Secondary untethering and re-untethering are both beneficial in adult tethered cord syndrome: a single-center cohort study

Introduction Adult tethered cord syndrome (TCS) represents a heterogeneous group of congenital and acquired conditions. While primary untethering is an established treatment, re-untethering remains controversial because of concerns regarding limited neurological benefit and increased complication rates. Research question This study evaluates neurological outcomes after adults re-untethering surgery and identifies perioperative factors associated with clinical improvement. Methods We performed a retrospective single-center cohort analysis of all patients surgically treated for TCS between 2008 and 2024. Patients were dichotomized into primary untethering and secondary re-untethering groups. Neurological status was assessed using the McCormick grade. Neurological improvement was defined as improvement of ≥1 McCormick grade. Postoperative complications and revision surgeries were recorded. Age and affected spinal level were analyzed as potential modifiers of outcome. Results Seventy-one patients were included (median age 51.5 years); 42 underwent primary untethering and 29 re-untethering. Patients undergoing re-untethering presented with significantly worse baseline neurological status. Neurological improvement at discharge was more frequent after primary untethering (52.4% vs. 31.0%), but this difference reversed at follow-up, with higher improvement rates after secondary re-untethering (68.4% vs. 61.5%). Neither age nor affected spinal level significantly influenced neurological outcome or revision rates. Re-untethering was associated with more complex surgeries, and higher wound-healing complication rates. Discussion and Conclusion Despite worse baseline neurological status, re-untethering is not associated with inferior neurological outcomes compared with primary untethering. Neurological improvement appears to be a time-dependent process, and baseline impairment alone should not preclude surgical intervention. Re-untethering in adult patients should therefore be considered on an individual basis.