Most series on tethered cord syndrome showed female predominance [3, 4], while our study showed male predominance (67%).
Tethered cord syndrome is mostly noted in children. There were 23 adult patients versus 50 children with tethered cord treated in Sofuoglu et al. [3] report. In our study, there were 33 children and the 10 adult patients.
Clinical manifestations of TCS differ among patients especially children and adults. The symptoms and signs may be noted since birth or appear later on with body growth as the spines elongate and stretch-induced functional disorders of the spinal cord and roots occur. Clinical manifestations of children in this study were back lump in 70%, skin dimple in 9%, back pain and parathesia from the age of 6 years old in 100% and 67% respectively, lower limb weakness in 61%, urine abnormalities from the of age 5 years in 75%, and bowel abnormalities from the age of 4 years in 65%. The study of Yelikbayev and Tutayeva [5] on 30 children aged 2–18 years reported weakness in 87%, impaired functions of pelvic organs in 90%, and skin manifestations in 77%. Khoshhal et al. [2] study on 35 patients aged 2 months to 11 years found that the most frequent dysraphism was lipomeningomylocele (34.3%) followed by myelomeningocele (22.8%) and dermal sinus (14.3%). Back lump was presented in 65.7%, and neurological impairment in 68.4% of 2 years or older.
Adult patients in this study presented with urine abnormalities in 100%, bowel abnormalities in 80%, back pain in 80%, lower limbs weakness in 60%, and back lump in 50% of the patients. Gao et al. [6] study on 82 adult tethered cord patients found low back pain in 83%, weakness in 71%, sensory dysfunction in 54%, and defecation dysfunction in 50%. Sofuoglu et al. [3] reported clinical manifestations of adult tethered cord as 65.2% back pain, 52.2% bladder dysfunction, 17.4% fecal incontinence, 52.2% weakness, 21.7% numbness, and 61% back swelling.
MRI, plain X-ray of the spine, and urodynamic studies are of great value for diagnosis and management of tethered cord syndrome. We found spina bifida in 33 (77%) patients, lipoma in 20 (47%) patients, dermoid in 3 (7%) patients, conus level at L5 in 15 (35%) patients, and urodynamic studies were impaired in all study cases, mostly hyper-reflexic bladder (67%). Sofuoglu et al. [3] noted in their study on 23 adult patients the commonest conus level was L5 (34.8%), lipoma in 37%, and dermal sinus in 21.7%. Gupta et al. [7] mentioned that the most frequent MRI finding was a low lying spinal cord with intradural and/or extradural lipoma. Yelikbayev and Tutayeva [5] study on children noted hyper-reflexic bladder is often marked, and they considered the tethered cord syndrome as the cause of neurogenic hyper-reflexic bladder even the conus at normal level without filum terminalis changes. In 18–54% of TCS patients, the conus lies at normal level, and diagnosis by dynamic MRI of the spine shows effort-induced symptoms [8, 9], but this not found in our study. Also, conus level varied between studies as Valentini et al. [10] reported L2–L3 level in 50% of patients.
Microscopical treatment was done for all patients dealing of the offending pathologies.
Cerebrospinal fluid leak occurred in eight patients (19%), two of them needed 2ry sutures. Wound infection occurred in two cases and 5% were treated conservatively. Duz et al. [11] reported 5% CSF leak, and no infections in 22 patients. Sofuoglu et al. [3] reported CSF leak in three patients and wound infection in three patients (13%). Rajpal et al. [12] reported 3/61 patients suffered wound infection, one patient suffered CSF leak, two patients suffered pseudomeningocele, and one patient suffered acute respiratory distress syndrome. Iskandar et al [13] reported one CSF leak and five pseudomeningocele in their study on 34 patients.
Clinical improvement 1 year after surgery in our study showed back pain improvement in 60% of children and 75% of adults, parathesia improved in 60% of children and 30% of adults, weakness improved in 40% of children and 17% of adults, urine abnormalities improved in 60% of children and 30% of adults, and bowel abnormalities improved in 47% of children and 25% of adult patients. Children in our study showed significant improvement regarding all symptoms except back pain in comparison with adults. Intraoperative filum sectioning showed significant improvement of patient symptoms except back pain, and absence of lipoma showed significant improvement in weakness. Review of literatures suggests that the tethered cord syndrome reversible symptoms are due to metabolic derangement and alterations in oxidative metabolism. Persistent symptoms may vary depending on severity and duration at presentation [8]. Iskandar et al. [13] found improvement in adults, 81.5% back pain, 43.1% motor or sensory dysfunctions, and 61.1% bowel and bladder disturbance. Sofuoglu et al. [3] reported 50% improvement in back pain, 66.7% motor weakness improvement, and 75% bladder and bowel improvement in adults. Lee et al. [1] found improvements in 78% back pain, 83% leg pain, 64% motor weakness, and 50% urological abnormalities. Duz et al. [11] reported back pain improvement in 57.1% and bladder dysfunction in 66.6%, and two patients with fecal incontinence did not improve. Rajpal et al. [12] reported back pain improved in 65% and bowel/bladder dysfunctions in 62%. Solmaz et al. [14] reported urological improvement in 21 patients (20%) and back pain improved in all patients on their study on 49 children. In Bowman et al. [15] study on children with myelomeningocele for untethering, the pain improved in 100%, and 70% showed improvement in lower extremities and 64% in bladder dysfunctions. Haro et al. [16] reported that adults showed better improvement in neurological and urinary problems than natal or juvenile onset tethered cord syndrome. Seki et al. [17] mentioned that age at surgery is not significantly associated with prognosis. Tethered cord syndrome may have different curative effect after surgery according to the cause. Removal of the thickened filum can get better results [6]. Recurrent surgeries and presence of lipoma had higher incidence of failed detethering [10]. Also, Selden et al. [18] found significant improvement with filum sectioning. These data agree with our results.
Conus location detected by MRI on follow-up found to be on the same location as preoperative MRI in 77% of the patients in our study, and urodynamic studies showed improvement in 73% of the studied patients. Postoperative MRI has no role for evaluation of good detethering but only clinical and urodynamic evaluation. Even the presence of lipoma residual is not significantly associated with retethering [19]. Kearns et al. [20] found 44% improvement in urodynamic studies on 34 children after tethered cord repair and mentioned that a review of five series showed improvement in 11.1–54.5% after untethering, but none of their patients or other studies became urologically normal as the conus and roots were inevitably exposed to some injuries, also documented by [21, 22]. Improvement of urological symptoms or urodynamic finding reported to be 38% and 100% respectively by Vernet et al. [23] and Flanigan et al. [24].
