{"paper_id":"20d879e7-2a0b-4929-bbe3-079bdbbcedbb","body_text":"Utilizing pre-operative quantitative radiological imaging to predict surgical outcomes following untethering for adult tethered cord syndrome | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Utilizing pre-operative quantitative radiological imaging to predict surgical outcomes following untethering for adult tethered cord syndrome Xingwen Sun, Chao Wu, Yupeng Zhu, Haihui Jiang, Kai Ye, Guangjin Zhou, and 7 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7027483/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Management of tethered cord syndrome (TCS) in adults remains controversial due to unpredictable surgical outcomes. This study aimed to evaluate quantitative MRI metrics—diffusional kurtosis imaging (DKI) and magnetization transfer ratio (MTR)—for predicting surgical outcomes in adult TCS patients. Methods Thirty-four adult TCS patients with tight/thickened/fatty filum underwent preoperative 3T MRI, including DKI and MT sequences. Patients with complex conditions were excluded. Clinical outcomes were mainly assessed by Japanese Orthopaedic Association (JOA) scores and bladder function. DKI parameters (mean/axial kurtosis: MK, KA) and MTR values at three levels at the end of the spinal cord were analyzed. Statistical methods included Spearman’s correlation, ROC analysis, and multivariate regression. Results Patients with recovery rate (RR) ≥ 50% (27/34) showed significantly lower KA (0.391 ± 0.017 vs. 0.434 ± 0.014, p < 0.001) and reduced MTR at upper spinal levels (MTR2: 52.411 ± 1.159 vs. 54.648 ± 1.254; MTR3: 52.523 ± 1.447 vs. 54.496 ± 1.049; p ≤ 0.003) compared to RR < 50% patients. KA and MTR3 independently correlated with RR (p < 0.001). ROC analysis confirmed KA and MTR3 as predictors for ≥ 50% RR (AUC: 0.971 and 0.873). Bladder improvement (12/21 patients) associated with higher preoperative KA (0.432 ± 0.013 vs. 0.393 ± 0.020, p < 0.001) but lacked independent predictors in regression. Conclusions Preoperative DKI and MTR of the lower spinal cord have prognostic value in assessing post-operative recovery in adult TSC patients. Advanced MRI imaging techniques may aid the decision-making process for these patients. Tethered cord syndrome outcome diffusion weighted MRI Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Background The tethered cord syndrome (TCS) is a neurological disorder characterized by abnormal attachment of the spinal cord, typically toward the caudal end of the spine, resulting in tension-induced dysfunction of the conus medullaris and lower spinal cord( 1 ). Common symptoms include back and pelvic pain, bowel and bladder dysfunction, lower extremity weakness or atrophy, and sensory loss or numbness ( 2 ). Usually diagnosed in childhood, adult tethered cord syndrome has been recognized as a definite clinical entity only in the past decades. Untethering surgery has demonstrated beneficial outcomes in pediatric patients with TCS ( 3 ). However, its role in adult patients remains controversial( 2 , 4 , 5 ). Clinical decision-making is complex due to the variability in postoperative outcomes. In asymptomatic adults with TCS, surgical intervention is generally not recommended, as many of these individuals may remain symptom-free throughout their lives. For symptomatic adults, the decision to pursue surgery remains inconclusive( 1 , 2 , 6 ). While some patients experience partial or complete symptom relief following surgery, others show no improvement or may even experience clinical deterioration. Previous studies have reported pain relief in 78–100% of patients( 1 , 2 , 6 )., improvement in bladder function in 3–66.6%( 6 ), motor function in 25–64% ( 1 , 6 ), and sensory symptoms in approximately 50%( 1 ). Conversely, 2.2–3.7% of patients may experience worsening of symptoms postoperatively( 1 ). Efforts have been made to use imaging characteristics to predict surgical outcomes. A study by Mualem et al. ( 3 ) demonstrated that anterior canal distance and the bending angle of the lower spinal cord were associated with an increased risk of reoperation. However, this study focused exclusively on pediatric patients. To date, no well-defined radiological markers have been established in the literature to predict surgical outcomes in adults with TCS. Study investigating correlations of MRI findings with postoperative recovery in adult TCS patients is absent due to its rareness. Diffusion-weighted imaging (DWI) is a sensitive technique for detecting microstructural changes in the spinal cord ( 7 – 9 ). A prospective cross-sectional study has shown that diffusion tensor imaging (DTI) metrics correlate with neurological outcome scores in TCS ( 10 ). While DTI is based on the assumption of homogeneous Gaussian water diffusion, diffusional kurtosis imaging (DKI) is a more advanced technique that measures non-Gaussian water diffusion, offering a more accurate reflection of tissue microstructure ( 7 ). DKI has been applied to various spinal cord disorders, including degenerative myelopathy, traumatic injury, and demyelinating diseases, and has demonstrated correlations with both neurological impairment and postoperative outcomes( 10 – 13 ). However, to our knowledge, no studies have explored the relationship between DKI metrics and surgical outcomes in TCS. Magnetization transfer ratio (MTR) is a well-established marker of myelin integrity. MT imaging has been used to quantify spinal cord injury and assist in clinical decision-making in various neurological conditions ( 7 , 8 , 12 – 14 ). In this study, we aim to evaluate the utility of DKI and MTR metrics in predicting surgical outcomes in adult patients with TCS. Methods Study Population From June 2022 to March 2025, we prospectively recruited 57 adult patients with TCS who underwent untethering surgery. Patients with low-lying syrinx or diastematomyelia were excluded because the T2 hyperintensity of syrinxes could interfere with the measurement of DKI and MTR values, and diastematomyelia often provides insufficient cross-sectional area for reliable measurements. We also excluded patients with TCS associated with lipomyelomeningocele, myelomeningocele, or lumbosacral lipoma, as the complexity of these conditions significantly affects postoperative outcomes. Only patients with tethering related to a tight, thickened, or fatty filum were included for analysis. Figure 1 presents the flowchart of patient recruitment. Ultimately, 34 patients with tethering due to a tight, thickened, or fatty filum were included in the final analysis. Additionally, we recruited 20 age- and sex-matched healthy volunteers without any neurological disorders to serve as controls. Ethics This study was performed in accordance with the principles of the Declaration of Helsinki. The study was approved by the Institutional Ethic Board (reference number M2022457). Informed consent was acquired from all recruited participants. Clinical Assessment Patients were included based on the following criteria: ( 1 ) Diagnosis of TCS with progressive symptoms and a clinical recommendation for detethering surgery by a neurosurgeon. ( 2 ) No history of previous detethering surgery. ( 3 ) TCS associated only with a tight, thickened, or fatty filum. Exclusion criteria are as following: ( 1 ) Contraindications to MRI. ( 2 ) TCS associated with diastematomyelia, lipomyelomeningocele, myelomeningocele, or lumbosacral lipoma. ( 3 ) History of prior detethering surgery. Demographic and clinical data—including age, sex, presence of back or leg pain, gait disturbance, sensory deficits, motor weakness, urinary bladder dysfunction, and bowel dysfunction—were recorded. Urodynamic examinations were conducted to objectively assess urinary bladder dysfunction. The final follow-up was conducted 12 months after surgery. To evaluate sensorimotor symptoms and urinary dysfunction before and after detethering, we used the Japanese Orthopaedic Association (JOA) scoring system ( 15 ) (Supplementary Table 1). The recovery rate (RR) was calculated using the following formula: Recovery rate (%) = (Postoperative score − Preoperative score) / (29 − Preoperative score) × 100 Based on the RR, patients were divided into two groups: those with RR ≥ 50% and those with RR < 50%. An RR < 50% was considered indicative of limited surgical benefit. In the JOA scoring system, urinary bladder function is classified into three categories: normal, mild dysuria, and severe dysuria. Patients reporting pollakiuria, hesitancy, a sense of incomplete emptying, or small residual urine volume on urodynamic testing were categorized as having mild dysuria. Patients with urinary retention, large residual urine volume on urodynamic testing, or incontinence were classified as having severe dysuria. Bowel function was graded as follows: 0 – Bowel incontinence 1 – Altered bowel movement frequency 2 – Normal bowel function Imaging Technique All MRI scans were performed preoperatively using a 3.0T scanner (uMR880, United Imaging Healthcare, Shanghai, China) equipped with a commercial 48-channel spine coil. Conventional sequences included sagittal T1-weighted (T1WI) fast spin echo (FSE) and T2-weighted FSE sequences in both axial and sagittal planes. Diffusion kurtosis imaging (DKI) and magnetization transfer (MT) imaging were conducted for the caudal spinal cord and conus medullaris. DKI was performed using a conventional diffusion tensor imaging (DTI) protocol with three b-values applied in 32 directions. MT imaging was conducted using a gradient echo (GRE) sequence with an MT preparation pulse, followed by the same GRE sequence without the MT pulse to serve as a reference. All imaging parameters are listed in Table 1 . Table 1 Parameters of MRI sequences. DKI: diffusion kurtosis imaging; MTR: magnetization transfer ratio; EPI: echo planer imaging; GRE: gradient echo sequence; FSE: fast spin echo DKI MT T1-weighted T2-weighted Imaging technique EPI GRE FSE FSE FSE Orientation transverse transverse sagittal sagittal transverse Repetition time(ms) 5466.0 6.5 653.0 1800.0 4056.0 Echo time(ms) 60.70 2.02 9.62 119.34 84.48 Field of view (mm 2 ) 160×280 160×280 380×300 380×300 150×200 Acquisition matrix 73×128 132×256 486×384 426×480 240×320 Flip angle(°) 90 9 120 120 120 Slice thickness (mm) 4.0 5.0 3.5 3.5 4.0 b values MT pulse 0, 1000, 2000 Gaussian envelop, Duration 10000µs Frequency offset 1,200 Hz - - - No. of averages 1, 2, 2 2 - - - Acquisition time 15 min 29 s 2 min 29 s 1 min 5 s 39.8 s *2 61 s *2 Imaging Analyses Quantitative MRI analysis Raw DKI images were transferred and processed using the UWS-MR post-processing workstation (United Imaging Healthcare), where mean kurtosis (MK) and axial kurtosis (KA) maps were generated for further analysis (Figs. 2 and 3 ). KA represents kurtosis aligned with the primary diffusion direction, whereas MK reflects the average kurtosis across all diffusion directions. MTR is expressed as a percentage and calculated by comparing the signal intensity of images acquired with and without a magnetization transfer pulse. The formula is as follows: $$\\:\\text{M}\\text{T}\\text{R}=\\frac{{MT}_{off}-{MT}_{on}}{{MT}_{off}}$$ Here, MToff denotes the signal intensity of the image acquired without the MT pulse, and MTon refers to the intensity with the MT pulse applied. The resulting ratio quantifies the extent of magnetization transfer in the tissue, providing a reliable indicator of myelin integrity. Region of interest (ROI) ROI analysis was performed using MRIcron software (v1.0.20190902, https://www.nitrc.org/projects/mricron/ ). For DKI analysis, an ROI mask was manually drawn around the caudal spinal cord just above the conus on the B0 map, using the T2-weighted image as an anatomical reference. This mask was applied to the co-registered MK and KA maps (Figs. 3 A–C). For MTR analysis, ROIs were also defined using T2-weighted images as anatomical references. MTR values were measured at three levels: the conus (MTR1) and the last two segmental levels of the caudal spinal cord (MTR2 and MTR3) (Fig. 3 D). Two neuroradiologists, with 10 and 4 years of experience in neuroimaging respectively, independently performed the measurements. The average of their readings was used for analysis and reporting. Statistical Analyses Since the JOA score does not include bowel dysfunction, this was analyzed as a separate variable. Additionally, bladder