Pediatric Tethered Cord Syndrome: Neurological Progression, Functional Evaluation, and Evidence-Based Decision-Making for Neurosurgical Release

Pediatric tethered cord syndrome (TCS) is a complex neurological condition characterized by abnormal spinal cord fixation and pathological traction that may lead to progressive motor, sensory, musculoskeletal, and autonomic dysfunction. Its heterogeneous clinical presentation and variable natural history create significant challenges in early recognition, functional assessment, and surgical decision-making. This narrative review aimed to analyze the neurological manifestations, diagnostic strategies, and clinical criteria supporting neurosurgical untethering in pediatric populations, incorporating international scientific evidence and contributions from Latin America. A descriptive and analytical review of 20 scientific publications addressing pediatric TCS was organized according to the principles of the scientific method, emphasizing clinical presentation, anatomical abnormalities, functional evaluation, surgical indications, and postoperative outcomes. The reviewed evidence demonstrated considerable variability in neurological manifestations, with motor deficits, urinary dysfunction, and musculoskeletal abnormalities representing recurrent clinical findings. Magnetic resonance imaging provided essential anatomical information, while neurological examination and urodynamic assessment contributed complementary functional evidence. Surgical investigations reported favorable neurological stabilization or improvement in selected patients, with effectiveness rates ranging from 65% to 91% across different anatomical categories in one large pediatric cohort. Another investigation documented postoperative improvement in bladder and sensorimotor function in 48% and 42% of patients with corresponding preoperative deficits, respectively. Postoperative complications were generally infrequent within individual categories, although recurrent tethering remained a relevant long-term concern. Considerable uncertainty persists regarding prophylactic surgery in asymptomatic children, optimal intervention timing, and standardized functional outcome measures. Overall, the findings support an individualized, multidisciplinary approach integrating clinical progression, neurological examination, imaging, and functional assessment to guide neurosurgical decisions. Further prospective and multicenter investigations, particularly involving Latin American populations, are necessary to refine surgical selection criteria, identify predictors of neurological deterioration, and improve long-term pediatric outcomes.