Tethered Cord as a Complication of Chronic Cerebral Spinal Fluid Diversion

The etiology and treatment of tethered cord syndrome remains controversial, especially in adults. We present an unusual case of tethered cord syndrome with an associated epidural lipomatosis likely due to chronic over shunting of cerebrospinal fluid (CSF).

A 25-year-old woman had a history of Chiari malformation, hydrocephalus, and a ventriculoperitoneal shunt. She demonstrated progressively worsening gait, which led to a diagnosis of myelopathy and a posterior cervical decompression and fusion was performed. Imaging revealed engorgement of the epidural veins ventral to the spinal cord which was causing cord compression. Magnetic resonance (MR) imaging of the lumbar spine demonstrated a low-lying conus at the level of L2-L3 with an absence of CSF in the lumbar cistern. This was associated with this was a widening of the epidural space with secondary epidural lipomatosis. She underwent a laminectomy of L5 as well as decompression of the inferior aspect of the L4 and superior aspect of the S1 lamina. No free flow of CSF could ever be appreciated as was suggested by postoperative MR imaging. Postoperatively, the patient did well and was discharged in stable condition.

Tethering of the spinal cord, associated with epidural lipomatosis, may be secondary to over-drainage of CSF. Symptoms of back pain and tethered cord phenomenon may warrant surgical intervention.