OVERVIEW

What is Tethered Cord Syndrome?

Tethered cord syndrome (TCS) is more common in children and is caused by various factors that pull or compress the caudal end of the spinal cord, leading to symptoms such as abnormal lower limb sensation, motor dysfunction or deformities, and urinary/fecal incontinence. Surgery is the primary treatment.

What is Occult Tethered Cord Syndrome?

Occult tethered cord syndrome (OTCS) results from the spinal cord being tethered by the filum terminale. Its symptoms are less typical than TCS, primarily manifesting as urinary dysfunction.

What are the types of Tethered Cord Syndrome?

Tethered cord syndrome can be classified as congenital or acquired.

SYMPTOMS

What are the common manifestations of tethered cord syndrome?

• Sensory abnormalities: Adult patients may experience sensory abnormalities early on, primarily pain in the lower back, groin, perianal area, perineum, or inner buttocks, sometimes radiating to both lower limbs. Sudden exertion, excessive bending, trauma, or pregnancy may trigger the pain. Additionally, patients may feel numbness, reduced or heightened sensitivity to temperature and pain.

• Motor dysfunction: Patients may develop cramps, muscle stiffness, weakness in the lower limbs, or difficulty walking. They may also experience muscle laxity in the lower limbs. Motor dysfunction often starts distally (e.g., toes) and progresses upward, potentially affecting one or both lower limbs.

• Urinary and bowel dysfunction: Common symptoms include frequent urination, urgency, and incontinence, possibly accompanied by constipation and/or fecal incontinence. Adults typically experience frequent urination, while children mainly exhibit frequent urination and incontinence (e.g., bedwetting).

• Skin changes: The lower back may show lipomas, hypertrichosis (excessive hair), dimples, dermal sinuses, ulcers, pigmented nevi, or hemangioma-like changes.

• Deformities: Adults may develop scoliosis, while children may exhibit foot deformities (e.g., pes cavus, adducted foot, supinated foot), meningocele, or diastematomyelia.

What are the common manifestations of occult tethered cord syndrome?

The most frequent symptom in occult tethered cord syndrome is urinary dysfunction. Children primarily present with frequent urination and incontinence, which may lead to recurrent urinary tract infections.

How does tethered cord syndrome develop?

Congenital tethered cord syndrome may show no obvious symptoms in childhood. As the patient ages, spinal cord damage gradually worsens, leading to symptom onset. Trauma or other factors can abruptly exacerbate symptoms, potentially causing paralysis. Some children initially exhibit only urinary symptoms (e.g., frequent urination, urgency, incontinence) and recurrent infections, often misdiagnosed and delaying treatment.

Symptoms of acquired tethered cord syndrome typically progress rapidly once they appear, requiring prompt diagnosis and treatment.

What severe complications can tethered cord syndrome cause?

Untreated tethered cord syndrome may lead to paralysis, urinary/fecal incontinence, or deformities. Prolonged bedridden states can cause recurrent infections, severely impacting quality of life and potentially resulting in fatal infections.

CAUSES

What are the causes of tethered cord syndrome?

The exact causes of tethered cord syndrome are not yet fully understood, but possible factors include:

• In children, the condition is primarily caused by congenital factors such as abnormal development of the filum terminale, spinal cord malformations, or chromosomal microdeletions leading to spinal deformities. Any factors affecting early neural embryonic development during pregnancy may contribute to congenital tethered cord syndrome, with folic acid deficiency being a recognized cause.

• In adults, the syndrome is often caused by acquired factors such as spinal inflammation, tumors, trauma, or surgery.

Who is more likely to develop tethered cord syndrome?

• If a pregnant mother experiences factors like folic acid deficiency or infections that affect neural embryonic development, the child may develop tethered cord syndrome after birth.

• Adults with spinal canal tumors, lumbar spondylolisthesis, herniated discs, or those who have undergone spinal surgery are at higher risk.

Is tethered cord syndrome hereditary?

Some congenital cases of tethered cord syndrome may be hereditary. Therefore, patients with congenital forms should undergo genetic screening, and genetic counseling is recommended before planning pregnancy.

DIAGNOSIS

How to Diagnose Tethered Cord Syndrome?

The diagnosis of tethered cord syndrome requires a combination of medical history, typical clinical manifestations, and imaging examinations. Among imaging techniques, magnetic resonance imaging (MRI) is currently the best method for diagnosing tethered cord syndrome. The diagnostic criteria for MRI include:

• Low-lying conus medullaris, with most scholars defining it as below the L1/L2 vertebral level;

• Thickened filum terminale, with a diameter greater than 2 mm;

• The spinal cord is anchored by a lipoma or other malformations.

