Spinal cord tethering syndrome may be caused by congenital (e.g., viral infection in early pregnancy of the mother, lack of vegetables and severe deficiency of folic acid, etc.) or acquired (e.g., lumbosacral spinal canal surgery) causes, during human growth and development, the growth rate of the spinal canal is greater than that of the spinal cord, so the lower end of the spinal cord is gradually elevated relative to the lower end of the spinal canal The lower end of the spinal cord is tethered and fixed, and the spinal cord is stretched and undergoes ischemic pathological changes, resulting in A series of neurological dysfunction and deformity syndromes. The neurological damage increases progressively with age, spinal cord development, and increased bending activities. Spinal cord tethering is a condition in which the lower end of the spinal cord is unable to rise normally due to various reasons, leaving it in a lower than normal position. It is one of the main pathological mechanisms of various congenital developmental abnormalities that lead to neurological symptoms, resulting in a series of clinical manifestations called spinal cord tethering syndrome.
Various congenital developmental abnormalities of the spinal cord and spinal ends can lead to spinal cord tethering, such as occult spina bifida, spondylolisthesis, spinal cord spondylolisthesis, spinal cord end filament tension, lumbosacral intraspinal lipoma, congenital cysts, and latent hair sinus. In addition to the aforementioned congenital factors, postoperative adhesions of lumbosacral spinal bulge can also lead to re-tethering of the spinal cord. It is generally believed that spinal cord tethering causes blood circulation disorders at the end of the spinal cord, resulting in the corresponding neurological symptoms.
Clinical manifestations
The clinical manifestations of spinal cord tethering syndrome (spinal cord tethering syndrome) are similar to those of spina bifida, mainly in the following aspects.
Lumbosacral skin changes :.
Lumbosacral skin bulges or depressions, possibly with discharge or infection; hirsutism; bulging large masses. These predict the presence of occult spina bifida, latent hair sinus, and spinal bulge, which may be combined with spinal cord tethering.
Motor disorders of the lower extremities.
They manifest as abnormal walking, weakness, deformity and pain in the lower extremities, and may also be combined with scoliosis.
Sensory disorders of the lower extremities.
The lower extremities, perineum and low back are abnormal and painful.
Dysfunction of urination and defecation.
Common manifestations are urinary retention, difficulty in urination, urinary incontinence, more frequent urination, less than normal volume each time, etc.; constipation, constipation, or incontinence.
Diagnosis and examination
Magnetic resonance imaging (MRI) is the main method to diagnose spinal cord tethering, which can clarify not only the presence of spinal cord tethering, but also other coexisting pathological changes, such as lipoma, spinal cord longitudinal bifida, etc. X-ray plain film can determine the presence of spina bifida. Urinary ultrasound and urodynamics are performed in conjunction with urinary and fecal function to evaluate the extent of urinary tract involvement and spinal cord neurological impairment.
The picture shows the skin manifestation of a case of spinal cord tethering syndrome
Treatment]
Spinal cord tethering has already undergone organic changes by the time symptoms appear, and we cannot restore it to normal, but can only treat it appropriately so that it does not continue to progress. The symptoms of spinal cord tethering syndrome may be the result of destructive damage to the nervous system, which is usually irreparable, and treatment is simply to keep the damage from getting worse. Symptoms may also be the result of irritative or incomplete damage to the nervous system, when surgery may have the dual effect of reducing symptoms and preventing progression.
Therefore, the fundamental goal of surgical treatment of spinal cord tethering syndrome is to prevent the progression of the disease, and some patients may be able to improve the motor and sensory functions of the lower extremities and even the function of urination and defecation. Usually, the presence of dysfunction in the urinary and fecal areas is a sign of poor prognosis, and surgery usually does not improve the dysfunction in the urinary and fecal areas or the deformities of the lower extremities and feet, but it may improve pain and incomplete muscle strength loss to some extent. The deformities of the lower extremities and feet can be partially improved by orthopedic surgery. Therefore, for many patients with spinal cord tethering syndrome, especially children, a combination of spinal spine surgery or neurosurgery, urology and orthopedic surgery is required.
For patients with normal spinal cord tethering syndrome, including those found with lumbosacral skin changes and lower extremity sensory and motor deficits, we recommend early and systematic examination, evaluation and surgery; for patients who have already developed urinary and fecal dysfunction, surgery should be chosen in the context of their general condition and related investigations, and most of these patients can and will require surgery. The purpose of surgery is to untether the lower end of the spinal cord and prevent further development of the disease. After surgery, some children show some improvement in their symptoms. The order of improvement is: pain relief or disappearance > recovery of sensorimotor function > recovery of urinary and defecation function > cessation of the deformity and self-correction. If the disease is detected early and treated promptly, the child can be cured. On the contrary, cases with early age of onset, severe symptoms and late treatment have relatively poor treatment outcomes. Some of those who have no curative effect or whose condition recurs after surgery may be operated again.
We found that some children had been operated before, but only the large bag of lumbosacral area (i.e., the bulging spinal capsule and lipoma) was removed without dealing with the spinal cord lesion in the spinal canal, which is actually equivalent to the “cosmetic” surgery of lumbosacral area, and the result is ineffective or aggravated; some doctors even think that the disease is untreatable and wait passively for the development of the disease. The lesson is painful.
When operating on patients, we should implement the concept of minimally invasive surgery, insist on microsurgery, and cooperate with neurophysiological monitoring when necessary, so as to completely release the tethering as much as possible, avoid nerve damage, reduce re-adhesion and tethering, and prevent postoperative wound complications.
Postoperative patients are followed up and given the best possible guidance on the prevention and treatment of urinary tract dysfunction, rehabilitation of lower limb movement and sensation, and correction of lower limb deformities. We believe it is detrimental to patients to focus solely on tethered surgery and to neglect proper guidance for the continued treatment of these dysfunctions.
Terminal filum lipoma Pre-operative Intra-operative Post-operative
Spinal cord lipoma preoperative postoperative
Longitudinal spinal cord bifida Pre-operative Intra-operative Post-operative
Giant spinal cord spondylolisthesis Pre-op Giant spinal cord spondylolisthesis Post-op
Delayed treatment of lower limb deformity