dysfunction is a critical symptom that plays an important role in guiding clinical management; therefore, it was also analyzed independently. Continuous variables were reported as means ± standard deviations and compared using independent Student’s t -tests or Fisher’s exact tests, as appropriate. Categorical variables were compared using the chi-square test or Fisher’s exact test, depending on data distribution. Interobserver agreements were assessed using intraclass correlation coefficients (ICC). The degree of agreement as interpreted using the following criteria: 0.8–1.0, excellent; 0.6–0.8, good; and < 0.6, poor. Spearman’s rank correlation was used to evaluate the association between postoperative recovery rate and radiographic metrics. The Mann–Whitney U test was applied to assess relationships between categorical and continuous variables. Multivariable linear regression and logistic regression analyses were conducted to identify independent predictors of recovery rate and postoperative improvement in bladder function. A p -value < 0.05 was considered statistically significant. Receiver operating characteristic (ROC) curve analyses were performed to evaluate the predictive performance of parameters independently associated with clinical outcomes. The area under the curve (AUC) and corresponding 95% confidence intervals were calculated for each parameter. Results Demographics, pre- and post-operative clinical symptoms 34 adult patients undergoing surgery for TCS performed preoperative imaging. The mean patient age was 34.88 ± 10.70 years, and 18 (52.94%) were male. The level of the conus was observed to be L1-2 or below. The mean duration of symptoms was 42.41 ± 51.51 months. On admission, 16 patients (47.06%) presented with lower back pain, 11 patients (32.35%) presented with leg pain or tingling, 9 patients (26.47%) presented with gait disturbance, 19 patients presented with sensory loss (55.88%), 13 patients (38.24%) presented with extremity motor weakness, 21 patients (61.76%) presented with urinary bladder dysfunction, 7 patients (20.59%) presented with bowel dysfunction. The median preoperative JOA lumbar score is 21.5 (Table 3 ). None of the patients experienced complication (including CSF leak, new neurological deficit, wound infection etc..). The mean length of hospital stay is 7 days. Patients were followed up for 12 months. Table 3 Comparisons of variables between patients with different clinical outcomes. DKI-KA: Diffusion kurtosis imaging, axial kurtosis; DKI-MK: Diffusion kurtosis imaging, mean kurtosis; MTR: magnetization transfer ratio Variables Total Recovery Rate P value Bladder Dysfunction P value < 50% (n = 9) ≥ 50% (n = 25) Improved (n = 12) No Change (n = 9) Age (Mean ± SD) 34.88 ± 10.70 36.44 ± 11.80 34.32 ± 10.48 0.617 29.58 ± 8.25 36.11 ± 11.88 0.153 Male No. (%) 18(52.94) 7(77.78) 9(36) 0.031* 5(41.67) 7(77.78) 0.098 Duration of Symptoms (month, Mean ± SD) 42.41 ± 51.51 53.22 ± 55.45 38.52 ± 50.63 0.471 38.17 ± 49.56 51.89 ± 55.97 0.559 Pre-operative JOA (Median, Range) 22(8–29) 25(23–29) 16(8–28) 0.002** 17.5(8–26) 22.5(13–25) 0.030* DKI-KA (Mean ± SD) 0.422 ± 0.024 0.391 ± 0.017 0.434 ± 0.014 < 0.001*** 0.432 ± 0.013 0.393 ± 0.020 < 0.001*** DKI-MK (Mean ± SD) 0.710 ± 0.101 0.766 ± 0.126 0.690 ± 0.084 0.050 0.700 ± 0.071 0.793 ± 0.099 0.021* MTR1 (Mean ± SD) 53.388 ± 3.096 52.578 ± 3.206 53.680 ± 3.069 0.368 52.608 ± 2.560 54.089 ± 1.680 0.149 MTR2 (Mean ± SD) 54.056 ± 1.572 52.411 ± 1.159 54.648 ± 1.254 < 0.001*** 53.958 ± 0.821 52.778 ± 1.119 0.012* MTR3 (Mean ± SD) 53.974 ± 1.445 52.523 ± 1.447 54.496 ± 1.049 0.003** 54.000 ± 0.704 52.779 ± 1.378 0.016* At the time of 12 months’ post-operative follow-up, patients experienced significant improvement (Table 2 ). The JOA score increased significantly from 21.5 (8–29) to 26.7 (23–29) (p < 0.001). The recovery rate (RR) ranged from 0–100% with a median rate of 73.21%. 9 patients had a RR < 50%. 25 patients had a RR ≥ 50%. Lower back pain was relieved in 14 out of 16 patients (87.5%). Leg pain or tingling was relieved in 11 out of 11 patients (100%). In 7 out of 9 patients (77.78%), gait disturbance was resolved. Sensory disturbance was improved in 11 patients (57.89%). Motor weakness was improved in 10 patients (76.92%). Among the 21 patients with pre-operative bladder dysfunction, 12(57.14%) were improved. All the patient showing improvement in bladder dysfunction were free of any bladder symptoms after the surgery. Table 2 Clinical symptoms before and after detethering surgery. JOA: Japanese Orthopaedic Association Symptoms No. (%) Pre-operative Post-operative Lower back pain 16(47.06) 9(26.47) Leg pain or tingling 11(32.35) 4(11.76) Gait disturbance 9(26.47) 3(8.82) Sensory loss 19(55.88) 9(26.47) Motor weakness 13(38.24) 6(17.65) Urinary bladder dysfunction 21(61.76) 9(26.47) Bowel dysfunction 7(20.59) 1(2.94) JOA score (Median, Range) 21.5(8–29) 26.7(23–29) Comparisons between patients with RR ≥ 50% and RR < 50% Patients with RR ≥ 50% and RR < 50% did not show significant difference in age (p = 0.617) and duration of the symptoms (p = 0.471). Patients with RR ≥ 50% have a significantly lower ratio of male sex (9/25, 36%) than patients with RR < 50% (7/9, 77.78%, p = 0.031). (Table 3 ) The ICCs of DKI and MTR parameters ranged from 0.791–0.913, which showed good to excellent agreement. The DKI KA value showed significant difference between patients with RR ≥ 50% and RR < 50% (0.391 ± 0.017 vs. 0.434 ± 0.014, p < 0.001). MTR2 (52.411 ± 1.159 vs. 54.648 ± 1.254, p < 0.001) and MTR3 (52.523 ± 1.447 vs. 54.496 ± 1.049, p = 0.003) showed significant differences between patients with RR ≥ 50% and RR < 50%. DKI MK value (p = 0.050) and MTR1 value (p = 0.368) did not show significant difference between two groups of patients. (Table 3 ) Correlations of demographic variables and MRI metrics with recovery rate Age (p = 0.789), sex(p = 0.506), and duration of the symptoms(p = 0.382) did not show significant correlation with recovery rate. Pre-operative JOA score showed significant negative correlation with recovery rate (ρ=-0.357, p = 0.038). DKI KA value is significantly correlated with recovery rate (ρ = 0.829, p < 0.001). DKI MK value showed significant negative correlation with recovery rate (ρ=-0.350, p = 0.042). MTR1 did not show significant correlation with recovery rate (ρ=-0.135, p = 0.447). MTR2 and MTR3 showed significant positive correlations with recovery rate (ρ = 0.691, p < 0.001; ρ = 0.669, p < 0.001). (Fig. 4 ) Comparisons between patients with improved bladder function and patients with no change in bladder dysfunction after the surgery Patients of these two groups did not show significant difference in age (p = 0.153), sex (p = 0.098), duration of the symptoms (p = 0.559). (Table 3 ) The pre-operative JOA score is significantly lower in patients with postoperatively improved bladder dysfunction than in patients with no change in bladder dysfunction after the surgery (p = 0.030). The DKI KA value and MK value showed significant differences between these two groups of patients (0.432 ± 0.013 vs. 0.393 ± 0.020, p < 0.001; 0.700 ± 0.071 vs. 0.793 ± 0.099, p = 0.021). MTR2 (53.958 ± 0.821 vs. 52.778 ± 1.119, p = 0.021) and MTR3 (54.000 ± 0.704 vs. 52.779 ± 1.378, p = 0.016) showed significant differences between two groups of patients. MTR1 value (p = 0.149) did not show significant difference between two groups of patients. (Table 3 ) Multivariate regressions analyzing factors associated with recovery rate and improved bladder function To identify independent factors associated with recovery rate, we performed multivariate linear regression and included pre-operative JOA score, DKI KA value, DKI MK value, MTR2 value, and MTR3 value into the analysis. Pre-operative JOA (p = 0.154), DKI MK value (p = 0.936), MTR1 value (p = 0.968), and MTR2 value (p = 0.702) were not significant independent variables. DKI KA value and MTR3 value were independently associated with recovery rate. Details of the multiple linear regression analysis were showed in Table 4 . Table 4 Independent factors associated with recovery rate. Variables β t P Adjusted R 2 of Model F of Model P of Model DKI-KA 0.534 3.304 0.003 0.744 20.201 < 0.001 MTR3 0.514 2.447 0.021 DKI-KA: Diffusion kurtosis imaging, axial kurtosis; DKI-MK: Diffusion kurtosis imaging, mean kurtosis; MTR: magnetization transfer ratio To identify independent factors associated with improved bladder function, we performed multivariate logistic regression. Pre-operative JOA score (p = 0.990), DKI KA value (p = 0.990), DKI MK value (p = 0.992), MTR2 value (p = 0.997), and MTR3 value (p = 0.988) were included into the analysis. None of the above variables is significant independent factor associated with improved bladder function. ROC analysis of independent factors associated with ≥ 50% recovery rate ROC analysis was performed to evaluate the predictive efficacy of the independent factors, including DKI KA and MTR3 values. The AUC of DKI KA is 0.971 (0.919-1.000). The AUC of MTR3 is 0.873(0.741-1.000). The results were showed in Fig. 5 . Discussion Our study is the first to investigate the use of DKI and MTR imaging in supporting clinical decision-making for adult patients with TCS. The integration of multiparametric quantitative MRI into clinical practice may offer valuable insights for predicting postoperative recovery and refining treatment strategies for this complex condition. We found that DKI metrics and MTR values of the tethered spinal cord were significantly associated with postoperative outcomes. These imaging biomarkers may help identify suitable surgical candidates among adult TCS patients. The application of quantitative MRI metrics in TCS remains relatively underexplored, especially in adult populations. Previous studies have primarily focused on morphological MRI features ( 3 , 13 ), which do not capture microstructural changes within the spinal cord. DKI extends beyond conventional DTI; whereas DTI models water diffusion as a Gaussian process, DKI accounts for non-Gaussian diffusion behaviors by incorporating kurtosis, which reflects the complexity and heterogeneity of tissue microstructure ( 7 ). Several studies have demonstrated that preoperative diffusion MRI metrics are associated with treatment outcomes in spinal cord disorders, including traumatic injury and cervical myelopathy ( 7 , 8 , 12 , 16 ). In TCS, pathological processes are secondary to mechanical stretching of the spinal cord and nerve roots, which can lead to reduced regional blood flow, impaired oxidative metabolism, alterations in neuronal membranes, myelinated axon damage, and ultimately, progressive fibrosis ( 17 ). A decreased KA value and increased MK (mean kurtosis) value may indicate microstructural damage such as axonal loss and demyelination. Our study demonstrated a positive correlation between KA values and RRs, and a negative correlation between MK values and RRs, suggesting that greater preoperative microstructural damage is associated with poorer surgical outcomes. These findings are consistent with previous research indicating that early surgical intervention in TCS leads to better neurological recovery ( 3 , 18 ). MTR provides a quantitative measure of myelin integrity ( 19 ), and MTR values of the spinal cord have been shown to correlate with its functional status. In patients with chronic spinal cord injury, MTR has been associated with both motor and sensory deficits as assessed by clinical evaluations ( 19 ). In our study, we measured MTR at three spinal cord segments above the conus. MTR values at the two higher levels were positively correlated with RRs, while no significant correlation was found between the lowest measured level and postoperative recovery. These findings suggest that neural damage caused by tethering may be associated with clinical outcomes. Consistent with previous studies investigating the role of MTR in predicting surgical outcomes in cervical myelopathy, our results also demonstrate that lower MTR values are associated with poorer postoperative outcomes ( 14 ). Our study is the first to apply DKI and MTR imaging in adult patients with TCS. The results suggest that DKI and MTR may provide objective biomarkers to support individualized clinical decision-making. We did not analyze the risk of potential retethering for several reasons. First, in adult patients