension of the tethered cord, resulting in improved neurological function. Ideal patients are those in whom the curve is both severe and rigid (Cobb >90°, flexibility <30%), and an osteotomy procedure may be indicated for correction of the deformity.24,25 Alternatively, patients with more moderate amounts of scoliosis and a progressive neural deficit may benefit from VCR to alleviate their neurological symptoms when detethering may be risky, as in patients with previous detethering who experienced complications. Jalanko et al.26 successfully used hemivertebrectomy alone to treat a tethered cord with subsequent neurological recovery for their patients. For patients with less severe scoliosis (Cobb <90°) who are not symptomatic from their tethered cord, a VCR may be more controversial.

Unfortunately, in our patient, a complete intraoperative loss of motor signals occurred after laminectomy. Although the patient’s neurological deficit ultimately improved, this report serves as an important reminder that questions on operative optimization remain. If the two surgical procedures are safe to be performed concurrently, does order matter? Additionally, when are spine-shortening osteotomies superior to intradural detethering in severe deformities? This case report further elucidates other questions; for example, during concurrent surgery, how are complications during the first stage addressed? Moreover, should the second stage proceed, and how much should we rely on intraoperative neuromonitoring to guide management in these cases? Ultimately, the goal of this surgery was to halt the feared complication of a progressive decline in motor function in our patient, which was successfully achieved.

Lessons

Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome. A tethered cord and scoliotic vertebral column can be safely treated in the same surgical procedure. Detethering may halt scoliosis progression in certain cases and vice versa. Novel techniques are continually being refined to address concurrent pathologies in unique ways through our understanding of the complex pathophysiology of tethered cord syndrome.

Author Contributions

Conception and design: Lo Bu, Kobets, Gomez. Acquisition of data: Kobets. Analysis and interpretation of data: Fluss, Kobets. Drafting the article: Fluss, Lo Bu, Gomez. Critically revising the article: Lo Bu, Kobets, Gomez. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Fluss. Study supervision: Kobets.

References

  • 1

    Barutçuoğlu M, Selçuki M, Umur AS, Mete M, Gurgen SG, Selcuki D Scoliosis may be the first symptom of the tethered spinal cord. Indian J Orthop. 2016;50(1):8086.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Basu PS, Elsebaie H, Noordeen MH Congenital spinal deformity: a comprehensive assessment at presentation. Spine (Phila Pa 1976). 2002;27(20):22552259.

  • 3

    Rajasekaran S, Kamath V, Kiran R, Shetty AP Intraspinal anomalies in scoliosis: an MRI analysis of 177 consecutive scoliosis patients. Indian J Orthop. 2010;44(1):5763.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Shen J, Wang Z, Liu J, Xue X, Qiu G Abnormalities associated with congenital scoliosis: a retrospective study of 226 Chinese surgical cases. Spine (Phila Pa 1976). 2013;38(10):814818.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Tao H, Yang K, Li T, et al. Is it possible to correct congenital spinal deformity associated with a tethered cord without prophylactic intradural detethering? Clin Orthop Relat Res. 2019;477(7):16891697.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Giddens JL, Radomski SB, Hirshberg ED, Hassouna M, Fehlings M Urodynamic findings in adults with the tethered cord syndrome. J Urol. 1999;161(4):12491254.

  • 7

    Lew SM, Kothbauer KF Tethered cord syndrome: an updated review. Pediatr Neurosurg. 2007;43(3):236248.

  • 8

    Dias M, Partington M Congenital brain and spinal cord malformations and their associated cutaneous markers. Pediatrics. 2015;136(4):e1105e1119.

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    Hertzler DA 2nd, DePowell JJ, Stevenson CB, Mangano FT Tethered cord syndrome: a review of the literature from embryology to adult presentation. Neurosurg Focus. 2010;29(1):E1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yamada S, Iacono RP, Andrade T, Mandybur G, Yamada BS Pathophysiology of tethered cord syndrome. Neurosurg Clin N Am. 1995;6(2):311323.

