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|LETTER TO EDITOR
|Year : 2014 | Volume
| Issue : 6 | Page : 687-689
Spinal metastasis presenting as adult tethered cord syndrome
Department of Brain and Spine surgery, Sri Gokulam hospitals, Salem, Tamil Nadu, India
|Date of Submission||28-Nov-2014|
|Date of Decision||02-Dec-2014|
|Date of Acceptance||05-Dec-2014|
|Date of Web Publication||16-Jan-2015|
Department of Brain and Spine surgery, Sri Gokulam hospitals, Salem, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Palani A. Spinal metastasis presenting as adult tethered cord syndrome. Neurol India 2014;62:687-9
Tethered cord syndrome (TCS) is defined as a stretch-induced functional disorder of the spinal cord with its caudal part anchored by an inelastic structure.  It is usually identified in childhood and includes a spectrum of congenital anomalies resulting in an abnormally low position of the conus medullaris that may lead to neurological, musculoskeletal, urological, or gastrointestinal abnormalities. A subset of patients with the congenital syndrome develops progressive symptoms and signs in adulthood. Such deterioration may occur after sudden movements that cause traction on the spinal cord.  The author here describes a rare presentation of spinal metastasis as adult TCS.
A 60-year-old gentleman presented with severe low backache radiating to bilateral lower limbs and bilateral foot weakness of 1-month duration. Neurological examination revealed power at both ankles 3/5; knee and hips 4-/5. Straight-leg raising test was positive bilaterally. There was no bladder and bowel involvement. Magnetic resonance imaging (MRI) of thoraco-lumbar spine [Figure 1] and [Figure 2] showed diffuse and multiple vertebral body lesions with epidural collections in the lower lumbar/sacral levels. The cord was noted extending till L4/5 level with a thickened filum terminale (>2mm). The patient underwent surgery; L5 limited laminectomy, decompression of epidural mass [Figure 3], and detethering of the filum terminale [Figure 4]. He recovered well post-operatively with subsidence of the radicular pain and no fresh deficits. The histopathological examination of the epidural mass was suggestive of a metastatic poorly differentiated carcinoma. The patient was subsequently referred to medical and radiation oncologists for further evaluation of primary site/radiotherapy.
|Figure 1: T2-weighted magnetic resonance imaging (MRI) of lumbo-sacral spine, sagittal images showing multiple hypointense vertebral body lesions with mildly hyperintense epidural components in the L4/5 and sacral levels. The cord is seen ending at L4/5 level|
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|Figure 2: T2-weighted magnetic resonance imaging (MRI) of lumbo-sacral spine, axial images showing anterior and lateral epidural mass with strangulation of the dura. Thickened filum terminale (>2 mm) is noted in the posterior aspect|
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|Figure 3: Peri-operative picture showing the epidural mass strangulating the dura|
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Garceau  in 1953 coined the term "filum terminale syndrome" after observing 3 patients with progressive spinal deformity and neurological symptoms. In 1976, Hoffman and colleagues  coined the term "tethered spinal cord" to describe the symptoms of their patients with an elongated spinal cord and a thick filum terminale. Yamada et al.  broadened the stretch-induced functional disorder to include patients with other anomalies, such as myelomeningocele, lipoma, lipomeningomyelocele, diastematomyelia, meningocele, and dermoid sinus. Unlike children, adult symptomatology is slightly different, with pain being the most common presenting symptom (rare in children), and this is followed by sensory disturbances, motor dysfunction and weakness, and urinary dysfunction.  Yamada et al.  identified several factors contributing to the onset of symptoms over time in patients with less severe traction, including: 1) Increasing fibrosis of the filum leading to progressive loss of viscoelasticity; 2) a growth spurt that could cause a rapid increase in spinal cord tension; 3) an increase in physical activity (sports, exercise); and 4) development of spinal stenosis that can restrict movement and may accentuate tension.
The understanding of adult TCS is evolving as the diagnosis becomes more prevalent than previously believed. Symptoms of adult TCS may mimic signs and symptoms associated with lumbar degenerative disease.  The identification of tethering is essential in this patient as mere decompression of epidural mass would not have given desirable neurological improvement and could have likely caused further worsening. The most likely reason for symptomatic tethered cord syndrome is the spinal canal stenosis due to the epidural mass causing significant traction on the cord. This patient essentially had an asymptomatic thickened filum terminale which was worsened by the spinal metastasis. The course of clinical presentation or worsening is related to the degree of traction and not necessarily its cause.  The timing of neurosurgical intervention in adult TCS is controversial. Some authors advocate intervention only if there is neurological deterioration, whereas others suggest intervention if the individual leads an active life and thus may be more susceptible to deterioration related to other factors, such as risk of trauma.  The presence of neurological deterioration at the time of presentation warrants surgical intervention.
| » References|| |
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]