considering detethering surgery, symptoms are typically severe or progressive, significantly impairing quality of life. Their primary concern is whether surgery will alleviate symptoms, rather than the long-term risk of retethering. Second, the risk of retethering is strongly associated with complex forms of TCS, such as those involving lipomyelomeningocele, myelomeningocele, or lumbosacral lipoma. In contrast, our study focused on patients with simple TCS, specifically those with a tight, thickened, or fatty filum. Prior studies have shown that the risk of retethering in this population is very low and unlikely to influence management decisions. Moreover, retethering is not directly related to the microstructural spinal cord damage that DKI and MTR are designed to detect. For instance, William Mualem et al. analyzed morphological MRI features, including anterior canal distance and spinal cord bending angle, in relation to postoperative outcomes ( 3 ). These parameters describe the spatial configuration of the spinal cord within the spinal canal and may be associated with retethering risk. In contrast, DKI and MTR are used to evaluate microstructural changes, such as myelin disruption. Stretching of the spinal cord can cause neuronal membrane alterations and damage to myelinated axons ( 17 ), which DKI and MTR are capable of detecting. There are several inherent limitations that should be addressed in future research. First, the follow-up duration in our study was relatively short, which limits our ability to assess long-term outcomes, such as symptom recurrence. However, previous studies have indicated that in patients with simple TCS, symptom recurrence is rare and typically occurs more than a decade after surgery. For most patients, the immediate concern is symptom relief. Second, our sample size was relatively small. Future studies with larger cohorts will be essential to validate our findings and further clarify the clinical utility of DKI and MTR. Additionally, integrating DKI and MTR with other imaging biomarkers may offer a more comprehensive understanding of TCS pathology and management. Exploring how these imaging metrics correlate with outcomes across diverse patient populations will also help optimize their application in clinical practice. Conclusions In conclusion, our study demonstrates the potential of multiparametric quantitative MRI—specifically DKI and MTR metrics—as valuable tools for predicting postoperative recovery in adult patients with tethered cord syndrome. These imaging biomarkers were significantly associated with clinical outcomes and may assist in identifying appropriate surgical candidates while avoiding unnecessary procedures. Abbreviations TCS tethered cord syndrome MRI Magnetic Resonance Imaging DKI diffusional kurtosis imaging DWI Diffusion-weighted imaging DTI Diffusion tensor imaging MTR magnetization transfer ratio JOA Japanese Orthopaedic Association RR Recovery Rate ROC Receiver operating characteristic AUC Area under the curve FSE Fast spin echo GRE Gradient echo ROI Region of interest ICC intraclass correlation coefficients Declarations Clinical Trial Number Not applicable. This study is not a clinical trial. Ethics approval and consent to participate The study was approved by the Institutional Ethic Board (reference number M2022457). Informed consent was acquired from all recruited participants. Name of the ethics committee: Peking University Third Hospital Ethics Committee Consent for publication Not applicable Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests Yuxin Yang, Dan Yu, Shipei He are employees of Research Institute of Intelligent Imaging. The other authors declare that they have no competing interests. Funding This research is not supported by any funding. Authors' contributions X.S., C.W, Y.Z., H.J. designed the research, had major contribution in data acquisition, analysis, interpretation, and have drafted the manuscript. G.Z. and J.X. had substantial contribution in data acquisition. Y.Y., D.Y., S.H. had substantial contribution in data acquisition and substantially revised the manuscript. B.L., Y.L., H.Y. had major contribution in design of the research, management of the research, data analysis, and manuscript revision. All of the above authors have approved the submitted version and. All of the above authors have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work. 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European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2023;32(3):986-93. Bian B, Zhou B, Shao Z, Zhu X, Jie Y, Li D. Feasibility of diffusion kurtosis imaging in evaluating cervical spinal cord injury in multiple sclerosis. Medicine. 2023;102(29):e34205. Paliwal M, Weber KA, 2nd, Hopkins BS, Cantrell DR, Hoggarth MA, Elliott JM, et al. Magnetization Transfer Ratio and Morphometrics of the Spinal Cord Associates with Surgical Recovery in Patients with Degenerative Cervical Myelopathy. World neurosurgery. 2020;144:e939-e47. Fujimori T, Okuda S, Iwasaki M, Yamasaki R, Maeno T, Yamashita T, et al. Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion. The spine journal : official journal of the North American Spine Society. 2016;16(6):728-36. Ahmed RU, Medina-Aguinaga D, Adams S, Knibbe CA, Morgan M, Gibson D, et al. Predictive values of spinal cord diffusion magnetic resonance imaging to characterize outcomes after contusion injury. Annals of clinical and translational neurology. 2023;10(9):1647-61. Yamada S, Won DJ, Pezeshkpour G, Yamada BS, Yamada SM, Siddiqi J, et al. Pathophysiology of tethered cord syndrome and similar complex disorders. Neurosurgical focus. 2007;23(2):E6. Lapsiwala SB, Iskandar BJ. The tethered cord syndrome in adults with spina bifida occulta. Neurological research. 2004;26(7):735-40. Cohen-Adad J, El Mendili MM, Lehéricy S, Pradat PF, Blancho S, Rossignol S, et al. Demyelination and degeneration in the injured human spinal cord detected with diffusion and magnetization transfer MRI. NeuroImage. 2011;55(3):1024-33. Additional Declarations Competing interest reported. Yuxin Yang, Dan Yu, Shipei He are employees of Research Institute of Intelligent Imaging. The other authors declare that they have no competing interests. Supplementary Files SupplementaryTable1.docx Supplementary Table 1. Japanese Orthopaedic Association (JOA) scoring system for assessment of the results of treatment for low back pain. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-7027483\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":516643838,\"identity\":\"a5146796-4489-4870-b489-10924798dc45\",\"order_by\":0,\"name\":\"Xingwen Sun\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Peking University Third Hospital\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Xingwen\",\"middleName\":\"\",\"lastName\":\"Sun\",\"suffix\":\"\"},{\"id\":516643839,\"identity\":\"b4c24837-d796-4d4c-beea-8c3630cbee58\",\"order_by\":1,\"name\":\"Chao 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recruitment.\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/ac7439f19fb023bfa16ee470.jpg\"},{\"id\":91829616,\"identity\":\"7466c18b-cacf-4e39-90ea-5b118f22c035\",\"added_by\":\"auto\",\"created_at\":\"2025-09-22 08:56:23\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":841265,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eDemonstration of measurements of DKI (yellow slices) values and MTR (green slices) values.\\u003c/strong\\u003e (A) Sagittal T2-weighted image demonstrates low-lying conus. DKI values were measured on the cord right above the conus (yellow). MTR values were measured three levels above the conus (green). (B-C) Fiber tracking of DKI imaging with demonstration of measured segments.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/30f989069f082c8291c330e3.jpg\"},{\"id\":91830541,\"identity\":\"efe02981-ca67-45d4-bbf4-8d0e90207e51\",\"added_by\":\"auto\",\"created_at\":\"2025-09-22 09:04:23\",\"extension\":\"jpg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":604973,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eMeasurements of KA, MK, and MTR values. \\u003c/strong\\u003e(A-C)\\u003cstrong\\u003e \\u003c/strong\\u003eROI mask (yellow ellipse) was created on the B0 map and was applied on co-registered MK and KA maps\\u003cstrong\\u003e. \\u003c/strong\\u003e(D) For MTR measurement, ROI was drawn on MTR map (yellow ellipse).\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig3.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/5cf50a919221e1ddf29c38d5.jpg\"},{\"id\":91829617,\"identity\":\"43f2861a-3f06-4c4f-80a4-b3dc14dabcdd\",\"added_by\":\"auto\",\"created_at\":\"2025-09-22 08:56:23\",\"extension\":\"jpg\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":562528,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eFactors showing significant correlations with recovery rates.\\u003c/strong\\u003e (A) Pre-operative JOA score showed significant negative correlation with recovery rate (ρ=-0.357, p=0.038). (B) DKI-KA value is significantly correlated with recovery rate (ρ= 0.829, p\\u0026lt;0.001). (C) DKI-MK value showed significant negative correlation with recovery rate (ρ=-0.350, p=0.042). (D-E) MTR2 and MTR3 showed significant positive correlations with recovery rate (ρ=0.691, p\\u0026lt;0.001; ρ=0.669, p\\u0026lt;0.001)\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig4.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/d8bc4a31a1c31ca8118e1434.jpg\"},{\"id\":91829624,\"identity\":\"99ac3e1a-e1ff-4cb1-8b9b-be9e47c608b6\",\"added_by\":\"auto\",\"created_at\":\"2025-09-22 08:56:23\",\"extension\":\"jpg\",\"order_by\":5,\"title\":\"Figure 5\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":63135,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eROC analysis of DKI-MK and MTR3.\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"Fig5.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/47b128d097ffc90808f0f716.jpg\"},{\"id\":108081083,\"identity\":\"5b974972-3d34-4bae-95a8-dd1d3d031c2d\",\"added_by\":\"auto\",\"created_at\":\"2026-04-29 07:41:37\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":3255354,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/08491011-ba74-4c44-8ff0-1b51630c6295.pdf\"},{\"id\":91829613,\"identity\":\"0d53aee2-87e8-4734-b32e-5297cd6b0217\",\"added_by\":\"auto\",\"created_at\":\"2025-09-22 08:56:23\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":22705,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003e\\u003cstrong\\u003eSupplementary Table 1. Japanese Orthopaedic Association (JOA) scoring system for assessment of the results of treatment for low back pain.\\u003c/strong\\u003e\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"SupplementaryTable1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-7027483/v1/cb9432df28c6a67ce8db077d.docx\"}],\"financialInterests\":\"Competing interest reported. Yuxin Yang, Dan Yu, Shipei He are employees of Research Institute of Intelligent Imaging. The other authors declare that they have no competing interests.\",\"formattedTitle\":\"Utilizing pre-operative quantitative radiological imaging to predict surgical outcomes following untethering for adult tethered cord syndrome\",\"fulltext\":[{\"header\":\"Background\",\"content\":\"\\u003cp\\u003eThe tethered cord syndrome (TCS) is a neurological disorder characterized by abnormal attachment of the spinal cord, typically toward the caudal end of the spine, resulting in tension-induced dysfunction of the conus medullaris and lower spinal cord(\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Common symptoms include back and pelvic pain, bowel and bladder dysfunction, lower extremity weakness or atrophy, and sensory loss or numbness (\\u003cspan class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eUsually diagnosed in childhood, adult tethered cord syndrome has been recognized as a definite clinical entity only in the past decades. Untethering surgery has demonstrated beneficial outcomes in pediatric patients with TCS (\\u003cspan class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). However, its role in adult patients remains controversial(\\u003cspan class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Clinical decision-making is complex due to the variability in postoperative outcomes. In asymptomatic adults with TCS, surgical intervention is generally not recommended, as many of these individuals may remain symptom-free throughout their lives. For symptomatic adults, the decision to pursue surgery remains inconclusive(\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e). While some patients experience partial or complete symptom relief following surgery, others show no improvement or may even experience clinical deterioration. Previous studies have reported pain relief in 78\\u0026ndash;100% of patients(\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e)., improvement in bladder function in 3\\u0026ndash;66.6%(\\u003cspan class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e), motor function in 25\\u0026ndash;64% (\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e), and sensory symptoms in approximately 50%(\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). Conversely, 2.2\\u0026ndash;3.7% of patients may experience worsening of symptoms postoperatively(\\u003cspan class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e).