Diagnosis and Treatment of Tethered Spinal Cord
Authors: Hsieh Patrick , Apaydin Eric , Briggs Robert G. , Al-Amodi Dalal , Aleman Andrea , Dubel Kellie , Sardano Ariana , Saint-Val Judy , Zhang Diana , Blythe Kevin , Sysawang Kimny , Yagyu Sachi , Motala Aneesa , Tolentino Danica , Hempel Susanne 
Published: October 2024

Objectives. To summarize the evidence regarding diagnosis, prophylactic treatment, symptomatic treatment, and repeat surgery of tethered spinal cord. Data sources. We searched PubMed®, Embase®, CINAHL, Web of Science, SCOPUS, clinicaltrials.gov, ICTRP, Cochrane Database of Systematic Reviews, PROSPERO, ECRI repository, G-I-N, MagicApp, and ClinicalKey from inception to March 2024; reference-mined reviews; and contacted research authors. Review methods. The review followed a detailed protocol and was supported by a Technical Expert Panel. Systematic review software (DistillerSR) was utilized for all screening and data extraction tasks. Citation screening was facilitated by machine learning; two independent reviewers each screened full text citations for eligibility; one literature reviewer extracted data and a methodologist checked for accuracy. Risk of bias assessments focused on key sources of bias for diagnostic and intervention studies. We conducted strength of evidence (SoE) and applicability assessments for key outcomes. The protocol for the review has been registered in PROSPERO (CRD42023461296). Results. Searches identified 6,285 citations; 2,005 were obtained as full text. In total, 103 studies met inclusion criteria, with an additional 355 case series providing additional information. We found the strongest evidence for accuracy of MRI in diagnosing tethered spinal cord. Specifically, studies indicated this modality has medium to high diagnostic sensitivity and specificity (moderate SoE). A small number of existing studies suggested benefits of prophylactic surgery, but it was also associated with complications such as surgical site infection (low SoE). A larger body of evidence evaluated various treatments for symptomatic patients, with the majority focused on surgical detethering. Studies reported improvement of neurological status after surgical detethering (low SoE), but it was also associated with post-operative complications such as cerebrospinal fluid leakage (moderate SoE). A very small body of evidence exists for revision detethering and spinal column shortening for repeat surgery (low or insufficient SoE for all outcomes). Across diagnosis, prophylactic treatment, symptomatic treatment, and repeat surgery there was insufficient evidence for multiple key outcomes (e.g., over- or undertreatment, clinical impact of diagnostic modalities, ambulation or quality of life outcomes) and thus no evidence statements could be derived. Conclusions. The evidence base for the diagnosis and treatment of tethered spinal cord is limited, with few exceptions (use of MRI or ultrasound for diagnosis, surgical detethering improving neurological status in symptomatic patients, complications associated with open detethering surgery) and would benefit from stronger study designs that include tool evaluations reporting diagnostic performance and treatment studies with concurrent comparator.