Pitfalls in diagnosis of cord tethering in scoliosis: Lessons learned from a series in a single centre

•Diagnosis of spinal cord tethering in scoliosis can be challenging.•Current concepts cannot answer the questions encountered in challenging spinal cord tethering cases.•Despite improvements in the handling of spinal cord tethering among patients with scoliosis, our current concepts are not able to answer the questions encountered in challenging cases.•Ongoing controversy existing in the diagnosis and optimal management of spinal cord tethering in patients with scoliosis should be addressed. Case-series. We intend to introduce three challenging cases suspicious of spinal cord tethering, who were managed in our center and their diagnosis was not so straightforward. Diagnosis of spinal cord tethering in scoliosis can be challenging. This is especially true when the tip of conus medullaris is slightly lower than its normal location and the patients are asymptomatic before corrective spinal surgery. Although in all three cases the tip of conus medullaris was in a relatively abnormal place (at the level of L2-L3), two of them did not show any evidences of spinal cord tethering in urodynamic study (UDS) and prone magnetic resonance imaging (MRI), thus corrective scoliosis surgery without previous un-tethering procedure was allowed. Spinal realignment was performed on these two cases with a favorable outcome. In the third case, un-tethering was done due to evidence of urinary impairment, which was suggested in (UDS) and tight filum terminale, which was detectable in lumbosacral MRI in prone position. In the follow-up period, the UDS properties of the patient turned into normal and later an uneventful corrective spinal surgery was performed. The main goal of this article is to highlight the ongoing controversy existing in the diagnosis and optimal management of spinal cord tethering in patients with scoliosis.