Tethered spinal cord syndrome with lumbar segmental stenosis treated with XLIF

Abstract

Background: Tethered cord syndrome (TCS) is a congenital malformation consisting in fixation of spinal cord and nerves to the base of spinal canal associated to various spinal dysraphisms as spina bifida, musculoskeletal deformities and typical cutaneus signs. Usually it is observed in infancy but adult onset is well described and characterized by low back pain, progressive paraparesis, hyperreflexia, and incontinence. Association of TCS and degenerative lumbar spinal diseases as lumbar canal stenosis and disc herniation is very rare. Matherials and method: We report the case of a 69 year old man, suffering from tethered cord and low lying cord (related to spina bifida and meningocele, operated on in infancy) who worsened his neurological deficits because of L3-L4 progressive lumbar canal stenosis associated to disc degenerative disease at the same level. Extreme lateral interbody fusion (XLIF) allowing adequate indirect spinal cord decompression and stability was performed, obtaining neurological improvement. In addition, literature review of association of lumbar spine degenerative disease and tethered spinal cord was performed and clinical aspects and surgical strategies are presented and discussed. In particular, the role of XLIF approach is emphasized and compared with other surgical approaches proposed (posterior approach with or without arthrodesis). Results: The preoperative paraparesis, gait disturbances, and bladder dysfunction of our patient improved markedly after surgery and he came back to normal working activity few weeks after surgery. Analyzing in detail the literature, 6 similar cases have been found and evaluated relatively to age, sex, spinal dysraphism associated to tethered cord syndrome, neurological symptoms onset, degenerative lumbar spinal disease associated, and surgical treatment. Conclusion: Literature review of adults TCS associated with lumbar spinal degenerative disease as lumbar canal stenosis or disc herniation, is reported. Moderate entity of traction of spinal cord may remain asymptomatic in childhood and may result in delayed neurological deficits in adult life. The stretching of conus medullaris and spinal nerves of cauda equina, reduces regional blood flow and causes neural death and fibrous tissue replacement. Sudden or progressive onset of paraparesis with spastic gait, bladder dysfunction and acute low back pain in patient with history of spinal dysraphism must be considered as possible lumbar spinal cord compression caused by low lying cord related to TCS. Surgical decompression should be performed as early as possible to ensure neurological recovery. XLIF approach seems to be safe and fast and represent an excellent surgical option to obtain spinal cord indirect decompression and lumbar interbody fusion. Keywords: Tethered cord, Lumbar stenosis