Pediatric enuresis – manifestation of spinal cord tethering syndrome We commonly see children wetting the bed at night, mainly due to physiological factors, such as immature neurological development and overexertion in children. However, there are also pathological causes that are often overlooked, and the most common cause is spinal cord tethering syndrome. Almost all spinal bulges are associated with spinal cord tethering, and the latter is the direct cause of morbidity, so it is highlighted here. Spinal cord tethering is not rare clinically, but the general public and even pediatricians and other specialists lack sufficient knowledge of it, resulting in parents not taking their children to the clinic or doctors misdiagnosing and mistreating them. When the condition progresses to a certain level, permanent damage to spinal cord nerve function occurs, resulting in severe disability, it is too late to regret. We urge parents to take pediatric enuresis seriously and bring their children to experienced neurosurgeons and pediatricians for consultation. What is the cause of spinal cord tethering syndrome? What are its manifestations and how is it treated? Causes of spinal cord tethering syndrome Spinal cord tethering syndrome is a syndrome caused by congenital (e.g., viral infection in early pregnancy of the mother, lack of vegetables and severe deficiency of folic acid) or acquired (e.g., lumbosacral spinal canal surgery) causes the lower end of the spinal cord to be tethered and fixed, and the spinal cord is stretched and undergoes ischemic pathological changes, resulting in a series of neurological dysfunctions and deformities. The neurological damage increases progressively with age, spinal cord development, and increased bending activities. Therefore, early diagnosis and treatment of spinal cord tethering syndrome is very important. Once diagnosed, the sooner tethering surgery is performed, the better. Clinical manifestations Children with spinal cord tethering syndrome may present only with enuresis, especially in infants and children who are inexpressive and uncooperative in physical examination. It may be accompanied by lower extremity and lumbosacral pain, perianal sensory disturbance (dull pinprick pain), lower extremity mobility disorders and deformities. These symptoms are significantly worse in children with rapid height development. Most children with lumbosacral spondylolisthesis may have cyanotic pigmentation, hair growth, or even large bulging pouches (medically known as spondylolisthesis or lipoma) in the median lumbosacral skin. MRI should be the first choice of examination and may reveal low spinal cord cone position and thickened end filaments. The presence of spinal cord tethering syndrome should be further considered in those who develop these symptoms after a period of time following surgery to repair cystic spina bifida. Treatment The only effective treatment at present is to perform spinal cord tethering release. Some parents of children with spinal cord tethering syndrome are afraid of surgery and choose various non-surgical therapies, which may lead to delayed treatment. Do not wait for symptoms to worsen before surgery. It is advisable to operate in asymptomatic cases of spinal cord lipoma combined with cone hypoplasia. Patients with occult spina bifida and post-spinal expansion repair should be followed year round and operated on as soon as symptoms of spinal cord tethering appear. Surgery should be performed by a neurosurgeon with experience in spinal cord surgery and microsurgery to improve outcomes and reduce complications such as spinal cord injury. We found that some children had been operated before, but only the large lumbosacral pouch (i.e., the bulging spinal capsule and lipoma) was removed without dealing with the spinal cord lesion in the spinal canal, which was actually equivalent to “cosmetic” surgery of the lumbosacral region, resulting in ineffectiveness or aggravation; some doctors even thought the disease was untreatable and waited passively for the development of the disease. The lesson is painful. Among the cases we operated on, the youngest was 2 months old (note: the youngest child was just born) and the oldest was 30 years old (note: the oldest is now 56 years old), and the majority of patients improved or even cured after surgery. The purpose of surgery is to release the tethering of the lower end of the spinal cord and prevent further progression of the disease. Some of the children showed some degree of improvement in their symptoms after surgery. The degree of improvement is as follows: pain relief or disappearance > restoration of sensorimotor function > restoration 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 the cases with no curative effect or recurrence of the disease after surgery can be operated again.