\\u003c/p\\u003e\\n\\u003cp\\u003eEfforts have been made to use imaging characteristics to predict surgical outcomes. A study by Mualem et al. (\\u003cspan class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) demonstrated that anterior canal distance and the bending angle of the lower spinal cord were associated with an increased risk of reoperation. However, this study focused exclusively on pediatric patients. To date, no well-defined radiological markers have been established in the literature to predict surgical outcomes in adults with TCS. Study investigating correlations of MRI findings with postoperative recovery in adult TCS patients is absent due to its rareness.\\u003c/p\\u003e\\n\\u003cp\\u003eDiffusion-weighted imaging (DWI) is a sensitive technique for detecting microstructural changes in the spinal cord (\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e\\u0026ndash;\\u003cspan class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e). A prospective cross-sectional study has shown that diffusion tensor imaging (DTI) metrics correlate with neurological outcome scores in TCS (\\u003cspan class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e). While DTI is based on the assumption of homogeneous Gaussian water diffusion, diffusional kurtosis imaging (DKI) is a more advanced technique that measures non-Gaussian water diffusion, offering a more accurate reflection of tissue microstructure (\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). DKI has been applied to various spinal cord disorders, including degenerative myelopathy, traumatic injury, and demyelinating diseases, and has demonstrated correlations with both neurological impairment and postoperative outcomes(\\u003cspan class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e\\u0026ndash;\\u003cspan class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). However, to our knowledge, no studies have explored the relationship between DKI metrics and surgical outcomes in TCS.\\u003c/p\\u003e\\n\\u003cp\\u003eMagnetization transfer ratio (MTR) is a well-established marker of myelin integrity. MT imaging has been used to quantify spinal cord injury and assist in clinical decision-making in various neurological conditions (\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e\\u0026ndash;\\u003cspan class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e). In this study, we aim to evaluate the utility of DKI and MTR metrics in predicting surgical outcomes in adult patients with TCS.\\u003c/p\\u003e\"},{\"header\":\"Methods\",\"content\":\"\\u003cp\\u003e\\u003cb\\u003eStudy Population\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eFrom June 2022 to March 2025, we prospectively recruited 57 adult patients with TCS who underwent untethering surgery. Patients with low-lying syrinx or diastematomyelia were excluded because the T2 hyperintensity of syrinxes could interfere with the measurement of DKI and MTR values, and diastematomyelia often provides insufficient cross-sectional area for reliable measurements. We also excluded patients with TCS associated with lipomyelomeningocele, myelomeningocele, or lumbosacral lipoma, as the complexity of these conditions significantly affects postoperative outcomes. Only patients with tethering related to a tight, thickened, or fatty filum were included for analysis.\\u003c/p\\u003e\\u003cp\\u003eFigure \\u003cspan refid=\\\"Fig1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e presents the flowchart of patient recruitment. Ultimately, 34 patients with tethering due to a tight, thickened, or fatty filum were included in the final analysis. Additionally, we recruited 20 age- and sex-matched healthy volunteers without any neurological disorders to serve as controls.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eEthics\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e This study was performed in accordance with the principles of the Declaration of Helsinki. The study was approved by the Institutional Ethic Board (reference number M2022457). Informed consent was acquired from all recruited participants.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eClinical Assessment\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003ePatients were included based on the following criteria: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Diagnosis of TCS with progressive symptoms and a clinical recommendation for detethering surgery by a neurosurgeon. (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) No history of previous detethering surgery. (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) TCS associated only with a tight, thickened, or fatty filum.\\u003c/p\\u003e\\u003cp\\u003eExclusion criteria are as following: (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e) Contraindications to MRI. (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e) TCS associated with diastematomyelia, lipomyelomeningocele, myelomeningocele, or lumbosacral lipoma. (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e) History of prior detethering surgery.\\u003c/p\\u003e\\u003cp\\u003eDemographic and clinical data—including age, sex, presence of back or leg pain, gait disturbance, sensory deficits, motor weakness, urinary bladder dysfunction, and bowel dysfunction—were recorded. Urodynamic examinations were conducted to objectively assess urinary bladder dysfunction. The final follow-up was conducted 12 months after surgery.\\u003c/p\\u003e\\u003cp\\u003eTo evaluate sensorimotor symptoms and urinary dysfunction before and after detethering, we used the Japanese Orthopaedic Association (JOA) scoring system (\\u003cspan citationid=\\\"CR15\\\" class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e) (Supplementary Table\\u0026nbsp;1). The recovery rate (RR) was calculated using the following formula:\\u003c/p\\u003e\\u003cp\\u003eRecovery rate (%) = (Postoperative score − Preoperative score) / (29 − Preoperative score) × 100\\u003c/p\\u003e\\u003cp\\u003eBased on the RR, patients were divided into two groups: those with RR ≥ 50% and those with RR \\u0026lt; 50%. An RR \\u0026lt; 50% was considered indicative of limited surgical benefit.\\u003c/p\\u003e\\u003cp\\u003eIn the JOA scoring system, urinary bladder function is classified into three categories: normal, mild dysuria, and severe dysuria. Patients reporting pollakiuria, hesitancy, a sense of incomplete emptying, or small residual urine volume on urodynamic testing were categorized as having mild dysuria. Patients with urinary retention, large residual urine volume on urodynamic testing, or incontinence were classified as having severe dysuria.\\u003c/p\\u003e\\u003cp\\u003eBowel function was graded as follows:\\u003c/p\\u003e\\u003cp\\u003e0 – Bowel incontinence\\u003c/p\\u003e\\u003cp\\u003e1 – Altered bowel movement frequency\\u003c/p\\u003e\\u003cp\\u003e2 – Normal bowel function\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eImaging Technique\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eAll MRI scans were performed preoperatively using a 3.0T scanner (uMR880, United Imaging Healthcare, Shanghai, China) equipped with a commercial 48-channel spine coil. Conventional sequences included sagittal T1-weighted (T1WI) fast spin echo (FSE) and T2-weighted FSE sequences in both axial and sagittal planes. Diffusion kurtosis imaging (DKI) and magnetization transfer (MT) imaging were conducted for the caudal spinal cord and conus medullaris. DKI was performed using a conventional diffusion tensor imaging (DTI) protocol with three b-values applied in 32 directions. MT imaging was conducted using a gradient echo (GRE) sequence with an MT preparation pulse, followed by the same GRE sequence without the MT pulse to serve as a reference. All imaging parameters are listed in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab1\\\" class=\\\"InternalRef\\\"\\u003e1\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab1\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 1\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eParameters of MRI sequences.\\u003c/b\\u003e DKI: diffusion kurtosis imaging; MTR: magnetization transfer ratio; EPI: echo planer imaging; GRE: gradient echo sequence; FSE: fast spin echo\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003c/colgroup\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eDKI\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eMT\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eT1-weighted\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e\\u003cp\\u003eT2-weighted\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eImaging technique\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eEPI\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eGRE\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eFSE\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eFSE\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eFSE\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eOrientation\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003etransverse\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003etransverse\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003esagittal\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003esagittal\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003etransverse\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eRepetition time(ms)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e5466.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e6.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e653.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e1800.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e4056.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eEcho time(ms)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e60.70\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2.02\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e9.62\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e119.34\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e84.48\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eField of view (mm\\u003c/b\\u003e\\u003csup\\u003e\\u003cb\\u003e2\\u003c/b\\u003e\\u003c/sup\\u003e\\u003cb\\u003e)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e160×280\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e160×280\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e380×300\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e380×300\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e150×200\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eAcquisition matrix\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e73×128\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e132×256\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e486×384\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e426×480\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e240×320\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eFlip angle(°)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e90\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e9\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e120\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e120\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e120\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eSlice thickness (mm)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e4.