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Tethered spinal cord comprises a group of dysraphic conditions in which the conus medullaris is located in an abnormally low position. Tethered cord syndrome is stretch induced symptoms manifested by motor and sensory deficits in the lower limbs and incontinence, and is often associated with musculoskeletal deformities. This book draws together all aspects of the embryology, pathophysiology, diagnosis, and treatment of this rare but important condition in a detailed but readable format. Inevitably there is repetition but this is unavoidable in a multiauthor text in which each chapter can be read as a whole. The text is well illustrated with diagrams, clear radiological images, and well chosen clinical photographs.
The chapter on pathophysiology of the tethered spinal cord is a fascinating summary of the various experimental studies that have been undertaken in this condition. Although the relevance of some of the models to the condition may be questioned one cannot help but admire the ingenuity and inventiveness of the investigators. Acute traction on the spinal cord has been shown to be associated with impairment of evoked potentials, reduction in spinal cord blood flow, and changes in glucose metabolism. Chronic experiments have shown recovery in neurological deficits after 9 months.
There are well written chapters on diagnosis, investigation, and surgical treatment with plenty of intraoperative detail. The final chapter considers controversies associated with the treatment of the tethered cord syndrome. Most neurosurgeons would now agree that surgical treatment is definitely indicated in patients with progressive neurological deficits and most are increasingly prepared to consider prophylactic surgery in patients with tethering but in whom neurological deficits are absent or established. Although urodynamic testing helps to identify patients with neurogenic bladders, urinary dysfunction may be intermittent and symptomatic tethering may not always be disclosed. A tethered spinal cord is prone to produce problems during periods of rapid growth in childhood, but even when growth is complete patients with an undiagnosed tethered cord may undergo serious deterioration if subjected to sudden flexion movements associated with trauma. A selection process is outlined to help decide treatment in four main categories of presentation. Unfortunately the algorithm can be difficult to interpret—for example, “fluctuating signs and symptoms noted in a patient with stable neurological deficits-patient must be followed closely for detection of minor progression”.
A useful book which I would recommend to all doctors who treat patients with spinal dysraphism and I suspect that many will wish to have a copy in their personal collection.