The patient was operated elsewhere in Kuwait for tethered cord with lipoma at L4-5 level in 1999. There surgery as the mother telling complicate with gross neurologic deterioration and CSF leak from the wound for several weeks. MRI lumbar spine performed 16-February-2006 showed tethering of the spinal cord at the same level. She underwent right hip fixation 2010.

On examination the patient is using pumpers for urination, feeling defecation with cauda equina syndrome, complete flail left foot 0/5 dorsi and planterflexion  and dorsiflexion right foot 1/5 and planterflexion right foot 0/5.  Talepis valgus deformity both feet more severe in the left. Weak abduction of the knees 4/5. Analgesia above the right knee and below the left knee. There are atrophic ulcers right foot. The patient did not deteriorate the last 4-5 years.

New MRI lumbar spine done 13-August-2013 showing the spinal cord still tethered at L4-5 level.

Laminectomy L3  with exposure of the dura down to L5 lamina. From the scar, it is clear that the intradural part of the previous surgery, was performed far inferior. The dura was opened from the most caudal point down to circumscribe the involved dura with the spinal cord until the running roots below the tethered cord were seen and preserved in the left side. Dissection of the arachnoid around the roots and spinal cord to eliminate all the tethering components. Using lyodura the dural defect was water-tightly closed. Check for CSF leak was done with elevation of the head and Valsalva maneuver, which ruled out CSF leak. Routine closure of the wound with removal of the lipoma and repair of the skin to have more acceptable cosmetic look.

Smooth postoperative recovery. 

It seems that in the first surgery, the tethered cord was ignored. Untethering was the main aim of this surgery.