In some cases of occult tethered cord syndrome, MRI may not show a low-lying conus, making it prone to misdiagnosis. Therefore, a comprehensive diagnosis based on other examinations is necessary.

What Tests Are Needed for Diagnosing Tethered Cord Syndrome?

• Ultrasound: Ultrasound can serve as an initial screening tool for suspected patients, especially infants and children. It is radiation-free, repeatable, and can be used for postoperative follow-up.

• Myelography and CT: CT scans can detect vertebral malformations and intraspinal/extraspinal lipomas. Myelography can reveal a thickened or shortened filum terminale and measure its diameter to aid in diagnosis.

• Magnetic Resonance Imaging (MRI): MRI is the best method for diagnosing tethered cord syndrome and can identify the underlying causes of tethering.

• Urological Examinations: Urodynamic studies assess urinary function and guide treatment. Continuous urological tests can determine whether the condition is worsening.

What Precautions Should Be Taken During These Diagnostic Tests?

• Myelography requires contrast injection, which may cause allergic reactions. A skin test is necessary. Patients with abnormal kidney function or a history of kidney disease should inform their doctor beforehand, and this test should be performed with caution.

• MRI scans can be noisy, so earplugs may be helpful. The procedure is lengthy, so children should be prepared in advance to cooperate with the examination.

• Urodynamic studies require full patient cooperation. Bladder function tests require holding urine. Electromyography of the sphincter may cause pain.

Is MRI Really Necessary for Diagnosing Tethered Cord Syndrome? It's Expensive.

MRI is currently the primary method for confirming tethered cord syndrome and a crucial basis for doctors to develop treatment plans. Therefore, it is highly necessary unless the patient has metal implants, a pacemaker, or cannot cooperate with the examination.

Which Diseases Can Tethered Cord Syndrome Be Confused With? How to Differentiate Them?

Since tethered cord syndrome presents with low back and leg pain, sensory and motor dysfunction, incontinence, and deformities, it must be differentiated from conditions such as intervertebral disc disease, spondylolisthesis, spinal cord disorders (e.g., tumors, syringomyelia), and peripheral neuropathy. Typically, doctors rely on MRI, electromyography, ultrasound, and urodynamic studies for differentiation.

The most important distinction is from lumbar disc herniation:

• Lumbar disc herniation causes radiating pain worsened by coughing or sneezing and relieved by lying down. Urinary/bowel dysfunction is rare, and there are usually no specific deformities.

• Tethered cord syndrome pain is usually localized to the lower back, non-radiating, and difficult to pinpoint. Coughing or sneezing does not affect the pain, and lying down does not relieve it. Patients often have urinary/bowel dysfunction, and some may exhibit severe lordosis, pes cavus, or other deformities.

TREATMENT

Which department should I visit for tethered cord syndrome?

Tethered cord syndrome requires consultation with spinal surgery or neurosurgery, but many patients initially seek treatment in the wrong departments. For example:

• Patients with low back and leg pain often mistake it for lumbar disc herniation or muscle strain and frequently visit clinics for massage, physical therapy, or chiropractic treatment.

• Many patients present with frequent urination, urgency, incontinence, or recurrent urinary tract infections and often visit urology or nephrology departments.

• Some patients experience lower limb weakness or sensory disturbances as early symptoms and typically consult neurology departments.

• A small number of patients show no early symptoms but have abnormal skin, hair, ulcers, or deformities and often visit dermatology departments.

Can tethered cord syndrome resolve on its own?

Tethered cord syndrome cannot improve on its own. If symptoms occur, prompt medical attention is recommended.

Do asymptomatic patients with tethered cord syndrome require treatment?

It depends on the specific situation.

Since asymptomatic patients may develop neurological damage at any time, and symptoms are often irreversible once they appear, some experts recommend preventive surgery to avoid neurological impairment.

However, due to significant surgical risks and uncertain long-term outcomes, doctors must weigh the pros and cons for each patient and develop individualized treatment plans.

How is tethered cord syndrome treated?

Treatment includes medication and surgery, with surgery being the primary approach.

Medication can only relieve symptoms or manage complications but cannot cure the condition. For example, painkillers may be prescribed for pain, antibiotics for urinary infections, and rehabilitation for motor dysfunction.

Drugs or therapies claiming to "cure" tethered cord syndrome are often fraudulent. Blind belief in such treatments may delay proper care, worsen the condition, and lead to permanent disabilities.

Surgery is the main treatment. Pediatric patients should undergo surgery as soon as diagnosed. Adult patients require surgery if they exhibit:

• Persistent low back and leg pain;

• Progressive neurological dysfunction, such as worsening limb weakness or sensory loss;

• Worsening bladder/bowel dysfunction or incontinence;

• Progressive scoliosis, lordosis, or limb deformities.

