Tethered Cord Syndrome (TCS) is a neurological disorder caused by an abnormal attachment of the spinal cord to surrounding tissues, limiting its movement within the spinal canal.
This anchoring exerts longitudinal tension on the spinal cord, particularly during growth spurts in children, and can result in progressive neurological deterioration.
The condition is most frequently associated with spina bifida occulta, lipomyelomeningocele, diastematomyelia, or a thickened filum terminale. It is considered a form of closed spinal dysraphism, often diagnosed during infancy or early childhood. Dr. Samuel H. Cheshier, a pediatric neurosurgeon at Stanford Children’s Health, emphasized in a 2024 neurosurgical update that “Tethered cord syndrome requires early recognition and precise surgical management to prevent irreversible neural damage.”
Epidemiology and Risk Factors
Although the precise incidence of TCS is difficult to determine due to its variability in presentation, studies suggest a prevalence of 0.05–0.25 per 1,000 live births. The condition is commonly diagnosed in pediatric neurosurgical settings, particularly in patients with congenital spinal anomalies.
Risk factors include:
- Congenital defects like myelomeningocele repair
- Thickened filum terminale (>2 mm on MRI)
- Cutaneous markers such as dermal sinus tracts or sacral dimples
- Familial history of neural tube defects
Symptoms: When the Cord Can’t Stretch
TCS may present subtly in its early stages. In children, hallmark features include:
- Lower limb weakness or atrophy
- Foot deformities (e.g., pes cavus or clubfoot)
- Urinary incontinence or urgency
- Gait disturbances and scoliosis
- Persistent lumbar or sacral pain
Diagnostic Workup: Imaging and Clinical Correlation
The gold standard for diagnosis is MRI of the lumbosacral spine, which typically reveals a low-lying conus medullaris (below L2) or a thickened filum terminale. Advanced imaging may also detect lipids, fibrous bands, or split cord malformations contributing to tethering. Neurophysiological studies, including urodynamic testing and somatosensory evoked potentials (SSEPs), may aid in evaluating neurological compromise, particularly in children with subtle or non-specific complaints.
Surgical Management: Timing and Techniques
Early surgical intervention is the cornerstone of treatment. Microsurgical detethering involves sectioning the filum terminale or releasing adhesions under high magnification, with intraoperative neurophysiological monitoring to preserve function. A 2024 multicenter trial led by Dr. Susan Durham at Children’s Hospital of Philadelphia reported that early surgery (before age 2) resulted in significantly improved long-term outcomes compared to delayed intervention, particularly in terms of urological function and lower limb motor development.
Postoperative improvement varies, and while surgery halts progression, it may not reverse established deficits. Re-tethering remains a known complication, especially in patients with complex dysraphic anatomy, requiring careful long-term surveillance.
Differentiating Primary and Secondary TCS
Primary TCS is typically congenital, while secondary forms arise following spinal trauma, surgery, or infection. Recognition of acquired tethering is crucial, particularly in children undergoing myelomeningocele closure, as repeated scarring can restrict cord mobility. Differentiation has both prognostic and therapeutic implications. For instance, secondary TCS following myelomeningocele repair may require re-exploration with intradural dissection, which carries higher surgical risks.
Research Horizons and Innovations
Emerging studies are exploring the role of ultrasound elastography in assessing cord tension non-invasively. Additionally, bioengineered dural substitutes and anti-adhesion gels are under investigation to reduce re-tethering rates. In 2025, a pilot study from the University of Michigan introduced robot-assisted microsurgery for TCS, suggesting enhanced precision and reduced operative times, although data on functional outcomes are still pending.
Tethered Cord Syndrome in children demands a multidisciplinary approach involving pediatric neurosurgeons, urologists, orthopedic specialists, and rehabilitation teams. Early diagnosis and timely microsurgical release remain the pillars of effective management. With expanding technology and refined surgical techniques, the outlook for children affected by TCS continues to improve—provided that vigilance and clinical awareness remain strong.
