Evaluation of Tethered Cord Syndrome: An In-Depth Medical Approach

What Is Tethered Cord Syndrome?

Tethered Cord Syndrome refers to any condition in which the spinal cord is abnormally tethered, restricting its movement. The condition may be congenital or acquired. In congenital forms, it often results from spinal dysraphism, including spina bifida occulta or thickened filum terminale. In acquired forms, it may follow trauma or surgery or be spontaneous. A key element in the tethering is the “filum terminale” internum.

In many EDS patients, we encounter an occult tethered cord, where traditional supine imaging appears normal. However, the symptoms remain. Through years of experience and detailed case evaluations, we’ve identified that prone imaging using advanced AI sequences is essential in revealing subtle tethering that might otherwise be missed.

Key Symptoms That Suggest TCS

Symptoms can vary depending on the age of the patient and the severity of the tethering:

• Lower back pain
• Leg weakness, pain or numbness
• Walking difficulties
• Gait abnormalities
• Urinary incontinence or frequency
• Constipation or bowel dysfunction
• Foot deformities (e.g., cavus foot)
• Scoliosis

From the perspective of our practice, many patients arrive after years of unresolved symptoms. We’ve witnessed numerous cases where tethered cord was the underlying pathology, overlooked by conventional evaluations. The earlier the diagnosis, the better the outcomes.

The Role of the Conus Medullaris and Filum Terminale

Understanding the anatomy is vital. The conus medullaris should normally terminate around the T12 to L1-L2 level in adults. In tethered cord syndrome, it may be found abnormally low. The filum terminale, a fibrous extension anchoring the spinal cord, is often thickened or fatty in TCS patients, restricting the spinal cord’s natural movement and/or is tethered in the posterior aspect of the duramater at the L2-L3 level.

Our evaluations consistently assess the length, position, and appearance of these structures. We often use both prone and supine 3T MRIs with AI-based noise correction to compare the spinal cord dynamics effectively. This protocol allows detection of even subtle anomalies.

Diagnostic Imaging: Why Prone MRI Is Essential

In traditional supine MRIs, gravity does not sufficiently act on the spinal cordusually impedes to reveal tethering. That’s why our protocol includes prone MR imaging, which introduces gravitational tension, making the tethering more evident to be visualized.

We employ a specialized 3T MRI with motion artifact reduction technology, making prone imaging viable even in sensitive patients. This unique imaging strategy has been central to our success in diagnosing cases previously deemed inconclusive.

For example, one of our patients, misdiagnosed for over a decade, was finally correctly evaluated using this method, revealing a tethered cord missed by several institutions.

Clinical and Radiological Correlation

Imaging alone is not enough. Clinical-radiological -neurophysiological correlation is the cornerstone of our diagnostic model. Symptoms must align with radiological findings and neurophysiology. We assess not only the level of the conus but also filum thickness, presence of lipomas, syrinx, adhesions and the presence of arachnoiditis or/and root clumping. The real diagnostic skill lies in correlating a patient’s history and symptoms with subtle imaging signs.

Our institution is uniquely positioned in Europe to conduct this level of in-depth evaluation. The protocol we use was developed in collaboration with top imaging centers and is refined through years of treating complex spinal cases.

Occult Tethered Cord: The Silent Culprit

In EDS patients, tethered cord often remains hidden under the radar of conventional diagnostics. Many of these patients report early childhood symptoms that were never attributed to a spinal cause. Our experience has taught us that in these populations, Occult Tethered Cord must always be considered.

One case involved a middle-aged patient with bladder dysfunction, chronic fatigue, and neuropathic pain. Standard imaging appeared normal. However, prone MRI revealed low-lying conus with a taut filum terminale. Post-surgical release resulted in significant symptom improvement.

Surgical Considerations

Surgical release of the tethered cord is considered when symptoms severely impact quality of life and are proven to result from confirmed tethering. The goal is to restore spinal cord mobility and reduce neurological deficits.

All surgical decisions at our clinic follow a personalized review by Dr. Gilete and his interdisciplinary team. We use intraoperative neurophysiological monitoring and minimally invasive techniques most of the times. In cases with extensive arachnoiditis or root clumping it could be necessary to do a procedure called “laminectomy”.

Patients usually stay 4 to 5 days at the hospital and are discharged afterwards.

In cases where multiple factors like EDS or prior surgeries complicate the anatomy, our team brings over 25 years of surgical and diagnostic experience to ensure safe and effective outcomes. As one of only a few centers in Europe recognized for treating EDS with advanced spinal techniques, we are uniquely equipped for these challenges.

Integrative Care for Complex Diagnoses

We don’t stop at imaging or surgery. Patients receive full neurophysiological testing, immunological screening, and tailored rehabilitation plans. For some, regenerative medicine options are considered as adjuncts. This holistic care model sets our clinic apart globally.

Many of our international patients choose to travel to Barcelona to benefit from this integrated model. The proximity of our imaging center to Teknon Hospital allows seamless coordination from diagnosis to surgery.

Frequently Asked Questions (FAQs)

How do I know if I have a tethered cord?

If you experience a combination of neurological symptoms like urinary issues, leg weakness, lower back pain or even walking difficulties—especially if you have EDS or a history of unexplained symptoms—you should undergo a proper prone and supine MRI assessment.

Can a normal MRI rule out TCS?

Not necessarily. Supine-only imaging can miss cases, especially in Occult Tethered Cord. We recommend prone MRI protocols developed specifically for detecting subtle forms.

Is surgery always necessary?

No. Surgery is considered only when there’s clinical-radiological confirmation and the symptoms affect daily functioning. Conservative management is always reviewed first.

What’s the recovery like?

Patients typically remain in Barcelona for 10–15 days post-surgery. We provide close monitoring, early mobilization, and ongoing remote follow-up support.

Can TCS occur in adults?

Yes. While traditionally associated with pediatric populations, we frequently diagnose and treat adult patients with tethered cord, particularly those with EDS, post-traumatic onset, post-viral or post-infectious syndromes.

Conclusion: A Personalized, Expert Approach

Evaluating Tethered Cord Syndrome requires more than standard protocols. It demands precision, experience, and integration of advanced imaging and clinical insight. At our institute, we specialize in identifying and treating these elusive but impactful conditions. With a team led by Dr. Gilete and supported by innovative technology, we offer one of the most advanced evaluations for Tethered Cord Syndrome in Europe.

If you suspect you may be suffering from TCS, or have been misdiagnosed elsewhere, we invite you to schedule a consultation. Your path to clarity and recovery could start here in Barcelona.