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Tethered cord release: a long-term study in 114 patients
Robin M Bowman1, Avinash Mohan, Joy Ito
1Division of Pediatric Neurosurgery, Children's Memorial Hospital, Chicago, USA. rbowman@childrensmemorial.org
Insights
Surgical untethering benefits children with myelomeningocele by improving pain, strength, and urological function. While scoliosis may progress, the procedure helps maintain overall neurological and orthopedic outcomes.
Area of Science:
- Pediatric Neurosurgery
- Spinal Cord Medicine
- Congenital Malformations
Background:
- Myelomeningocele is a complex congenital condition requiring ongoing management.
- Shunt malfunction and spinal cord tethering are common causes of functional decline in these patients.
- Symptomatic spinal cord tethering requires timely diagnosis and intervention.
Purpose of the Study:
- To review indicators of symptomatic spinal cord tethering in children with myelomeningocele.
- To discuss surgical interventions and outcomes for tethered cord release.
- To evaluate the long-term functional impact of untethering procedures.
Main Methods:
- Retrospective review of 502 children with myelomeningocele treated between 1975 and 2008.
- Analysis of 114 patients (23%) who developed symptomatic tethered cord.
- Evaluation of indicators including scoliosis, motor strength, spasticity, gait, and urological function.
Main Results:
- Pain resolved in 100% of patients post-surgery.
- 70% showed improved lower-extremity motor strength; gait also improved.
- 52% experienced scoliosis progression, with 28% needing spinal fusion; 64% had improved bladder function.
Conclusions:
- Tethered cord release is beneficial for maintaining neurological, urological, and orthopedic function in children with myelomeningocele.
- While scoliosis progression is a concern, untethering offers significant functional improvements.
- The study highlights the importance of monitoring and intervening in spinal cord tethering.
Object:
All children born with a myelomeningocele at the authors' institution undergo aggressive treatment to maintain or improve functional outcome. Consequently, when any neurological, orthopedic, and/or urological changes are noted, a search for the cause is initiated. The most common cause of decline in a child born with a myelomeningocele is shunt malfunction. The second most common cause is tethering of the distal spinal cord at the site of the original back closure. In this report, the authors review the indicators of symptomatic spinal cord tethering and discuss the surgical interventions and outcomes in the children with myelomeningocele who underwent treatment at Children's Memorial Hospital from 1975 to 2008.
Methods:
Among the 502 children who underwent original closure at Children's Memorial Hospital, a symptomatic tethered spinal cord developed in 114 (23%). Eighty-one patients (71%) have undergone 1 untethering procedure, and 33 patients (29%) have undergone multiple untetherings, for a total of 163 total surgeries. The indicators of symptomatic spinal cord tethering include scoliosis, decline in lower-extremity (LE) motor strength, LE contractures, LE spasticity, gait change, urinary changes, and pain.
Results:
Pain has shown the best response to surgical untethering, with 100% of children experiencing postoperative improvement. The results of long-term follow-up (average 12 years, range 1 month-23.3 years) in this cohort demonstrated scoliosis progression after surgical untethering in 52% of patients, with 28% requiring spinal fusion. On the 3-month postoperative manual muscle test, 70% of patients showed improved LE muscle strength compared to preoperatively. Gait was also similarly improved after untethering as evaluated by an orthopedic surgeon. Spasticity improved in two-thirds of the cohort, and as expected, LE contractures were stable (78%) postoperatively, as assessed by orthopedic and rehabilitation medicine specialists. Urologically, 64% of patients showed improvements on postoperative bladder evaluation.
Conclusions:
Although this is a clinical outcome study with no control group, the authors' experience has been that tethered cord release is beneficial in maintaining neurological, urological, and orthopedic functioning in children born with a myelomeningocele.