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e5.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e3.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e3.5\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e4.0\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eb values\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMT pulse\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0, 1000, 2000\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003eGaussian envelop, Duration 10000µs\\u003c/p\\u003e\\u003cp\\u003eFrequency\\u003c/p\\u003e\\u003cp\\u003eoffset 1,200 Hz\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e-\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e-\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e-\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eNo. of averages\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e1, 2, 2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e-\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e-\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e-\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eAcquisition time\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e15 min 29 s\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e2 min 29 s\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e1 min 5 s\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e39.8 s *2\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e61 s *2\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003cp\\u003e\\u003cb\\u003eImaging Analyses\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eQuantitative MRI analysis\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eRaw DKI images were transferred and processed using the UWS-MR post-processing workstation (United Imaging Healthcare), where mean kurtosis (MK) and axial kurtosis (KA) maps were generated for further analysis (Figs.\\u0026nbsp;\\u003cspan refid=\\\"Fig2\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e and \\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). KA represents kurtosis aligned with the primary diffusion direction, whereas MK reflects the average kurtosis across all diffusion directions.\\u003c/p\\u003e\\u003cp\\u003eMTR is expressed as a percentage and calculated by comparing the signal intensity of images acquired with and without a magnetization transfer pulse. The formula is as follows:\\u003c/p\\u003e\\u003cdiv id=\\\"Equa\\\" class=\\\"Equation\\\"\\u003e\\u003cdiv format=\\\"TEX\\\" class=\\\"mathdisplay\\\" id=\\\"FileID_Equa\\\" name=\\\"EquationSource\\\"\\u003e\\n$$\\\\:\\\\text{M}\\\\text{T}\\\\text{R}=\\\\frac{{MT}_{off}-{MT}_{on}}{{MT}_{off}}$$\\u003c/div\\u003e\\u003c/div\\u003e\\u003cp\\u003eHere, MToff denotes the signal intensity of the image acquired without the MT pulse, and MTon refers to the intensity with the MT pulse applied. The resulting ratio quantifies the extent of magnetization transfer in the tissue, providing a reliable indicator of myelin integrity.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eRegion of interest (ROI)\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eROI analysis was performed using MRIcron software (v1.0.20190902, \\u003cspan class=\\\"ExternalRef\\\"\\u003e\\u003cspan class=\\\"RefSource\\\"\\u003ehttps://www.nitrc.org/projects/mricron/\\u003c/span\\u003e\\u003cspan address=\\\"https://www.nitrc.org/projects/mricron/\\\" targettype=\\\"URL\\\" class=\\\"RefTarget\\\"\\u003e\\u003c/span\\u003e\\u003c/span\\u003e). For DKI analysis, an ROI mask was manually drawn around the caudal spinal cord just above the conus on the B0 map, using the T2-weighted image as an anatomical reference. This mask was applied to the co-registered MK and KA maps (Figs.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eA–C). For MTR analysis, ROIs were also defined using T2-weighted images as anatomical references. MTR values were measured at three levels: the conus (MTR1) and the last two segmental levels of the caudal spinal cord (MTR2 and MTR3) (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig3\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003eD).\\u003c/p\\u003e\\u003cp\\u003eTwo neuroradiologists, with 10 and 4 years of experience in neuroimaging respectively, independently performed the measurements. The average of their readings was used for analysis and reporting.\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eStatistical Analyses\\u003c/b\\u003e\\u003c/p\\u003e\\u003cp\\u003eSince the JOA score does not include bowel dysfunction, this was analyzed as a separate variable. Additionally, bladder dysfunction is a critical symptom that plays an important role in guiding clinical management; therefore, it was also analyzed independently.\\u003c/p\\u003e\\u003cp\\u003eContinuous variables were reported as means ± standard deviations and compared using independent Student’s \\u003cem\\u003et\\u003c/em\\u003e-tests or Fisher’s exact tests, as appropriate. Categorical variables were compared using the chi-square test or Fisher’s exact test, depending on data distribution. Interobserver agreements were assessed using intraclass correlation coefficients (ICC). The degree of agreement as interpreted using the following criteria: 0.8–1.0, excellent; 0.6–0.8, good; and \\u0026lt; 0.6, poor.\\u003c/p\\u003e\\u003cp\\u003eSpearman’s rank correlation was used to evaluate the association between postoperative recovery rate and radiographic metrics. The Mann–Whitney \\u003cem\\u003eU\\u003c/em\\u003e test was applied to assess relationships between categorical and continuous variables.\\u003c/p\\u003e\\u003cp\\u003eMultivariable linear regression and logistic regression analyses were conducted to identify independent predictors of recovery rate and postoperative improvement in bladder function. A \\u003cem\\u003ep\\u003c/em\\u003e-value \\u0026lt; 0.05 was considered statistically significant.\\u003c/p\\u003e\\u003cp\\u003eReceiver operating characteristic (ROC) curve analyses were performed to evaluate the predictive performance of parameters independently associated with clinical outcomes. The area under the curve (AUC) and corresponding 95% confidence intervals were calculated for each parameter.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003e\\u003cem\\u003eDemographics, pre- and post-operative clinical symptoms\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003e34 adult patients undergoing surgery for TCS performed preoperative imaging. The mean patient age was 34.88\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10.70 years, and 18 (52.94%) were male. The level of the conus was observed to be L1-2 or below. The mean duration of symptoms was 42.41\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;51.51 months.\\u003c/p\\u003e\\u003cp\\u003eOn admission, 16 patients (47.06%) presented with lower back pain, 11 patients (32.35%) presented with leg pain or tingling, 9 patients (26.47%) presented with gait disturbance, 19 patients presented with sensory loss (55.88%), 13 patients (38.24%) presented with extremity motor weakness, 21 patients (61.76%) presented with urinary bladder dysfunction, 7 patients (20.59%) presented with bowel dysfunction. The median preoperative JOA lumbar score is 21.5 (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e). None of the patients experienced complication (including CSF leak, new neurological deficit, wound infection etc..). The mean length of hospital stay is 7 days. Patients were followed up for 12 months.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab2\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 3\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eComparisons of variables between patients with different clinical outcomes.\\u003c/b\\u003e DKI-KA: Diffusion kurtosis imaging, axial kurtosis; DKI-MK: Diffusion kurtosis imaging, mean kurtosis; MTR: magnetization transfer ratio\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"8\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c8\\\" colnum=\\\"8\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eVariables\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003eTotal\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c4\\\" namest=\\\"c3\\\"\\u003e\\u003cp\\u003eRecovery Rate\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eP value\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colspan=\\\"2\\\" nameend=\\\"c7\\\" namest=\\\"c6\\\"\\u003e\\u003cp\\u003eBladder Dysfunction\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003eP value\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;50%\\u003c/p\\u003e\\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u0026ge;\\u0026thinsp;50%\\u003c/p\\u003e\\u003cp\\u003e(n\\u0026thinsp;=\\u0026thinsp;25)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003eImproved (n\\u0026thinsp;=\\u0026thinsp;12)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003eNo Change (n\\u0026thinsp;=\\u0026thinsp;9)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c8\\\"\\u003e\\u0026nbsp;\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eAge (Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e34.88\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10.70\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e36.44\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;11.80\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e34.32\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;10.48\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.617\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e29.58\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;8.25\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e36.11\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;11.88\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.153\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMale No. (%)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e18(52.94)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e7(77.78)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e9(36)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.031*\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e5(41.67)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e7(77.78)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.098\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eDuration of Symptoms (month, Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e42.41\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;51.51\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e53.22\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;55.45\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e38.52\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;50.63\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.471\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e38.17\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;49.56\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e51.89\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;55.97\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.559\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003ePre-operative JOA (Median, Range)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e22(8\\u0026ndash;29)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e25(23\\u0026ndash;29)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e16(8\\u0026ndash;28)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.002**\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e17.5(8\\u0026ndash;26)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e22.5(13\\u0026ndash;25)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.030*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eDKI-KA (Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.422\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.024\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.391\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.017\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.434\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.014\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e0.432\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.013\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.393\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.020\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001***\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eDKI-MK (Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.710\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.101\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e0.766\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.126\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.690\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.084\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.050\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e0.700\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.071\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e0.793\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.099\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.021*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMTR1 (Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e53.388\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.096\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e52.578\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.206\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e53.680\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;3.069\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.368\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e52.608\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;2.560\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e54.089\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.680\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.149\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMTR2 (Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e54.056\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.572\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e52.411\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.159\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e54.648\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.254\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001***\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e53.958\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.821\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e52.778\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.119\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.012*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMTR3 (Mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;SD)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e53.974\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.445\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e52.523\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.447\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e54.496\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.049\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003e0.003**\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e54.000\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.704\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e52.779\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.378\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c8\\\"\\u003e\\u003cp\\u003e0.016*\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eAt the time of 12 months\\u0026rsquo; post-operative follow-up, patients experienced significant improvement (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab3\\\" class=\\\"InternalRef\\\"\\u003e2\\u003c/span\\u003e). The JOA score increased significantly from 21.5 (8\\u0026ndash;29) to 26.7 (23\\u0026ndash;29) (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). The recovery rate (RR) ranged from 0\\u0026ndash;100% with a median rate of 73.21%. 9 patients had a RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50%. 25 patients had a RR\\u0026thinsp;\\u0026ge;\\u0026thinsp;50%. Lower back pain was relieved in 14 out of 16 patients (87.5%). Leg pain or tingling was relieved in 11 out of 11 patients (100%). In 7 out of 9 patients (77.78%), gait disturbance was resolved. Sensory disturbance was improved in 11 patients (57.89%). Motor weakness was improved in 10 patients (76.92%). Among the 21 patients with pre-operative bladder dysfunction, 12(57.14%) were improved. All the patient showing improvement in bladder dysfunction were free of any bladder symptoms after the surgery.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab3\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 2\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eClinical symptoms before and after detethering surgery.\\u003c/b\\u003e JOA: Japanese Orthopaedic Association\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"3\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eSymptoms No. (%)\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003ePre-operative\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003ePost-operative\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eLower back pain\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e16(47.06)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e9(26.47)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eLeg pain or tingling\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e11(32.35)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e4(11.76)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eGait disturbance\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e9(26.47)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3(8.82)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eSensory loss\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e19(55.88)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e9(26.47)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMotor weakness\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e13(38.24)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e6(17.65)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eUrinary bladder dysfunction\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e21(61.76)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e9(26.47)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eBowel dysfunction\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e7(20.59)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e1(2.94)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eJOA score (Median, Range)\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e21.5(8\\u0026ndash;29)\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e26.7(23\\u0026ndash;29)\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eComparisons between patients with RR\\u0026thinsp;\\u0026ge;\\u0026thinsp;50% and RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50%\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003ePatients with RR\\u0026thinsp;\\u0026ge;\\u0026thinsp;50% and RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50% did not show significant difference in age (p\\u0026thinsp;=\\u0026thinsp;0.617) and duration of the symptoms (p\\u0026thinsp;=\\u0026thinsp;0.471). Patients with RR\\u0026thinsp;\\u0026ge;\\u0026thinsp;50% have a significantly lower ratio of male sex (9/25, 36%) than patients with RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50% (7/9, 77.78%, p\\u0026thinsp;=\\u0026thinsp;0.031). (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003eThe ICCs of DKI and MTR parameters ranged from 0.791\\u0026ndash;0.913, which showed good to excellent agreement. The DKI KA value showed significant difference between patients with RR\\u0026thinsp;\\u0026ge;\\u0026thinsp;50% and RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50% (0.391\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.017 vs. 0.434\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.014, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). MTR2 (52.411\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.159 vs. 54.648\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.254, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and MTR3 (52.523\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.447 vs. 54.496\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.049, p\\u0026thinsp;=\\u0026thinsp;0.003) showed significant differences between patients with RR\\u0026thinsp;\\u0026ge;\\u0026thinsp;50% and RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50%. DKI MK value (p\\u0026thinsp;=\\u0026thinsp;0.050) and MTR1 value (p\\u0026thinsp;=\\u0026thinsp;0.368) did not show significant difference between two groups of patients. (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eCorrelations of demographic variables and MRI metrics with recovery rate\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eAge (p\\u0026thinsp;=\\u0026thinsp;0.789), sex(p\\u0026thinsp;=\\u0026thinsp;0.506), and duration of the symptoms(p\\u0026thinsp;=\\u0026thinsp;0.382) did not show significant correlation with recovery rate. Pre-operative JOA score showed significant negative correlation with recovery rate (ρ=-0.357, p\\u0026thinsp;=\\u0026thinsp;0.038). DKI KA value is significantly correlated with recovery rate (ρ\\u0026thinsp;=\\u0026thinsp;0.829, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). DKI MK value showed significant negative correlation with recovery rate (ρ=-0.350, p\\u0026thinsp;=\\u0026thinsp;0.042). MTR1 did not show significant correlation with recovery rate (ρ=-0.135, p\\u0026thinsp;=\\u0026thinsp;0.447). MTR2 and MTR3 showed significant positive correlations with recovery rate (ρ\\u0026thinsp;=\\u0026thinsp;0.691, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; ρ\\u0026thinsp;=\\u0026thinsp;0.669, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). (Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eComparisons between patients with improved bladder function and patients with no change in bladder dysfunction after the surgery\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003ePatients of these two groups did not show significant difference in age (p\\u0026thinsp;=\\u0026thinsp;0.153), sex (p\\u0026thinsp;=\\u0026thinsp;0.098), duration of the symptoms (p\\u0026thinsp;=\\u0026thinsp;0.559). (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003eThe pre-operative JOA score is significantly lower in patients with postoperatively improved bladder dysfunction than in patients with no change in bladder dysfunction after the surgery (p\\u0026thinsp;=\\u0026thinsp;0.030). The DKI KA value and MK value showed significant differences between these two groups of patients (0.432\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.013 vs. 0.393\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.020, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001; 0.700\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.071 vs. 0.793\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.099, p\\u0026thinsp;=\\u0026thinsp;0.021). MTR2 (53.958\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.821 vs. 52.778\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.119, p\\u0026thinsp;=\\u0026thinsp;0.021) and MTR3 (54.000\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.704 vs. 52.779\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.378, p\\u0026thinsp;=\\u0026thinsp;0.016) showed significant differences between two groups of patients. MTR1 value (p\\u0026thinsp;=\\u0026thinsp;0.149) did not show significant difference between two groups of patients. (Table\\u0026nbsp;\\u003cspan refid=\\\"Tab2\\\" class=\\\"InternalRef\\\"\\u003e3\\u003c/span\\u003e)\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eMultivariate regressions analyzing factors associated with recovery rate and improved bladder function\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eTo identify independent factors associated with recovery rate, we performed multivariate linear regression and included pre-operative JOA score, DKI KA value, DKI MK value, MTR2 value, and MTR3 value into the analysis. Pre-operative JOA (p\\u0026thinsp;=\\u0026thinsp;0.154), DKI MK value (p\\u0026thinsp;=\\u0026thinsp;0.936), MTR1 value (p\\u0026thinsp;=\\u0026thinsp;0.968), and MTR2 value (p\\u0026thinsp;=\\u0026thinsp;0.702) were not significant independent variables. DKI KA value and MTR3 value were independently associated with recovery rate. Details of the multiple linear regression analysis were showed in Table\\u0026nbsp;\\u003cspan refid=\\\"Tab4\\\" class=\\\"InternalRef\\\"\\u003e4\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003cdiv class=\\\"gridtable\\\"\\u003e\\u003ctable float=\\\"Yes\\\" id=\\\"Tab4\\\" border=\\\"1\\\"\\u003e\\u003ccaption language=\\\"En\\\"\\u003e\\u003cdiv class=\\\"CaptionNumber\\\"\\u003eTable 4\\u003c/div\\u003e\\u003cdiv class=\\\"CaptionContent\\\"\\u003e\\u003cp\\u003eIndependent factors associated with recovery rate.