How to care for patients after tethered cord syndrome surgery?

• After anesthesia wears off, position the patient in a head-low, feet-high prone position, changing head direction every 2–4 hours to avoid facial pressure.

• For patients requiring oxygen, ensure the mask or nasal cannula stays in place.

• For catheterized patients, the catheter is usually removed about a week post-surgery. Assist with changing urine bags, recording output, and monitoring appearance. Some may experience urinary retention—encourage hydration, abdominal massage, and psychological support to restore function.

• For patients with epidural drains, prevent dislodgment, keep the drainage bag below spinal level (as instructed), and clamp the tube during movement.

• Notify medical staff immediately if surgical dressings become wet.

• After bowel movements, provide high-protein, high-calorie, and vitamin-rich foods to maintain smooth digestion and prevent straining. Clean promptly to reduce infection risks.

Can tethered cord syndrome be completely cured?

Currently, tethered cord syndrome cannot be fully cured.

Surgery may remove the tethering cause, but some patients require multiple procedures. Others may have lasting issues like high arches, scoliosis, limb weakness, or bladder/bowel dysfunction. Early diagnosis and timely surgery can maximize nerve function preservation and improve quality of life.

DIET & LIFESTYLE

Are there any dietary restrictions for patients with tethered cord syndrome?

No dietary restrictions are necessary; a normal diet is sufficient.

Do patients with tethered cord syndrome need follow-up examinations? How should they be conducted?

Tethered cord syndrome requires regular follow-up examinations, such as ultrasound and urodynamic tests. It is recommended to schedule periodic check-ups at the hospital where the surgery was performed.

Does tethered cord syndrome affect fertility?

For female patients, reproductive function is not affected by spinal cord function. Therefore, women with tethered cord syndrome can still have normal menstrual cycles, and the natural conception process is not significantly different from that of healthy individuals.

For male patients, fertility is closely related to spinal cord function. Men with tethered cord syndrome may experience erectile and ejaculatory dysfunction, impaired sperm production, and abnormalities in sperm motility, viability, and morphology. They are also prone to recurrent genitourinary infections, which can significantly impact fertility. Early treatment is recommended for symptomatic male patients.

Can patients with tethered cord syndrome engage in strenuous exercise, travel by plane, or visit high-altitude regions?

• Sudden exertion or excessive bending may worsen the tethering and exacerbate symptoms. Therefore, patients should avoid strenuous activities, sudden force, or excessive bending.

• Prolonged sitting during air or train travel may trigger symptom progression due to posture issues. It is advisable to avoid extended periods of sitting during such trips.

• Generally, high-altitude travel does not significantly affect patients with tethered cord syndrome. However, they should avoid prolonged walking or excessive fatigue.

How should caregivers assist patients with tethered cord syndrome?

For bedridden patients who cannot move independently, the following care is necessary:

• Under the guidance of a rehabilitation therapist, provide limb massages and passive movements to prevent disuse atrophy.

• Position the patient in a lateral position with support cushions and turn them at least every two hours to prevent pressure sores.

For patients with incontinence, the following care is necessary:

• Keep the patient's skin dry and hygienic.

• For catheterized patients, change the urine bag daily, disinfect the urethral opening, and replace the catheter at least once a month to prevent urinary tract infections.

For patients with frequent constipation, the following care is necessary:

• Increase intake of whole grains and fruits, and ensure adequate hydration.

• Under a doctor's guidance, use laxatives such as lactulose or polyethylene glycol, or administer glycerin enemas.

• For severe constipation, hospital treatment such as enemas may be required.

PREVENTION

Can Tethered Cord Syndrome Be Prevented? How to Prevent It?

Some cases of tethered cord syndrome can be prevented:

• Patients with spinal conditions such as lumbar disc herniation or spondylolisthesis should avoid excessive bending or strenuous activities.

• Expectant mothers should start taking folic acid supplements at least three months before pregnancy.

How Can Patients with Tethered Cord Syndrome Prevent Related Complications?

Tethered cord syndrome may lead to complications such as paralysis, incontinence, deformities, and infections, which can severely impact quality of life.

• For lower limb paralysis: Seek early medical attention if sensory or motor dysfunction occurs. Begin active and passive limb exercises promptly, adhere to standardized rehabilitation training, and strive to improve mobility to avoid bedridden paralysis.

• For bladder/bowel dysfunction: Start sphincter stimulation and rehabilitation therapy post-surgery (if no contraindications exist). Combine dietary adjustments, medication, localized care, infection prevention, and functional training to minimize incontinence.

• For deformities: Consider corrective surgery if they significantly affect daily life.