Clinical Application of Intraoperative Neurophysiological Monitoring during Detethering Surgery of a Newborn: A Case Report

Background: Tethered cord syndrome (TCS) is a rare congenital condition that causes abnormal tension on the spinal cord and often requires early surgical intervention to prevent progressive neurological and orthopedic deficits. However, performing detethering surgery in neonates presents unique challenges due to their immature neural pathways, which complicate intraoperative neuromonitoring (IONM). Case Description: We report the case of a 13-day-old neonate with TCS who underwent successful detethering surgery under advanced IONM. Double-train stimulation with a linked quadripolar montage was employed to elicit motor evoked potentials (MEPs), overcoming the challenge of monitoring immature corticospinal tracts. Additionally, subdural strip electrodes were used for robust somatosensory evoked potential (SSEP) monitoring, while bulbocavernosus reflex (BCR) testing safeguarded the integrity of the lower sacral circuit. The surgery proceeded uneventfully with no intraoperative complications. Postoperatively, the patient demonstrated normal motor development, achieving independent walking before the age of one. There were no signs of musculoskeletal deformity, and bowel and bladder dysfunction. Conclusion: This case demonstrates the feasibility and efficacy of advanced IONM techniques, including double-train stimulation with a linked quadripolar montage and subdural SSEP recording, in neonatal TCS surgery. Early diagnosis, timely intervention, and customized neuromonitoring strategies were critical in achieving favorable outcomes. While long-term follow-up remains essential to identify and address subtle residual deficits, this case provides valuable insights into optimizing surgical approaches for TCS in neonates and underscores the need for further research to refine neuromonitoring methods for this vulnerable population. Keywords: Intraoperative neurophysiological monitoring (IONM), Tethered cord syndrome (TCS), Motor evoked potential (MEP), Somatosensory evoked potential (SSEP), Bulbocavernosus reflux (BCR)