\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/caption\\u003e\\u003ccolgroup cols=\\\"7\\\"\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c1\\\" colnum=\\\"1\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c2\\\" colnum=\\\"2\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c3\\\" colnum=\\\"3\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"char\\\" char=\\\".\\\" class=\\\"colspec\\\" colname=\\\"c4\\\" colnum=\\\"4\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c5\\\" colnum=\\\"5\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c6\\\" colnum=\\\"6\\\"\\u003e\\u003c/div\\u003e\\u003cdiv align=\\\"left\\\" class=\\\"colspec\\\" colname=\\\"c7\\\" colnum=\\\"7\\\"\\u003e\\u003c/div\\u003e\\u003cthead\\u003e\\u003ctr\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003eVariables\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eβ\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003et\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c5\\\"\\u003e\\u003cp\\u003eAdjusted \\u003cem\\u003eR\\u003c/em\\u003e\\u003csup\\u003e\\u003cem\\u003e2\\u003c/em\\u003e\\u003c/sup\\u003e of Model\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c6\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eF\\u003c/em\\u003e of Model\\u003c/p\\u003e\\u003c/th\\u003e\\u003cth align=\\\"left\\\" colname=\\\"c7\\\"\\u003e\\u003cp\\u003e\\u003cem\\u003eP\\u003c/em\\u003e of Model\\u003c/p\\u003e\\u003c/th\\u003e\\u003c/tr\\u003e\\u003c/thead\\u003e\\u003ctbody\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eDKI-KA\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.534\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e3.304\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.003\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c5\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003e0.744\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c6\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003e20.201\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c7\\\" morerows=\\\"1\\\" rowspan=\\\"2\\\"\\u003e\\u003cp\\u003e\\u0026lt;\\u0026thinsp;0.001\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003ctr\\u003e\\u003ctd align=\\\"left\\\" colname=\\\"c1\\\"\\u003e\\u003cp\\u003e\\u003cb\\u003eMTR3\\u003c/b\\u003e\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c2\\\"\\u003e\\u003cp\\u003e0.514\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c3\\\"\\u003e\\u003cp\\u003e2.447\\u003c/p\\u003e\\u003c/td\\u003e\\u003ctd align=\\\"char\\\" char=\\\".\\\" colname=\\\"c4\\\"\\u003e\\u003cp\\u003e0.021\\u003c/p\\u003e\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tbody\\u003e\\u003c/colgroup\\u003e\\u003ctfoot\\u003e\\u003ctr\\u003e\\u003ctd colspan=\\\"7\\\"\\u003eDKI-KA: Diffusion kurtosis imaging, axial kurtosis; DKI-MK: Diffusion kurtosis imaging, mean kurtosis; MTR: magnetization transfer ratio\\u003c/td\\u003e\\u003c/tr\\u003e\\u003c/tfoot\\u003e\\u003c/table\\u003e\\u003c/div\\u003e\\u003c/p\\u003e\\u003cp\\u003eTo identify independent factors associated with improved bladder function, we performed multivariate logistic regression. Pre-operative JOA score (p\\u0026thinsp;=\\u0026thinsp;0.990), DKI KA value (p\\u0026thinsp;=\\u0026thinsp;0.990), DKI MK value (p\\u0026thinsp;=\\u0026thinsp;0.992), MTR2 value (p\\u0026thinsp;=\\u0026thinsp;0.997), and MTR3 value (p\\u0026thinsp;=\\u0026thinsp;0.988) were included into the analysis. None of the above variables is significant independent factor associated with improved bladder function.\\u003c/p\\u003e\\u003cp\\u003e\\u003cem\\u003eROC analysis of independent factors associated with \\u0026ge;\\u0026thinsp;50% recovery rate\\u003c/em\\u003e\\u003c/p\\u003e\\u003cp\\u003eROC analysis was performed to evaluate the predictive efficacy of the independent factors, including DKI KA and MTR3 values. The AUC of DKI KA is 0.971 (0.919-1.000). The AUC of MTR3 is 0.873(0.741-1.000). The results were showed in Fig.\\u0026nbsp;\\u003cspan refid=\\\"Fig5\\\" class=\\\"InternalRef\\\"\\u003e5\\u003c/span\\u003e.\\u003c/p\\u003e\\u003cp\\u003e\\u003c/p\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003eOur study is the first to investigate the use of DKI and MTR imaging in supporting clinical decision-making for adult patients with TCS. The integration of multiparametric quantitative MRI into clinical practice may offer valuable insights for predicting postoperative recovery and refining treatment strategies for this complex condition. We found that DKI metrics and MTR values of the tethered spinal cord were significantly associated with postoperative outcomes. These imaging biomarkers may help identify suitable surgical candidates among adult TCS patients.\\u003c/p\\u003e\\u003cp\\u003eThe application of quantitative MRI metrics in TCS remains relatively underexplored, especially in adult populations. Previous studies have primarily focused on morphological MRI features (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR13\\\" class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e), which do not capture microstructural changes within the spinal cord. DKI extends beyond conventional DTI; whereas DTI models water diffusion as a Gaussian process, DKI accounts for non-Gaussian diffusion behaviors by incorporating kurtosis, which reflects the complexity and heterogeneity of tissue microstructure (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e). Several studies have demonstrated that preoperative diffusion MRI metrics are associated with treatment outcomes in spinal cord disorders, including traumatic injury and cervical myelopathy (\\u003cspan citationid=\\\"CR7\\\" class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR8\\\" class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR12\\\" class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR16\\\" class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eIn TCS, pathological processes are secondary to mechanical stretching of the spinal cord and nerve roots, which can lead to reduced regional blood flow, impaired oxidative metabolism, alterations in neuronal membranes, myelinated axon damage, and ultimately, progressive fibrosis (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e). A decreased KA value and increased MK (mean kurtosis) value may indicate microstructural damage such as axonal loss and demyelination. Our study demonstrated a positive correlation between KA values and RRs, and a negative correlation between MK values and RRs, suggesting that greater preoperative microstructural damage is associated with poorer surgical outcomes. These findings are consistent with previous research indicating that early surgical intervention in TCS leads to better neurological recovery (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR18\\\" class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eMTR provides a quantitative measure of myelin integrity (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e), and MTR values of the spinal cord have been shown to correlate with its functional status. In patients with chronic spinal cord injury, MTR has been associated with both motor and sensory deficits as assessed by clinical evaluations (\\u003cspan citationid=\\\"CR19\\\" class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). In our study, we measured MTR at three spinal cord segments above the conus. MTR values at the two higher levels were positively correlated with RRs, while no significant correlation was found between the lowest measured level and postoperative recovery. These findings suggest that neural damage caused by tethering may be associated with clinical outcomes. Consistent with previous studies investigating the role of MTR in predicting surgical outcomes in cervical myelopathy, our results also demonstrate that lower MTR values are associated with poorer postoperative outcomes (\\u003cspan citationid=\\\"CR14\\\" class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eOur study is the first to apply DKI and MTR imaging in adult patients with TCS. The results suggest that DKI and MTR may provide objective biomarkers to support individualized clinical decision-making.\\u003c/p\\u003e\\u003cp\\u003eWe did not analyze the risk of potential retethering for several reasons. First, in adult patients considering detethering surgery, symptoms are typically severe or progressive, significantly impairing quality of life. Their primary concern is whether surgery will alleviate symptoms, rather than the long-term risk of retethering. Second, the risk of retethering is strongly associated with complex forms of TCS, such as those involving lipomyelomeningocele, myelomeningocele, or lumbosacral lipoma. In contrast, our study focused on patients with simple TCS, specifically those with a tight, thickened, or fatty filum. Prior studies have shown that the risk of retethering in this population is very low and unlikely to influence management decisions.\\u003c/p\\u003e\\u003cp\\u003eMoreover, retethering is not directly related to the microstructural spinal cord damage that DKI and MTR are designed to detect. For instance, William Mualem et al. analyzed morphological MRI features, including anterior canal distance and spinal cord bending angle, in relation to postoperative outcomes (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). These parameters describe the spatial configuration of the spinal cord within the spinal canal and may be associated with retethering risk. In contrast, DKI and MTR are used to evaluate microstructural changes, such as myelin disruption. Stretching of the spinal cord can cause neuronal membrane alterations and damage to myelinated axons (\\u003cspan citationid=\\\"CR17\\\" class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e), which DKI and MTR are capable of detecting.\\u003c/p\\u003e\\u003cp\\u003eThere are several inherent limitations that should be addressed in future research. First, the follow-up duration in our study was relatively short, which limits our ability to assess long-term outcomes, such as symptom recurrence. However, previous studies have indicated that in patients with simple TCS, symptom recurrence is rare and typically occurs more than a decade after surgery. For most patients, the immediate concern is symptom relief. Second, our sample size was relatively small. Future studies with larger cohorts will be essential to validate our findings and further clarify the clinical utility of DKI and MTR. Additionally, integrating DKI and MTR with other imaging biomarkers may offer a more comprehensive understanding of TCS pathology and management. Exploring how these imaging metrics correlate with outcomes across diverse patient populations will also help optimize their application in clinical practice.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eIn conclusion, our study demonstrates the potential of multiparametric quantitative MRI\\u0026mdash;specifically DKI and MTR metrics\\u0026mdash;as valuable tools for predicting postoperative recovery in adult patients with tethered cord syndrome. These imaging biomarkers were significantly associated with clinical outcomes and may assist in identifying appropriate surgical candidates while avoiding unnecessary procedures.