Management of Spina Bifida Occulta and Tethered Cord Syndrome in Children

Initial Management at Presentation

• Surgical release for progressive symptoms: Surgical release of the tethered cord should be offered in the setting of weakness, progressive sensory or urodynamic changes, and radiological evidence of tethering.
• Limited laminotomy for tight filum: A minimal hemi-laminotomy should be completed between L4/5 or L3/4 based on preoperative imaging. The dural opening should be minimized to only that necessary to identify filum and/or lipoma if present. Closure should be water tight with a small permanent suture such as a 4-0 silk with a layering of fibrin glue and oxidized regenerated cellulose matrix.
• Use of physiological mapping: The use of intraoperative monitoring is indicated in all cases to appropriately identify the filum terminale apart from functional nerve rootlets.

Adjunctive Therapies

• Physical therapy: Physical therapy is necessary in the postoperative period and should be continued on an outpatient basis if significant preoperative weakness was present. Physical therapy may also be useful in nonoperative patients for body mechanics, lower extremity flexibility, and core strengthening exercises.
• Occupational therapy: Age-appropriate occupational therapy may be useful.
• Pain control: NSAIDS, gabapentin for neuropathic pain. Judicious use of narcotics, primarily for immediate postoperative pain. These agents usually are not required for long-term management.

Follow-up

• Routine plus rehabilitation: Postoperative follow up begins at 2 weeks for a wound check and to ensure that the closure does not have any CSF leak. Follow-up is also established with physical medicine and rehab and outpatient physical therapy at this time if it was not done prior to hospital discharge.
• Continues as long as needed: Additional follow-up occurs 3 months postoperatively and then as needed.