Child's Nervous System

, Volume 35, Issue 11, pp 2187–2194 | Cite as

Increased complications without neurological benefit are associated with prophylactic spinal cord untethering prior to scoliosis surgery in children with myelomeningocele

  • Hannah E. GoldsteinEmail author
  • Belinda Shao
  • Peter J. Madsen
  • Sara M. Hartnett
  • Jeffrey P. Blount
  • Douglas L. Brockmeyer
  • Robert M. Campbell
  • Michael Conklin
  • Todd C. Hankinson
  • Gregory G. Heuer
  • Andrew H. Jea
  • Benjamin C. Kennedy
  • Gerald F. Tuite
  • Luis Rodriguez
  • Neil A. Feldstein
  • Michael G. Vitale
  • Richard C. E. Anderson
Original Article



Children with myelomeningocele (MMC) are at increased risk of developing neuromuscular scoliosis and spinal cord re-tethering (Childs Nerv Syst 12:748-754, 1996; Neurosurg Focus 16:2, 2004; Neurosurg Focus 29:1, 2010). Some centers perform prophylactic untethering on asymptomatic MMC patients prior to scoliosis surgery because of concern that additional traction on the cord may place the patient at greater risk of neurologic deterioration peri-operatively. However, prophylactic untethering may not be justified if it carries increased surgical risks. The purpose of this study was to determine if prophylactic untethering is necessary in asymptomatic children with MMC undergoing scoliosis surgery.


A multidisciplinary, retrospective cohort study from seven children’s hospitals was performed including asymptomatic children with MMC < 21 years old, managed with or without prophylactic untethering prior to scoliosis surgery. Patients were divided into three groups for analysis: (1) untethering at the time of scoliosis surgery (concomitant untethering), (2) untethering within 3 months of scoliosis surgery (prior untethering), and (3) no prophylactic untethering. Baseline data, intra-operative reports, and 90-day post-operative outcomes were analyzed to assess for differences in neurologic outcomes, surgical complications, and overall length of stay.


A total of 208 patients were included for analysis (mean age 9.4 years, 52% girls). No patient in any of the groups exhibited worsened motor or sensory function at 90 days post-operatively. However, comparing the prophylactic untethering groups with the group that was not untethered, there was an increased risk of surgical site infection (SSI) (31.3% concomitant, 28.6% prior untethering vs. 12.3% no untethering; p = 0.0104), return to the OR (43.8% concomitant, 23.8% prior untethering vs. 17.4% no untethering; p = 0.0047), need for blood transfusion (51.6% concomitant, 57.1% prior untethering vs. 33.8% no untethering; p = 0.04), and increased mean length of stay (LOS) (13.4 days concomitant, 10.6 days prior untethering vs. 6.8 days no untethering; p < 0.0001). In multivariable logistic regression analysis, prophylactic untethering was independently associated with increased adjusted relative risks of surgical site infection (aRR = 2.65, 95% CI 1.17–5.02), unplanned re-operation (aRR = 2.17, 95% CI 1.02–4.65), and any complication (aRR = 2.25, 95% CI 1.07–4.74).


In this study, asymptomatic children with myelomeningocele who underwent scoliosis surgery developed no neurologic injuries regardless of prophylactic untethering. However, those who underwent prophylactic untethering were more likely to experience SSIs, return to the OR, need a blood transfusion, and have increased LOS than children not undergoing untethering. Based on these data, prophylactic untethering in asymptomatic MMC patients prior to scoliosis surgery does not provide any neurological benefit and is associated with increased surgical risks.


Myelomeningocele Scoliosis Tethered cord release Prophylactic untethering 


Compliance with ethical standards

Conflict of interest

The authors have no relevant disclosures to report.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  • Hannah E. Goldstein
    • 1
    Email author
  • Belinda Shao
    • 2
  • Peter J. Madsen
    • 3
  • Sara M. Hartnett
    • 4
  • Jeffrey P. Blount
    • 5
  • Douglas L. Brockmeyer
    • 6
  • Robert M. Campbell
    • 7
  • Michael Conklin
    • 8
  • Todd C. Hankinson
    • 9
  • Gregory G. Heuer
    • 10
  • Andrew H. Jea
    • 11
  • Benjamin C. Kennedy
    • 10
  • Gerald F. Tuite
    • 12
  • Luis Rodriguez
    • 12
  • Neil A. Feldstein
    • 2
  • Michael G. Vitale
    • 13
  • Richard C. E. Anderson
    • 2
  1. 1.Department of Neurological SurgeryColumbia University Medical Center, Columbia-PresbyterianNew YorkUSA
  2. 2.Division of Pediatric Neurosurgery, Department of Neurological SurgeryChildren’s Hospital of New York, Columbia-PresbyterianNew YorkUSA
  3. 3.Department of NeurosurgeryUniversity of PennsylvaniaPhiladelphiaUSA
  4. 4.Department of NeurosurgeryUniversity of South FloridaTampaUSA
  5. 5.Division of Pediatric Neurosurgery, Department of NeurosurgeryThe University of Alabama at Birmingham, Children’s Hospital BirminghamBirminghamUSA
  6. 6.Division of Pediatric Neurosurgery, Department of NeurosurgeryUniversity of Utah Medical CenterSalt Lake CityUSA
  7. 7.Department of Orthopedic SurgeryChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  8. 8.Division of Pediatric Orthopedics, Department of SurgeryUniversity of Alabama at Birmingham, Children’s HospitalBirminghamUSA
  9. 9.Department of NeurosurgeryUniversity of Colorado School of MedicineAuroraUSA
  10. 10.Department of NeurosurgeryChildren’s Hospital of PhiladelphiaPhiladelphiaUSA
  11. 11.Department of NeurosurgeryGoodman Campbell Brain and SpineIndianapolisUSA
  12. 12.Department of NeurosurgeryJohns Hopkins All Children’s HospitalSt. PetersburgUSA
  13. 13.Division of Pediatric Orthopedic Surgery, Department of Orthopedic SurgeryColumbia University Medical CenterNew YorkUSA

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