What is Tethered Cord Syndrome? Symptoms, Causes, and Treatment Methods

Tethered Cord Syndrome

Tethered cord syndrome is a neurological disorder that occurs when the spinal cord is abnormally attached to the spinal canal, preventing it from moving freely. Normally, the spinal cord can move slightly up and down within a fluid-filled canal. However, in the case of a tethered cord, the spinal cord is pulled as if it were attached to something, and this tension can lead to nerve damage over time. Although this condition is generally considered a congenital issue, it can also develop later in some individuals. While it most often presents symptoms during childhood, its diagnosis can sometimes be delayed until adulthood. In later ages, it may manifest with findings such as muscle weakness, pain, and difficulty walking.

What is Tethered Cord Syndrome?

Tethered cord syndrome is a neurological disorder caused by the spinal cord being pulled downward from its anatomically normal position and adhering to the spinal canal. This condition restricts the free movement of the spinal cord and causes pressure on the nerve tissue over time. As the body grows, the spinal cord should move freely upward. In this syndrome, the range of motion is restricted due to the tethered structure. Tethered cord syndrome and scoliosis can sometimes occur together and negatively affect each other.

What Are the Symptoms of Tethered Cord Syndrome?

Tethered cord syndrome does not present with the same symptoms in everyone. Symptoms may vary depending on age, cause, and the severity of the pressure on the spinal cord. Tethered cord syndrome can increase complaints during pregnancy and requires careful monitoring. In general, the most common symptoms of tethered cord syndrome are:

Lower back and back pain (especially increasing with movement),

Numbness, tingling, or burning sensation in the legs,

Muscle weakness or atrophy,

Gait disturbances,

Urinary incontinence, frequent urination, or excretion problems,

Foot deformities (flat feet, hammer toes, etc.),

Dimples, hair growth, or skin changes in the tailbone area.

In some patients, it may not show symptoms for a long time, which can delay diagnosis. Cases that are not noticed, especially during childhood, can lead to serious neurological disorders in adulthood.

What Causes Tethered Cord Syndrome?

The most fundamental reason for the emergence of tethered cord syndrome is abnormal connective tissues that cause the spinal cord to be pulled downward anatomically. Normally, the spinal cord can move freely within the spinal canal. As a result of the syndrome, the spinal cord is stuck to the surrounding tissues, and this exerts a chronic pulling force on the spinal cord. This tension leads to damage in the nerve tissue over time. Congenital causes are the most common reason for this syndrome. Spina bifida is a congenital anomaly characterized by the incomplete closure of the spinal bones and has a close relationship with a tethered cord. Additionally, structural disorders such as lipomas (fatty tissue tumors) and dermal sinus tracts also restrict the normal movement capacity of the spinal cord and cause tension over time. Most of these conditions are present from birth, but symptoms may appear over the years. Acquired (later-developing) causes are usually seen at older ages. Previous spine or spinal cord surgeries, especially scar tissues that develop after spina bifida repairs performed in childhood, can lead to the spinal cord becoming re-attached and tethered. At the same time, traumas, infections, or tumoral formations within the spine can also pave the way for the development of this syndrome. In growing children, the spinal cord ending lower than it should can also trigger this condition. Because as the child grows, the spine lengthens, but the abnormally attached spinal cord cannot adapt to this growth and becomes stretched. This leads to nerve pressure that causes symptoms over time.

How is Tethered Cord Syndrome Diagnosed?

The diagnosis of tethered cord syndrome is made by evaluating clinical symptoms together with radiological imaging. Both physical examination and advanced imaging techniques play an important role in the diagnostic process. Since symptoms are not always obvious, the physician must perform a careful evaluation. The first step is usually a detailed neurological examination. In this examination, muscle strength, reflexes, gait, loss of sensation in the legs, or bladder functions are evaluated. Developmental delays in children, foot deformities, or bedwetting are important clues that initiate the diagnostic process.

The most commonly used method for diagnosis is magnetic resonance imaging (MRI). MRI findings of tethered cord syndrome show that the spinal cord is abnormally pulled downward at the lower end. MRI clearly shows exactly where the spinal cord ends, whether it is tethered, and its relationship with surrounding tissues. Normally, the spinal cord ends at the L1-L2 level. If an ending is seen below this level and is consistent with clinical symptoms, the preliminary diagnosis of tethered cord syndrome is strengthened.

In some cases, additional imaging methods such as computed tomography (CT) or CT-myelography may be used. CT is preferred, especially in cases where bone structures need to be examined in detail. CT-myelography is used in patients who cannot undergo MRI or for detailed spinal canal evaluations. In the presence of bladder and bowel complaints, urodynamic tests are used. These tests can reveal whether there is a spinal cord-related disorder by evaluating the function of the bladder. Finally, neurophysiological tests (e.g., somatosensory evoked potentials – SSEP) are sometimes used to assist in diagnosis. These tests reveal whether there is a disruption in nerve conduction and provide information about the degree of nerve pressure.

How is Tethered Cord Syndrome Treated?