  • 11

    Yaltırık K, El Tecle NE, Pierson MJ, Puryear A, Atalay B, Elbabaa SK Management of concomitant scoliosis and tethered cord syndrome in non-spina bifida pediatric population. Childs Nerv Syst. 2017;33(11):18991903.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chern JJ, Dauser RC, Whitehead WE, Curry DJ, Luerssen TG, Jea A The effect of tethered cord release on coronal spinal balance in tight filum terminale. Spine (Phila Pa 1976). 2011;36(14):E944E949.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kulwin CG, Patel NB, Ackerman LL, Smith JL, Boaz JC, Fulkerson DH Radiographic and clinical outcome of syringomyelia in patients treated for tethered cord syndrome without other significant imaging abnormalities. J Neurosurg Pediatr. 2013;11(3):307312.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Samdani AF, Asghar J, Pahys J, D’Andrea L, Betz RR Concurrent spinal cord untethering and scoliosis correction: case report. Spine (Phila Pa 1976). 2007;32(26):E832E836.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Hamzaoglu A, Ozturk C, Tezer M, Aydogan M, Sarier M, Talu U Simultaneous surgical treatment in congenital scoliosis and/or kyphosis associated with intraspinal abnormalities. Spine (Phila Pa 1976). 2007;32(25):28802884.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Mehta VA, Gottfried ON, McGirt MJ, Gokaslan ZL, Ahn ES, Jallo GI Safety and efficacy of concurrent pediatric spinal cord untethering and deformity correction. J Spinal Disord Tech. 2011;24(6):401405.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Oda JE, Shah SA, Mackenzie WG, Akbarnia BA, Yazici M Concurrent tethered cord release and growing-rod implantation—is it safe? Global Spine J. 2012;2(4):207212.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Mooney JF, Glazier SS, Barfield WR Concurrent orthopedic and neurosurgical procedures in pediatric patients with spinal deformity. J Pediatr Orthop B. 2012;21(6):602605.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kunes J, Quan T, Iyer R, et al. Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis. Spine Deform. 2022;10(6):14731480.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kokubun S, Ozawa H, Aizawa T, Ly NM, Tanaka Y Spine-shortening osteotomy for patients with tethered cord syndrome caused by lipomyelomeningocele. J Neurosurg Spine. 2011;15(1):2127.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Kokubun S Shortening spinal osteotomy for tethered cord syndrome in adults]. Article in Japanese. Spine Spinal Cord. 1995;8(12 suppl):5.

  • 22

    Hsieh PC, Stapleton CJ, Moldavskiy P, et al. Posterior vertebral column subtraction osteotomy for the treatment of tethered cord syndrome: review of the literature and clinical outcomes of all cases reported to date. Neurosurg Focus. 2010;29(1):E6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Theodore N, Cottrill E, Kalb S, et al. Posterior vertebral column subtraction osteotomy for recurrent tethered cord syndrome: a multicenter, retrospective analysis. Neurosurgery. 2021;88(3):637647.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Liao H, Xie P, Zheng G, et al. Evaluation of parallel endplate osteotomy for severe rigid spinal deformities: a retrospective analysis of 36 cases with a minimum 2-year follow-up. BMC Musculoskelet Disord. 2021;22(1):1011.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Zhou C, Liu L, Song Y, et al. Anterior and posterior vertebral column resection for severe and rigid idiopathic scoliosis. Eur Spine J. 2011;20(10):17281734.

    • PubMed
    • Search Google Scholar
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  • 26

    Jalanko T, Rintala R, Puisto V, Helenius I Hemivertebra resection for congenital scoliosis in young children: comparison of clinical, radiographic, and health-related quality of life outcomes between the anteroposterior and posterolateral approaches. Spine (Phila Pa 1976). 2011;36(1):4149.

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  • Collapse
  • Expand
  • FIG. 1

    Anteroposterior (left) and lateral (right) scoliosis radiographs showing a 25° scoliosis and a 40° thoracolumbar kyphosis.

  • FIG. 2

    Sagittal (left) and axial (right) magnetic resonance imaging depicting focal kyphosis at the thoracolumbar junction, resulting in severe spinal canal stenosis and impingement of the cord. Note the segmentation anomaly including a dominant L1 HV with focal angular kyphosis at the thoracic lumbar junction and low-lying conus medullaris abutting the posterior sac at L3–4.

  • FIG. 3

    Postoperative anteroposterior (left) and lateral (right) scoliosis radiographs showing successful scoliosis correction.

  • 1

    Barutçuoğlu M, Selçuki M, Umur AS, Mete M, Gurgen SG, Selcuki D Scoliosis may be the first symptom of the tethered spinal cord. Indian J Orthop. 2016;50(1):8086.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Basu PS, Elsebaie H, Noordeen MH Congenital spinal deformity: a comprehensive assessment at presentation. Spine (Phila Pa 1976). 2002;27(20):22552259.

