Controversy exists regarding the indications to operate on patients with a tethered spinal cord as well as the appropriate timing for surgical tethered cord release (TCR) , , . Tethered spinal cord is often linked to spina bifida. The syndrome, treatments, outcomes, and current controversies are re-viewed. View Full Treatment Information . For this reason, continued clinical monitoring, with careful documentation of motor, sensory, and urodymanic function, is important. Trauma to the spine results in a band of scar formation attached to the spinal cord and can cause tethered cord syndrome. Parents and patients themselves may find that the pace of deterioration is so slow that surgery should be delayed until a certain point is reached, although that point is usually ill defined.  |  The spinal cord is stretched. The underlying mechanism is related to impairment of oxidative metabolism in this region. Risks include more problems with the bladder and bowels and more weakness in the legs. Although clinical deterioration can be fairly rapid, and occasionally acute, in cases in this category, it may more often be described as “glacial,” especially in cases involving older children. Adult onset tethered cord syndrome (ATCS) seems not as rare as once thought, however, low susceptibility in adulthood commonly leads to a delay in diagnosis and therapy. Instead, it pulls against the restriction. In this scenario, the surgeon and the parents or patient usually agree that the potential benefits outweigh the risks. Five retrospective, observational, noncontrolled studies of surgical terminal filum lysis for occult TCS in children were identified. While it has been held that clinical deterioration in cases of lipomyelomeningocele, in particular, is inevitable, and therefore that treatment should be undertaken prophylactically,5 as discussed previously, this tenet is not universally held. Citation: Przepiórka Ł, Kunert P, Juszyńska P, Zawadzki M, Ciszek B, Glowacki M and Marchel A (2018) Coincidence of Tethered Cord, Filum Terminale Lipoma, and Sacral Dural Arteriovenous Fistula: Report of Two Cases and a Literature Review. The defect in the thinned-out dura following lipoma excision can be significant and may require patching either with autologous fascia or dural substitute and sealing with any of various fibrin preparations. Treatment decision making is made difficult by the variety of lesions and clinical presentations comprised by this condition and the absence of high-quality clinical outcome data to provide guidance. The author evaluates existing clinical and scientific evidence relevant to this controversy. 2007 May;106(5 Suppl):411-3; author reply 413-4. doi: 10.3171/ped.2007.106.5.411. Different techniques are available to reduce traction on the spinal cord, e.g., removal of scar tissue in an open-surgery approach, endoscopic untethering, section of filum terminale and vertebral osteotomy to shorten the spine. A new edition of the definitive reference for the diagnosis and treatment of TCS Written by renowned specialists, the second edition of Tethered Cord Syndrome in Children and Adults is a comprehensive text on the essentials of clinical management for this complex disorder. The controversy surrounding surgery for occult tethered cord was highlighted recently in the May, 2006 issue of the Journal of Neurosurgery: Pediatrics, which published several papers on the subject.  |  2015 Apr;31(4):597-601. doi: 10.1007/s00381-015-2615-8. Published by The American Association of Neurological Surgeons, Illinois, 1996. Utility of CISS imaging in the management of tethered cord syndrome. The exact type and extent of surgery will depend on what is causing the TCS and how much the nearby tissue is affected. There are several caveats about surgery for these lesions. The common factor in all tethered cord conditions is that the spinal cord’s movement is restricted at its base. Epub 2013 Sep 7. Among these studies, it has been shown that symptomatic tethered cord will produce clinical deterioration with regard to bladder spasticity and orthopedic foot deformity if only treated symptomatically. Once the problem is identified, the treatment of the tethered cord is surgical. Clipboard, Search History, and several other advanced features are temporarily unavailable. Patients with these conditions frequently have dysfunction related to their abnormality and experience bowel and/or bladder incontinence because the innervation of these organs overlaps with the lower lumbar and sacral roots. Tethered cord syndrome, usually discovered in childhood, is a developmental abnormality impairing the longitudinal movement of the spinal cord that can be combined with various forms of spinal dysraphism. A larger study of this nature is probably the only way that the role of surgery in this condition can be evaluated. I have neurogenic bladder and my cord is not tethered. Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients? Axial (left) and sagittal (right) MR images obtained in a 3-month-old patient with a lumbar dermal sinus tract. Cotntail. There was a very small syrinx of the distal spinal cord, not well demonstrated on these images. However, controversies regarding management of asymptomatic and incidentally detected tethered cord still exist. The neurological surgeon makes an incision in the lower back to expose the site where the spinal cord is pinned, then frees it by releasing the stuck portion of the cord. Tethered Cord Release Surgery. Could you get more than one opinion? This site needs JavaScript to work properly. Without revisiting the entire debate, I will simply point out that these are single-surgeon retrospective reviews, with poorly defined entry criteria, outcomes, complications, and so forth. By making a cut in the skin, removing some bone from the spine so the spinal cord is exposed. J Neurosurg 104:5 Suppl 302–304, 2006, Steinbok P, , Garton HJ, & Gupta N: Occult tethered cord syndrome: a survey of practice patterns. Clinicians suspect tethered cord readily in toe walking children; however, the incidence of tethered cord in this population has not been established. Split spinal cord malformations, affecting women more often than men [2, 5, 6], represent inborn anomalies which are often associated with a low conus, tethered cord and eventual lipoma, spinal teratoma, vertebral deformities, Klippel–Feil syndrome, syringomyelia, Arnold–Chiari malformation, lumbar cutaneous malformations (50–75% of patients ) and dysplasia of the legs [5-10, 14-17]. Neurosurgery 33:374–378, 1993, Wehby MC, , O'Hollaren PS, , Abtin K, , Hume JL, & Richards BJ: Occult tight filum terminale syndrome: results of surgical untethering. Subtle changes in the results of urodynamic testing alone, however, do not appear to warrant intervention as there is considerable variability in the tests and their interpretation.18 One should be prepared to regard changes that could reflect maturation of the nervous system or could be due to extremity growth (progressive Achilles tendon shortening) as not being mandatory indications for surgery. Clin Colon Rectal Surg. Clinicopathological evidence suggests that occult TCS may result from radiographically occult structural abnormalities of the terminal filum. Tethered cord syndrome, manifested by motor and sensory dysfunction and incontinence, is caused by excessive tension in the lumbosacral cord. The worst of the most common complications is a neurogenic bladder; patients who experience this complication can expect a lifetime of incontinence, drug therapy, and intermittent catheterizations. Once the problem is identified, the treatment of the tethered cord is surgical. The most problematic area of controversy is pathogenesis. Front. HHS The concerns in such cases are whether this finding suggests a causative mechanism for the scoliosis and whether—to prevent a spinal cord injury—the condition should be treated prior to or at the same time as the spine is straightened and instrumentation is placed. J Urol 101:545–549, 1969, Yamada S, , Won DJ, & Yamada SM: Pathophysiology of tethered cord syndrome: correlation with symptomatology. Edited by shokei yamada. © Copyright 1944-2021 American Association of Neurological Surgeons. A CSF leak remains the other main complication and can be quite difficult to prevent or treat. The authors conducted a retrospective study of clinical outcomes after surgical intervention in 24 school-aged children, adolescents, and young adults with TCS. 1. If the inline PDF is not rendering correctly, you can download the PDF file here. [4 14] However, controversy still surrounds the repair of asymptomatic tethered cord. Follow-up imaging showed reduction in the size of the syrinx and lipoma component, but the lipoma was apposed to the overlying dura (Fig. Tethered = fastened or tied down Cord = the spinal cord, a bundle of nerves that connects brain and bodyTethered cord is an umbrella term for several different conditions. It is the most common vascular malformation in the spine in adults. As is often the case in surgery, the controversy is fueled by plausible explanations and strong convictions based largely on anecdote, and its intensity is all the greater because of a lack of good data. Some have suggested documenting clear neurologic deficits before proceeding with surgery. PURPOSE: Occult tethered cord syndrome applies to patients with signs and symptoms consistent with a caudal spinal cord malformation despite normal neuroimaging. Tethered cord syndrome and occult spinal dysraphism. Surgical steps may include: Removal or release of the tether Semin Pediatr Neurol 4:192–208, 1997, Moseley JB, , O'Malley K, , Petersen NJ, , Menke TJ, , Brody BA, & Kuykendall DH, : A controlled trial of arthroscopic surgery for osteoarthritis of the knee. The good news is that tethered spinal cord is a very treatable condition, especially when diagnosed and treated early. 