Tethered cord

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  1. Due to spinal cord lipoma – associated with a low lying conus medullaris
    1. Three types of spinal cord lipomas – dorsal, transitional, and terminal
      1. Terminal and transitional have an intradural part that blends with the substance of the spinal cord and an extramedullary part in the form of a fibrofatty stalk that fuses with the subcutaneous adipose layer through a dorsal midline defect in the dura, lumbodorsal fascia, and neural arches
      2. In dorsal lipomas, the fibrofatty stalk inserts into the dorsal surface of the cord in one isolated, segmental region only; the cord caudal to the lipoma is completely normal and is covered by normal dura
    2. tethered cord is the spinal cord combined with the spinal cord lipoma and not the nerve roots
  2. symptoms:
    1. adults have excruciating and unrelenting pain; <50% of adults have cutaneous signs of a tethered cord; motor deficits; urologic deficits are common
    2. children seldom complain of severe pain but instead have dysesthetic, diffuse pain in the groin and perineum; almost all children have some cutaneous stigmata of underlying dysraphism such as subcutaneous lipoma, capillary hemangiomas, dermal pits (which can lead to a dermal sinus tract but may have other tethering lesions underlying them), or hypertrichosis (associated with split cord malformation); foot abnormalities; urologic deficits are common
  3. position of conus at various ages
    1. 6 months gestation – S1
    2. Birth – L2-3
    3. Adults – L1
  4. treatment: resection of lipoma and preservation of motor elements (functional neural elements are anterior to the lipoma)
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