Adult Versus Pediatric Tethered Cord Syndrome: Clinicoradiological Differences and its Management

Abstract

Background: Dysraphic lesions in adults, presenting clinically as tethered cord syndrome (TCS), are relatively rare, and their optimal management remains controversial.

Patients and methods: We performed a retrospective analysis of our pediatric database over a period of last 7 years to focus on the adult TCS. Our aim was to determine the clinicoradiological and etiopathological differences between adult and pediatric patients as well as to determine the results of surgery in adult TCS.

Results: Adult spinal dysraphisms constituted 15.4% of our patients (20 out of 130). Motor weakness, sphincteric dysfunction, and backache (n = 13, 65.0% each) predominated in adults unlike children who presented with subcutaneous swellings (n = 74, 67.6%) followed by motor weakness (n = 40, 46.4%), backache being reported by only three patients. The different pathologic substrates underlying adult dysraphisms were lipomeningocele (n = 8), split cord malformation (total = 7; Type 1: n = 5; Type 2: n = 2), dermal sinus (n = 2), and fatty filum (n = 3). On the other hand, meningomyelocele/meningocele (61, 54.9%) followed by split cord malformation Type 1 and 2 (n = 29, 26.1%) predominated in children. The radiological differences between the two groups were a higher incidence of vertebral body defects (hemivertebrae and butterfly vertebrae) and lack of intracranial anomalies in adults. At a mean follow-up of 20.5 months, the most common symptoms to improve following detethering were pain (11 out of 13, 84.6%) followed by motor weakness (six out of 13, 56.2%) and sphincteric control (7 out of 13, 53.8%).

Conclusion: Most common symptoms to improve following detethering in adult TCS were pain followed by motor weakness. The major radiological differences between these two groups were a higher incidence of vertebral body defects (hemivertebrae and butterfly vertebrae) and lack of intracranial anomalies in adults.

Keywords: Adult spinal dysraphism; lipomyelomeningocele; split cord malformation; tethered cord syndrome.

Figure 1

(a) Cutaneous stigmata of swelling and dimple in lumbar region with (b) split cord malformation Type 1 with (c and d) arachnoid cyst at L1 level. (e) Another patient with swelling at lumbosacral region with (f-i) sacral meningomyelocele with intraspinal lipoma

Figure 2

(a) T1 hyperintense (b) T2 hyperintense lobular mass in the conus region with extension along the filum (c) with tethering of the cord suggestive of transitional lipoma. A subcutaneous lipoma is also seen. On computed tomography, the mass is hypodense, no posterior element deficit is seen (d). Postoperative scan shows small residual fat along filum with detethering of the cord (e and f)

Figure 3

(a) T1 and T2 hyperintense subcutaneous mass with extension intradurally s/o lipomeningocele (a and b). The mass is continuing on the dorsal aspect of a low-lying cord. Bony defects are visible. Postoperative scan shows excision of majority of the mass with detethering of cord (c)

Figure 4

It depicted various types of skin stigmata associated with occult spina bifida: (a) Swelling with midline pits (depression); (b) overlying soft swelling; (c) cafe lau-spots with midline dermal sinus; (d) overlying hypopigmented skin