  • 3

    Rajasekaran S, Kamath V, Kiran R, Shetty AP Intraspinal anomalies in scoliosis: an MRI analysis of 177 consecutive scoliosis patients. Indian J Orthop. 2010;44(1):5763.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Shen J, Wang Z, Liu J, Xue X, Qiu G Abnormalities associated with congenital scoliosis: a retrospective study of 226 Chinese surgical cases. Spine (Phila Pa 1976). 2013;38(10):814818.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Tao H, Yang K, Li T, et al. Is it possible to correct congenital spinal deformity associated with a tethered cord without prophylactic intradural detethering? Clin Orthop Relat Res. 2019;477(7):16891697.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Giddens JL, Radomski SB, Hirshberg ED, Hassouna M, Fehlings M Urodynamic findings in adults with the tethered cord syndrome. J Urol. 1999;161(4):12491254.

  • 7

    Lew SM, Kothbauer KF Tethered cord syndrome: an updated review. Pediatr Neurosurg. 2007;43(3):236248.

  • 8

    Dias M, Partington M Congenital brain and spinal cord malformations and their associated cutaneous markers. Pediatrics. 2015;136(4):e1105e1119.

  • 9

    Hertzler DA 2nd, DePowell JJ, Stevenson CB, Mangano FT Tethered cord syndrome: a review of the literature from embryology to adult presentation. Neurosurg Focus. 2010;29(1):E1.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Yamada S, Iacono RP, Andrade T, Mandybur G, Yamada BS Pathophysiology of tethered cord syndrome. Neurosurg Clin N Am. 1995;6(2):311323.

  • 11

    Yaltırık K, El Tecle NE, Pierson MJ, Puryear A, Atalay B, Elbabaa SK Management of concomitant scoliosis and tethered cord syndrome in non-spina bifida pediatric population. Childs Nerv Syst. 2017;33(11):18991903.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Chern JJ, Dauser RC, Whitehead WE, Curry DJ, Luerssen TG, Jea A The effect of tethered cord release on coronal spinal balance in tight filum terminale. Spine (Phila Pa 1976). 2011;36(14):E944E949.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    Kulwin CG, Patel NB, Ackerman LL, Smith JL, Boaz JC, Fulkerson DH Radiographic and clinical outcome of syringomyelia in patients treated for tethered cord syndrome without other significant imaging abnormalities. J Neurosurg Pediatr. 2013;11(3):307312.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Samdani AF, Asghar J, Pahys J, D’Andrea L, Betz RR Concurrent spinal cord untethering and scoliosis correction: case report. Spine (Phila Pa 1976). 2007;32(26):E832E836.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Hamzaoglu A, Ozturk C, Tezer M, Aydogan M, Sarier M, Talu U Simultaneous surgical treatment in congenital scoliosis and/or kyphosis associated with intraspinal abnormalities. Spine (Phila Pa 1976). 2007;32(25):28802884.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Mehta VA, Gottfried ON, McGirt MJ, Gokaslan ZL, Ahn ES, Jallo GI Safety and efficacy of concurrent pediatric spinal cord untethering and deformity correction. J Spinal Disord Tech. 2011;24(6):401405.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Oda JE, Shah SA, Mackenzie WG, Akbarnia BA, Yazici M Concurrent tethered cord release and growing-rod implantation—is it safe? Global Spine J. 2012;2(4):207212.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Mooney JF, Glazier SS, Barfield WR Concurrent orthopedic and neurosurgical procedures in pediatric patients with spinal deformity. J Pediatr Orthop B. 2012;21(6):602605.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Kunes J, Quan T, Iyer R, et al. Reduced complication rate with simultaneous detethering and spinal deformity correction surgery compared to staged surgeries in patients with early onset scoliosis. Spine Deform. 2022;10(6):14731480.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Kokubun S, Ozawa H, Aizawa T, Ly NM, Tanaka Y Spine-shortening osteotomy for patients with tethered cord syndrome caused by lipomyelomeningocele. J Neurosurg Spine. 2011;15(1):2127.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Kokubun S Shortening spinal osteotomy for tethered cord syndrome in adults]. Article in Japanese. Spine Spinal Cord. 1995;8(12 suppl):5.

  • 22

    Hsieh PC, Stapleton CJ, Moldavskiy P, et al. Posterior vertebral column subtraction osteotomy for the treatment of tethered cord syndrome: review of the literature and clinical outcomes of all cases reported to date. Neurosurg Focus. 2010;29(1):E6.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Theodore N, Cottrill E, Kalb S, et al. Posterior vertebral column subtraction osteotomy for recurrent tethered cord syndrome: a multicenter, retrospective analysis. Neurosurgery. 2021;88(3):637647.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Liao H, Xie P, Zheng G, et al. Evaluation of parallel endplate osteotomy for severe rigid spinal deformities: a retrospective analysis of 36 cases with a minimum 2-year follow-up. BMC Musculoskelet Disord. 2021;22(1):1011.

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