Occult Tethered Cord Syndrome: Clinical Characteristics, Diagnostic Challenges, and Management Considerations

Occult tethered cord syndrome (OTCS) is defined as the clinical manifestation of a tethered cord without radiographic evidence of a low-lying conus; however, there is no consensus on surgical indications or evaluation criteria. We present three cases treated surgically at our hospital, and in contrast to that, a narrative review of the literature on OTCS was conducted, focusing on epidemiology, pathophysiology, clinical features, diagnostic tools, and surgical versus conservative management. Emphasis was placed on pediatric populations, in whom the syndrome is most frequently described. Between April 2010 and June 2025, three patients with OTCS underwent surgical sectioning of the filum terminale at our institution. All patients presented with urological abnormalities, and one patient also demonstrated orthopedic involvement. Improvement in urological symptoms was observed in two patients (66%), including resolution of vesicoureteral reflux and nocturnal enuresis, whereas no improvement was noted in orthopedic abnormalities. No perioperative complications were observed. During the follow-up period (median (interquartile range) = 1281 (1264-1490) days), these results indicated that while urinary symptoms after surgical dislocation were highly likely to recover, orthopedic symptoms remained largely refractory in the majority of cases. OTCS remains controversial and heterogeneous. Diagnosis depends largely on clinical judgment, and treatment decisions must balance the potential surgical benefits with the risks and uncertain long-term outcomes. Prospective controlled studies and the development of objective biomarkers are essential for establishing standardized diagnostic and therapeutic guidelines.