Surgical management of tethered cord syndrome in adults: indications, techniques, and long-term outcomes in 60 patients

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Object

The adult presentation of tethered cord syndrome (TCS) is well recognized but continues to pose significant diagnostic and management challenges. The authors performed a retrospective study of clinical outcomes after neurosurgical intervention in 60 adults with TCS.

Methods

All patients who underwent detethering surgery for caudal cord tethering at Toronto Western Hospital between August 1993 and 2004 were identified. Their clinical charts, operative records, and follow-up data were reviewed. Detethering procedures were performed in 62 patients (age range 17–72 years) for TCS of various origins. Long-term (mean 41.5 months) follow-up data were obtained in 60 patients. The tethering lesions were tight terminal filum in 29 patients, postrepair myelomeningocele in 15, lipomyelomeningocele/lipoma in nine, split cord malformation in four, and arachnoidal adhesions in three. Fifty-nine patients presented with progressive pain and/or neurological dysfunction. One patient underwent prophylactic sectioning of the terminal filum. Most patients (71%) had bladder dysfunction at presentation. Microsurgical release of the tethered cord was performed in each case while using multimodality intraoperative neurophysiological monitoring. The most common complication was cerebrospinal fluid leakage, which occurred in nine patients and was managed by reinforcement sutures in four patients, temporary external drainage in three, and the placement of a lumboperitoneal shunt in two. Infective complications included superficial wound infection in three patients, meningitis in one, and urinary tract infection in one. One patient who had undergone multiple previous intradural procedures experienced worsened foot weakness postoperatively. Another patient experienced temporary unilateral lower-limb numbness. At follow up, improvement was noted in the majority of patients presenting with back (78%) and leg (83%) pain. Improvement was more likely in patients with preoperative motor weakness than in those with sensory deficits. Overall, neurological status was improved or stabilized in 90% of patients. Subjective improvement in bladder function was noted in 50% of patients with bladder dysfunction at presentation.

Conclusions

Surgery in adult patients with TCS is safe and effective for improving pain and neurological status in the majority of patients; however, patients who have undergone previous intradural detethering procedures in general fare less well, and considerable judgment is required in their management.

Abbreviations used in this paper: CSF = cerebrospinal fluid; EMG = electromyographic; MR = magnetic resonance; SCM = split cord malformation; SSEP = somatosensory evoked potential; TCS = tethered cord syndrome.

Article Information

Address for Dr. Lee: Yale-New Haven Hospital, New Haven, Connecticut.

Address reprint requests to: Michael G. Fehlings, M.D., Ph.D., F.R.C.S.(C), Division of Neurosurgery, Spinal Program, Toronto Western Hospital, 399 Bathurst Street, 4W 449, Toronto, Ontario M5T 2S8, Canada. email: Michael.fehlings@uhn.on.ca.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Sagittal (left) and axial (right) T2-weighted MR images obtained in a patient with SCM presenting with leg pain and progressive leg weakness. Excision of the bone spur at L-5 (arrows) with dural reconstruction led to resolution of the patient’s leg pain and to neurological improvement.

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    Sagittal (left) and axial (right) T2-weighted MR images obtained in a patient with dorsal lipoma tethering the conus (arrows) within the low lumbosacral spine. Intraoperatively, the patient was also found to have a tight terminal filum. Complete detethering surgery addressing both lesions led to stabilization of his progressive lower-limb weakness.

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    Sagittal T2-weighted (left) and contrast-enhanced axial (right) MR images obtained in a patient with postrepair myelomeningocele demonstrating a low-lying conus medullaris associated with extensive epidural scarring (arrow). At surgery, severe arachnoidal scarring was also observed. Despite microsurgical detethering with lysis of extensive adhesions, the patient experienced recurrence of leg pain although the initial outcome was favorable.

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