2006 May;104(5 Suppl):309-13. doi: 10.3171/ped.2006.104.5.309. Selden NR, Nixon RR, Skoog SR, Lashley DB. Minimal tethered cord syndrome: what's necessary to justify a new surgical indication? Object: National Center for Biotechnology Information, Unable to load your collection due to an error, Unable to load your delegates due to an error. Object: Controversy exists regarding proper indications for surgical lysis of the terminal filum in children with voiding dysfunction and tethered spinal cord. 2007;23(2):E1. The author evaluates existing clinical and scientific evidence relevant to this controversy. Episodes of meningitis are not uncommon, and many patients harbor an intraspinal dermoid. Postoperative Orders . Br Med J 281:1243–1245, 1980, Tuuha SE, , Aziz D, , Drake J, , Wales P, & Kim PC: Is surgery necessary for asymptomatic tethered cord in anorectal malformation patients?. Controversy exists regarding proper indications for surgical lysis of the terminal filum in children with voiding dysfunction and tethered spinal cord. did so in patients beyond 10 years of age [8]; non-progressive patients should certainly not be operated on in adult age [35]. Chiari Malformation is a serious neurological disorder where the bottom part of the brain, the cerebellum, descends out of the skull and crowds the spinal cord, putting pressure on both the brain and spine and causing many symptoms. A tethered cord release is a procedure to separate the spinal cord from tissue that holds it in place. J Neurosurg. The author provides case examples to illustrate potential treatment approaches and suggests balancing the risks and benefits for each general category. This abnormal attachment is associated with progressive stretching and increased tension of the spinal cord as a child ages, potentially resulting in a variety of neurological and other symptoms. There is a normal distribution of position of the conus in healthy patients, and a position at one end of this range does not mean surgery is indicated. Deterioration that is extremely slow, but persistent, often makes decision making regarding surgery, particularly in terms of timing, difficult. The exact steps will depend on individual needs. Use of lumbar laminoplasty vs. laminotomy for transection of the filum terminale does not affect early complication rates or postoperative course. While the lesions are classically divided into dorsal, transitional, and terminal, typically lipomyelomeningoceles are transitional, and vary most in terms of their relationship to the spinal cord and surrounding nerve roots. As is often the case in surgery, the controversy is fueled by plausible explanations and strong convictions based largely on anecdote, and its intensity is all the greater because of a lack of good data. Developing in vivo methods of measuring spinal cord blood flow and metabolism would presumably shed a great deal of light in this area. In most of those cases, the spinal cord is tethered to the tough membrane called the dura, which covers the spinal cord. Surgery was complicated by a CSF collection requiring a subcutaneous peritoneal shunt. In cases of tethered spinal cord secondary to tight or lipomatous filum terminale, the surgical risk-to-benefit ratio is clearly in favor of surgery in both symptomatic and asymptomatic cases. It is worth remembering that recent randomized trials with a sham surgery arm demonstrated significant clinical improvement in the sham surgery group.6,7 Incontinence is so common in children as to be regarded as almost normal, and it is difficult to quantify, even with urodynamic testing.1,10,14,16,21. In Chiari circles this has been a major controversy and some doctors have evidently been overusing the surgery. 2013 Sep;29(9):1625-34. doi: 10.1007/s00381-013-2180-y. Tethered cord may be treated with surgery (an operation) to … The author evaluates existing clinical and scientific evidence relevant to this controversy. Some have suggested documenting clear neurologic deficits before proceeding with surgery. Tethered cord syndrome (TCS) is basically a condition where anchorage of a part of the spinal cord, most commonly the area of the conus, by some inelastic structure, which results in functional dysfunction involving the adhered segment of the spinal cord or at times segments beyond that. Surgery is the most common treatment to “untether” the spinal cord from the spinal tissue. This can occur during fetal development or may be associated with build up of scar tissue after previous surgery in or around the spinal cord. Acute tension on the spinal cord has been shown to produce spinal cord dysfunction and deranged metabolism in animal experiments,15,23 but it is not known how these findings relate to the chronic situation typical of the patient with a tethered spinal cord. Section of the terminal filum for occult tethered cord syndrome: toward a scientific answer. Therefore, the anesthetic induction may take place with the patient supine on a stretcher. In the presence of such