The treatment of tethered cord syndrome requires a multidisciplinary approach aimed at eliminating the source of the disease. The fundamental problem in this syndrome is the abnormal stretching of the spinal cord. Therefore, the main goal of treatment is to reduce or completely eliminate this tension on the spinal cord. For this purpose, the most effective and permanent solution is surgical intervention. Surgical treatment involves releasing the structure that is tethering the spinal cord. This procedure is performed precisely under a microscope. The surgeon carefully separates the adhesions, abnormal connective tissues, or formations like lipomas that are holding the spinal cord, allowing the spinal cord to be freed. In this way, both existing symptoms can be regressed and the progression of the disease can be prevented. Especially in patients with symptoms such as urinary control issues, gait disturbances, or loss of muscle strength, surgical treatment can provide significant improvement. The decision for surgery is made based on the patient's age, the severity of symptoms, and neurological findings. In patients with mild progression, no neurological loss, or those who cannot tolerate surgery, non-surgical treatment options are considered. This approach is applied to control symptoms but does not eliminate the mechanical tension on the spinal cord. Risks of tethered cord syndrome surgery may include nerve damage, infection, and spinal fluid leakage. Among non-surgical methods for tethered cord syndrome, physical therapy and rehabilitation hold an important place. Muscle strength and balance skills can be improved by supporting tethered cord syndrome with physical therapy. Personalized exercise programs are organized to maintain muscle strength and support balance and walking ability. In addition, medication may be used to control pain. If bladder functions are affected, pelvic floor therapies and bladder training programs are implemented.

Frequently Asked Questions

Tethered cord syndrome is often congenital. This condition is usually seen together with congenital spine and spinal cord anomalies such as spina bifida occulta. The abnormal development of tissues surrounding the spinal cord or the spinal cord remaining pulled downward occurs while the baby is still in the mother's womb. In infants, tethered cord syndrome can be seen with congenital spinal anomalies. The congenital form usually shows symptoms during childhood, but in some cases, diagnosis may be delayed until adolescence or adulthood. Tethered cord syndrome in the infant age group can manifest itself with neurological developmental delay. In adults, tethered cord syndrome usually appears in cases that were not diagnosed during childhood. This syndrome can be congenital or can develop later. Especially adhesions that form after previously performed spine or spinal cord surgeries, such as spina bifida repairs, can cause the spinal cord to become tethered again. Apart from this, traumas, intraspinal tumors, or infections are also among the factors that pull the spinal cord downward abnormally. Symptoms of tethered cord syndrome in adults are usually in the form of lower back pain, difficulty standing, and urinary problems. Pain is usually felt in the lower back and can spread to the hips and legs over time. This pain increases when remaining inactive or sitting for a long time. Sometimes it is described as burning, stinging, or electric shock-like sensations. Because it is a type of pain triggered by movement, it can significantly restrict daily life. Symptoms of tethered cord syndrome can vary from person to person and sometimes remain limited to pain that increases only when standing. Especially in children, the inability to express pain can delay diagnosis. When left untreated, the tension on the spinal cord increases over time and can leave permanent damage to the nerve tissue. The syndrome, which initially manifests itself only with pain or mild gait disturbance, can progress to urinary incontinence, muscle wasting, and even loss of the ability to walk. Therefore, early diagnosis and intervention are critical. In advanced stages, especially in untreated cases, there is a risk of paralysis. Paralysis is usually felt in the lower extremities, i.e., the legs. Consequences such as loss of muscle strength, foot deformities, and complete loss of the ability to walk can develop. Although this is not seen in every patient, paralysis can become permanent if the progression of the disease is allowed. Surgical treatment is the primary and most effective treatment for tethered cord syndrome. With surgery, the structures tethering the spinal cord are released, thereby reducing pressure. Especially in cases where symptoms are in the early stage, the surgical success rate is high; however, since some neurological damage may be irreversible, not all symptoms may completely resolve in late interventions. It can recur, albeit rarely. Especially in growing children, adhesions may develop again over time or the spinal cord may become tethered again. In such cases, a second surgery may be required. Regular follow-up and control ensure that possible recurrences are noticed early and prevent progression. The most important test in the diagnosis of tethered cord syndrome is magnetic resonance imaging (MRI). Thanks to MRI, the position of the spinal cord, the level of termination, and the state of adhesion are evaluated in detail. While the spinal cord normally ends at the L1–L2 level, a spinal cord that ends lower and appears tethered raises suspicion for the syndrome. In some cases, imaging methods such as computed tomography (CT) or CT-myelography may also be used. Additionally, if there are urinary problems, bladder function is evaluated with urodynamic tests. In necessary cases, neurophysiological tests that measure nerve conduction can also assist in diagnosis. Understanding the syndrome in children may not always be easy because symptoms cannot be clearly expressed in young age groups, but some physical signs are noteworthy. For example, skin findings such as dimples, hair growth, skin color differences, or birthmarks in the tailbone area are important clues. Furthermore, findings such as urinary incontinence, delayed walking, weakness in leg muscles, or foot deformities should suggest an underlying spinal cord problem. In such cases, the child must be evaluated by a pediatric neurology or neurosurgery specialist. Physical therapy does not eliminate the root cause of tethered cord syndrome but plays a relieving and supportive role for symptoms. Especially in patients with muscle weakness, gait disturbance, or limited movement, quality of daily life can be improved with physical therapy, but as long as the tension on the spinal cord continues, the disease continues to progress. Therefore, physical therapy is not a treatment on its own but is usually applied as a complementary method before or after surgery.

If you are experiencing spinal cord-related pain, difficulty walking, or muscle weakness, consult a specialist without delay.

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