\\u003c/p\\u003e\"},{\"header\":\"Abbreviations\",\"content\":\"\\u003cdiv class=\\\"DefinitionList\\\"\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eTCS\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003etethered cord syndrome\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eMRI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eMagnetic Resonance Imaging\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eDKI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003ediffusional kurtosis imaging\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eDWI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eDiffusion-weighted imaging\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eDTI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eDiffusion tensor imaging\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eMTR\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003emagnetization transfer ratio\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eJOA\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eJapanese Orthopaedic Association\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eRR\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eRecovery Rate\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eROC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eReceiver operating characteristic\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eAUC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eArea under the curve\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eFSE\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eFast spin echo\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eGRE\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eGradient echo\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eROI\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eRegion of interest\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003cdiv class=\\\"DefinitionListEntry\\\"\\u003e\\u003cdiv class=\\\"Term\\\"\\u003eICC\\u003c/div\\u003e\\u003cdiv class=\\\"Description\\\"\\u003e\\u003cp\\u003eintraclass correlation coefficients\\u003c/p\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\\u003c/div\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eClinical Trial Number\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable. This study is not a clinical trial.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eEthics approval and consent to participate\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe study was approved by the Institutional Ethic Board (reference number M2022457). Informed consent was acquired from all recruited participants.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eName of the ethics committee: Peking University Third Hospital Ethics Committee\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eConsent for publication\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNot applicable\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAvailability of data and materials\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eCompeting interests\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eYuxin Yang, Dan Yu, Shipei He are employees of Research Institute of Intelligent Imaging. The other authors declare that they have no competing interests.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eFunding\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research is not supported by any funding.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAuthors' contributions\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eX.S., C.W, Y.Z., H.J. \\u0026nbsp;designed the research, had major contribution in data acquisition, analysis, interpretation, and have drafted the manuscript. G.Z. and J.X. had substantial contribution in data acquisition. Y.Y., D.Y., S.H. had substantial contribution in data acquisition and substantially revised the manuscript.\\u003c/p\\u003e\\n\\u003cp\\u003eB.L., Y.L., H.Y. had major contribution in design of the research, management of the research, data analysis, and manuscript revision.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eAll of the above authors have approved the submitted version and. All of the above authors have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAcknowledgements\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eNone\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eLee GY, Paradiso G, Tator CH, Gentili F, Massicotte EM, Fehlings MG. Surgical management of tethered cord syndrome in adults: indications, techniques, and long-term outcomes in 60 patients. Journal of neurosurgery Spine. 2006;4(2):123-31.\\u003c/li\\u003e\\n\\u003cli\\u003eO\\u0026apos;Connor KP, Smitherman AD, Milton CK, Palejwala AH, Lu VM, Johnston SE, et al. Surgical Treatment of Tethered Cord Syndrome in Adults: A Systematic Review and Meta-Analysis. World neurosurgery. 2020;137:e221-e41.\\u003c/li\\u003e\\n\\u003cli\\u003eMualem W, Nathani KR, Durrani S, Zamanian C, Ghaith AK, Michalopoulos GD, et al. Utilizing pre- and postoperative radiological parameters to predict surgical outcomes following untethering for tethered cord syndrome in a pediatric population. Journal of neurosurgery Pediatrics. 2023;31(2):159-68.\\u003c/li\\u003e\\n\\u003cli\\u003eShukla M, Sardhara J, Sahu RN, Sharma P, Behari S, Jaiswal AK, et al. Adult Versus Pediatric Tethered Cord Syndrome: Clinicoradiological Differences and its Management. Asian journal of neurosurgery. 2018;13(2):264-70.\\u003c/li\\u003e\\n\\u003cli\\u003eHe K, Wang K, Liu Z, Zhang L, Liu S, Zhang X, et al. Tethered cord syndrome from pediatric and adult perspectives: a comprehensive systematic review of 6135 cases. Neurosurgical focus. 2024;56(6):E18.\\u003c/li\\u003e\\n\\u003cli\\u003eRezaee H, Keykhosravi E. Effect of untethering on occult tethered cord syndrome: a systematic review. British journal of neurosurgery. 2022;36(5):574-82.\\u003c/li\\u003e\\n\\u003cli\\u003eThygesen MM, Lund TE, Mikkelsen IK, Kasch H, Dalby RB, Dyrskog SE, et al. Diffusional kurtosis imaging as a possible prognostic marker of cervical incomplete spinal cord injury outcome: a prospective pilot study. Acta neurochirurgica. 2022;164(1):25-32.\\u003c/li\\u003e\\n\\u003cli\\u003eNi M, Wen X, Zhang M, Jiang C, Li Y, Wang B, et al. Predictive Value of the Diffusion Magnetic Resonance Imaging Technique for the Postoperative Outcome of Cervical Spondylotic Myelopathy. J Magn Reson Imaging. 2023.\\u003c/li\\u003e\\n\\u003cli\\u003eZhang Y, Sun D, Xie Y, Li R, Zhao H, Wang Z, et al. Predictive value of preoperative magnetic resonance imaging structural and diffusion indices for the results of trigeminal neuralgia microvascular decompression surgery. Neuroradiology. 2023;65(8):1255-61.\\u003c/li\\u003e\\n\\u003cli\\u003eWang H, Li X, Wang Y, Sun J, Wang Y, Xu X, et al. Assessing Spinal Cord Injury Area in Patients with Tethered Cord Syndrome by Diffusion Tensor Imaging. World neurosurgery. 2019;127:e542-e7.\\u003c/li\\u003e\\n\\u003cli\\u003ePanara V, Navarra R, Mattei PA, Piccirilli E, Bartoletti V, Uncini A, et al. Correlations between cervical spinal cord magnetic resonance diffusion tensor and diffusion kurtosis imaging metrics and motor performance in patients with chronic ischemic brain lesions of the corticospinal tract. Neuroradiology. 2019;61(2):175-82.\\u003c/li\\u003e\\n\\u003cli\\u003eSinghal S, Saran S, Saxena S, Bhadoria AS, Grimm R. Role of diffusion kurtosis imaging in evaluating microstructural changes in spinal cord of patients with cervical spondylosis. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2023;32(3):986-93.\\u003c/li\\u003e\\n\\u003cli\\u003eBian B, Zhou B, Shao Z, Zhu X, Jie Y, Li D. Feasibility of diffusion kurtosis imaging in evaluating cervical spinal cord injury in multiple sclerosis. Medicine. 2023;102(29):e34205.\\u003c/li\\u003e\\n\\u003cli\\u003ePaliwal M, Weber KA, 2nd, Hopkins BS, Cantrell DR, Hoggarth MA, Elliott JM, et al. Magnetization Transfer Ratio and Morphometrics of the Spinal Cord Associates with Surgical Recovery in Patients with Degenerative Cervical Myelopathy. World neurosurgery. 2020;144:e939-e47.\\u003c/li\\u003e\\n\\u003cli\\u003eFujimori T, Okuda S, Iwasaki M, Yamasaki R, Maeno T, Yamashita T, et al. Validity of the Japanese Orthopaedic Association scoring system based on patient-reported improvement after posterior lumbar interbody fusion. The spine journal : official journal of the North American Spine Society. 2016;16(6):728-36.\\u003c/li\\u003e\\n\\u003cli\\u003eAhmed RU, Medina-Aguinaga D, Adams S, Knibbe CA, Morgan M, Gibson D, et al. Predictive values of spinal cord diffusion magnetic resonance imaging to characterize outcomes after contusion injury. Annals of clinical and translational neurology. 2023;10(9):1647-61.\\u003c/li\\u003e\\n\\u003cli\\u003eYamada S, Won DJ, Pezeshkpour G, Yamada BS, Yamada SM, Siddiqi J, et al. Pathophysiology of tethered cord syndrome and similar complex disorders. Neurosurgical focus. 2007;23(2):E6.\\u003c/li\\u003e\\n\\u003cli\\u003eLapsiwala SB, Iskandar BJ. The tethered cord syndrome in adults with spina bifida occulta. Neurological research. 2004;26(7):735-40.\\u003c/li\\u003e\\n\\u003cli\\u003eCohen-Adad J, El Mendili MM, Leh\\u0026eacute;ricy S, Pradat PF, Blancho S, Rossignol S, et al. Demyelination and degeneration in the injured human spinal cord detected with diffusion and magnetization transfer MRI. NeuroImage. 2011;55(3):1024-33.\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Tethered cord syndrome, outcome, diffusion weighted MRI\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-7027483/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-7027483/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003eBackground\\u003c/h2\\u003e\\u003cp\\u003eManagement of tethered cord syndrome (TCS) in adults remains controversial due to unpredictable surgical outcomes. This study aimed to evaluate quantitative MRI metrics\\u0026mdash;diffusional kurtosis imaging (DKI) and magnetization transfer ratio (MTR)\\u0026mdash;for predicting surgical outcomes in adult TCS patients.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e\\u003cp\\u003eThirty-four adult TCS patients with tight/thickened/fatty filum underwent preoperative 3T MRI, including DKI and MT sequences. Patients with complex conditions were excluded. Clinical outcomes were mainly assessed by Japanese Orthopaedic Association (JOA) scores and bladder function. DKI parameters (mean/axial kurtosis: MK, KA) and MTR values at three levels at the end of the spinal cord were analyzed. Statistical methods included Spearman\\u0026rsquo;s correlation, ROC analysis, and multivariate regression.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e\\u003cp\\u003ePatients with recovery rate (RR)\\u0026thinsp;\\u0026ge;\\u0026thinsp;50% (27/34) showed significantly lower KA (0.391\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.017 vs. 0.434\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.014, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) and reduced MTR at upper spinal levels (MTR2: 52.411\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.159 vs. 54.648\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.254; MTR3: 52.523\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.447 vs. 54.496\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;1.049; p\\u0026thinsp;\\u0026le;\\u0026thinsp;0.003) compared to RR\\u0026thinsp;\\u0026lt;\\u0026thinsp;50% patients. KA and MTR3 independently correlated with RR (p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001). ROC analysis confirmed KA and MTR3 as predictors for \\u0026ge;\\u0026thinsp;50% RR (AUC: 0.971 and 0.873). Bladder improvement (12/21 patients) associated with higher preoperative KA (0.432\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.013 vs. 0.393\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;0.020, p\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.001) but lacked independent predictors in regression.\\u003c/p\\u003e\\u003ch2\\u003eConclusions\\u003c/h2\\u003e\\u003cp\\u003ePreoperative DKI and MTR of the lower spinal cord have prognostic value in assessing post-operative recovery in adult TSC patients. Advanced MRI imaging techniques may aid the decision-making process for these patients.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Utilizing pre-operative quantitative radiological imaging to predict surgical outcomes following untethering for adult tethered cord syndrome\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2025-09-22 08:56:18\",\"doi\":\"10.21203/rs.3.rs-7027483/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"d4d168a8-f4e4-42a8-b679-11e6ef0c986b\",\"owner\":[],\"postedDate\":\"September 22nd, 2025\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-29T07:41:10+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2025-09-22 08:56:18\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-7027483\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-7027483\",\"identity\":\"rs-7027483\",\"version\":[\"v1\"]},\"buildId\":\"8U1c8b4HqxoKbykW_rLl7\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}