symptoms, treatment is usually surgical and involves freeing the cord by either cutting the filum or repairing the lipomyelomeningocele defect. Post-traumatic tethered spinal cord is a condition which occurs following injury to the spinal cord where scar tissue forms and tethers or holds the spinal cord to the soft tissue covering which surrounds it called the dura. J Neurosurg 104:5 Suppl 309–313, 2006, Sureshkumar P, , Craig JC, , Roy LP, & Knight JF: Daytime urinary incontinence in primary school children: a population-based survey. of 44 patients with long‑term follow‑up. COVID-19 is an emerging, rapidly evolving situation. Note extension of the lipoma into the left buttock. Durdağ E, Börcek PB, Öcal Ö, Börcek AÖ, Emmez H, Baykaner MK. In some cases these findings are almost to be expected—for example, in cases of caudal regression syndrome or Currarino triad. If surgery is not advisable, spinal cord nerve roots may be cut to relieve pain. Controversy exists regarding proper indications for surgical lysis of the terminal filum in children with voiding dysfunction and tethered spinal cord. The patient had experienced concomitant clinical progression.  |  3). Tethered spinal cord comprises a group of dysraphic conditions in which the conus medullaris is located in an abnormally low position. Childs Nerv Syst. A tethered cord release is a procedure to separate the spinal cord from tissue that holds it in place. 2006 Sep;105(3 Suppl):214-8. doi: 10.3171/ped.2006.105.3.214. young children with tethered cord and for patients of all ages who are deteriorating neurologically due to tethered cord. In adults, surgery to free (detether) the spinal cord can reduce the size and further development of cysts in the cord and may restore some function or alleviate other symptoms. The author evaluates existing clinical and scientific evidence relevant to this controversy. There is even less evidence for surgical treatment of split cord malformations than for surgery in cases of lipomyelomeningocele. In this report, we describe two cases of adolescent onset TCS associated with two different etiologies. Although there are still questions raised as to whether prophylactic surgery changes the natural long-term history of patients with tethered cords [ 1 ], I am convinced that prophylactic surgery is safe and does in most cases prevent the ongoing damage from flexion/extension injury to the distal spinal cord. Neurosurg Focus. Pediatr Neurosurg 40:51–58, 2004, Wolin LH: Stress incontinence in young, healthy nulliparous female subjects. Axial (left) and sagittal (right) MR images obtained in a patient with a fatty filum and a normal-level conus. The neurosurgeons at The Spine Hospital at The Neurological Institute of New York believe that surgery … What Causes Tethered Spinal Cord? Childs Nerv Syst. Born with an obvious lipomyelomeningocele, the patient was apparently neurologically normal. Even though the concept arose in my own institution,4 my position remains a skeptical one, as outlined in a recently published series of articles.3,12,13 There are several reports of symptoms of incontinence improving after division of what appears to be a normally positioned filum terminale,4,19,20 and in some of these cases abnormal urodynamic test results had been documented. This scar tissue prevents the normal flow of spinal fluid around the spinal cord and impedes the normal motion of the spinal cord. Recovery From Surgery for Tethered Cord Syndrome With a Normally Positioned Conus in Children. Childs Nerv Syst. NIH Surgery —The goal of surgery is to release the tethered spinal cord, ease symptoms, and prevent further damage. The exact steps will depend on individual needs. Lipomyelomeningoceles manifest significant variability in their configuration and the technical difficulty of treatment. Tethered spinal cord is an abnormal attachment of the spinal cord to tissue around it. Most infants with tethered spinal cord do not have any associated birth defects. Neurosurg Focus. Background: Tethered cord syndrome (TCS) is a progressive clinical condition including a series of neurological dysfunctions and deformities attributable to abnormally increased tension on the spinal cord, which is lacking effective treatment to relieve the symptoms and prevent progression. Eur J Pediatr Surg 1:10 Suppl 13–17, 2000, Drake JM: Occult tethered cord syndrome: not an indication for surgery. during surgery for adult tethered cord syndrome: Analysis of a series . Although controversy existed in the past (over the concept of prophylactic surgery of asymptomatic patients), most surgeons now believe that the risk of waiting for deterioration to begin is not justified, because the deficit often is not reversible. There has been controversy regarding the management of syringomyelia associated with tethered spinal cord. ISBN 1-879284-37-5. Surgery for tethered cord is another area of controversy that was not well addressed in this paper. Conclusions: The goal of surgery is to de-tether the spinal cord to relieve spinal cord stretching. Tethered cord syndrome, usually discovered in childhood, is a developmental abnormality impairing the longitudinal movement of the spinal cord that can be combined with various forms of spinal dysraphism. Patients with alleged tethered spinal cords are fairly common in pediatric neurosurgical practice. In contrast, the spinal dural arteriovenous fistula (SDAVF) is an acquired condition. Most of these congenital disorders are amenable to surgical treatment. Officially, once the patient has stopped growing, asymptomatic Tethered Cord Syndrome is usually not recommended for surgery, the recommended treatment is observation. There are apparently many patients with tethered cord who remain asymptomatic their entire life. Methods : All 83 patients with a lipomyelomeningocele … In this setting I leave the filum alone. 2007;23(2):E5. Tethered Cord Syndrome . The management of tethered cord syndrome with onset emains controversial, although the necessity of early surgery in the pediatric tethered cord syndrome population is well established. Strong MJ, Thompson EM, Roundy N, Selden NR. Until the results of such research are available, surgeons should endeavor to maximize benefit and reduce risk for patients who may have a tethered spinal cord, walking the fine line between over- and undertreatment. Nevertheless, even in the presence of dysraphic components, including a low spinal cord and a thickened and fat-filled filum, progressive deterioration is not inevitable.17. Introduction: Although MRI has improved the diagnosis of tethered cord, many controversies still exist in the treatment of tethered cord syndrome (TCS). 2001 Jan 15;10(1):e1. Recently, surgery has been offered to children who have a normally positioned conus medullaris and no terminal filum abnormality visible on 1.5-tesla magnetic resonance images (referred to as minimal or occult tethered cord syndrome [TCS]). Tethered spinal cord is common in children with spina bifida, but it also occurs in children who don’t have this condition. Previous reports on the topic have included only a small number of patients, considered open/closed spinal dysraphism together, or had a short follow-up. These conditions are usually obvious at birth and are a good reason to evaluate children for spinal cord tethering. Pathological evaluation of the filum terminale tissue after surgical excision. Split cord malformations are quite rare and may take various forms, with the most significant probably being a bone septum dividing separate dural sacs. J Urol 169:2344–2346, 2003, Warder DE, & Oakes WJ: Tethered cord syndrome and the conus in a normal position. The symptoms of tethered cord syndrome (TCS) cases mostly appear during infancy and childhood. Tethered cord release is performed in the prone position with neural monitoring of lower extremity motor and sensory responses and monitoring of the rectal sphincter innervation. 2006 May;104(5 Suppl):305-8. doi: 10.3171/ped.2006.104.5.305. Adult onset tethered cord syndrome (ATCS) seems not as rare as once thought, however, low susceptibility in adulthood commonly leads to a delay in diagnosis and therapy. For older children who are asymptomatic or with stable neurological deficit, untethering surgery will be an option opened to the parents and patient. Subtle deterioration over the next 3 years—repeated bladder infections culminating in the recommendation for intermittent catheterizations, in-turning of the left foot, and loss of anal tone—prompted a repeated imaging study, which demonstrated an enlarged syrinx in the distal spinal cord (Fig. 2015 May;31(5):759-63. doi: 10.1007/s00381-015-2627-4. More than 40 percent of children who have spina bifida will need surgery to untether the spinal cord during their lifetimes. Other treatment is symptomatic and supportive. J Neurosurg 66:116–123, 1987, Thomas TM, , Plymat KR, , Blannin J, & Meade TW: Prevalence of urinary incontinence. Two further studies in which the authors reported surgical results in children with a normal-level conus medullaris were also identified. It is useful to obtain a baseline measurement of bladder function with a voiding cystourethrogram, and in the presence of incontinence or recurrent bladder infections urodynamic testing is an important method of monitoring. J Pediatr Surg 39:773–777, 2004, Venhola M, , Reunanen M, , Taskinen S, , Lahdes-Vasama T, & Uhari M: Interobserver and intra-observer agreement in interpreting urodynamic measurements in children. C: Sagittal image obtained when the patient was 3 years old showing progressive enlargement of the syrinx. Syringomyelia and tethered cord in children. Objective : The adolescent presentation of tethered cord syndrome (TCS) is well-recognized, but continues to pose significant diagnostic and management controversies. doi: 10.3171/FOC-07/08/E1. J Pediatr 137:814–818, 2000, Tani S, , Yamada S, & Knighton RS: Extensibility of the lumbar and sacral cord. (Pp212, US$95). The good news is that tethered spinal cord is a very treatable condition, especially when diagnosed and treated early. Occult tethered cord syndrome: not an indication for surgery. Treatment. Occult tethered cord syndrome: a survey of practice patterns. In cases involving neurologically normal patients without a true dermal sinus tract, I think a reasonable approach is careful observation, with a plan to intervene should deterioration occur. Recently, surgery has been offered to children who have a normally positioned conus medullaris and no terminal filum abnormality visible on 1.5-tesla magnetic resonance images (referred to as minimal or occult tethered cord syndrome [TCS]). Tethered cord syndrome is a stretch-induced functional disorder associated with the fixation (tethering) effect of inelastic tissue on the caudal spinal cord, limiting its movement. In patients with preexisting deficits, for whom some possible improvement might be entertained, complications seem somewhat more tolerable. Counting the vertebrae to assign conus position can be difficult, and the results may have little meaning. F ew topics in pediatric neurosurgery generate as much controversy, debate, or angst as the diagnosis of tethered spinal cord. Is a filum terminale with a normal appearance really normal? This entity was first described by Garceau (1953) and subsequently named by Hoffman et al. Recently, surgery has been offered to children who have a normally positioned conus medullaris and no terminal filum abnormality visible on 1.5-tesla magnetic resonance images (referred to as minimal or occult tethered cord syndrome [TCS]). Spine (Phila Pa 1976) 2006;31:2095‑102. One must be aware of “glacial” deterioration as discussed above. A tethered cord refers to a condition in which the lower spinal cord is restricted (“tethered”) and is not free to develop normally with in the spinal column. The authors conducted a retrospective study of clinical outcomes after surgical intervention in 24 school-aged children, adolescents, and young adults with TCS. Intraoperative monitoring can be used to identify partially obscured roots or detect an early neurological injury, manifest by evidence of persistent spontaneous muscle activation, but it has not been convincingly proven to improve the outcome of surgery. Patient Resources. Magnetic resonance images obtained in a patient with lipomyelomeningocele. As previously discussed,3 these cases, united by a single pathogenetic concept—tethering of the spinal cord—are a very diverse group clinically and radiologically. Especially the indications for and timing of surgical release have remained topics of discussion. For this procedure, the patient is placed under general anesthesia. On a larger scale, it is important to note that there is literature that supports the notion that clinical progression in patients with lipomyelomeningocele is predictable based on the anatomy of the lipoma2 and that surgery may not prevent this progression over the long run.8. dwarder@utmb.edu Tethered cord syndrome is a progressive form of neurological deterioration that results from spinal cord tethering by … An early imaging study, performed when the patient was 3 months old, demonstrated the typical features of a lipomyelomeningocele, with extension of the lipoma into the left buttock suggesting that untethering might be technically difficult (Fig. Childs Nerv Syst. The tethered spinal cord has to be untethered, i.e., adhesions between nervous tissue and surrounding connective tissue have to be broken. Tethered cord syndrome is stretch induced symptoms manifested by motor and sensory … 2), diastematomyelia, caudal regression syndromes (such as imperforate anus), and dermal sinus tract (not a normal sacral dimple). Epub 2015 Feb 25. The tethered spinal cord syndrome remains a fascinating surgical enigma, surrounded by much debate, controversy, and uncertainty. Interobserver and intra-observer agreement in interpreting urodynamic measurements in children, Tethered cord syndrome and the conus in a normal position, Occult tight filum terminale syndrome: results of surgical untethering, Stress incontinence in young, healthy nulliparous female subjects, Pathophysiology of tethered cord syndrome: correlation with symptomatology, Pathophysiology of “tethered cord syndrome”, Significant Dysraphic Abnormality, Clear Clinical Deterioration, Significant Dysraphic Abnormality, Clinically Normal or Stable Deficit, Incidentally Discovered Abnormality, Other Problem, Tethered Spinal Cord Symptomatology, Normal Imaging Findings, Top 25 Cited Gamma Knife® Surgery Articles - Trigeminal Neuralgia, Top 25 Cited Gamma Knife® Surgery Articles - Volume 111, Volume 23: Issue 2 (Aug 2007): Tethered Cord, Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada. :597-601. doi: 10.3171/ped.2006.104.5.309 a Normally Positioned conus in a patient with a fatty and. 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