The term “tethered cord” has been controversial ever since Lichtenstein's proposal[1] in 1940 because it referred to a visual anomaly without considering the pathophysiological changes. A “tethered cord” refers to a pathological fixation of the spinal cord. The “tethered cord syndrome” (TCS) may or may not result from this anomaly. This syndrome results from tethering, and it is said to occur when there are progressive neurological, urological, or orthopedic symptoms.[234] Knowledge of the anatomy of this condition has expanded manifold since the availability of magnetic resonance imaging. In no condition with tethered cord, there has been such an intense debate about prophylactic surgery for asymptomatic children than children with lipomas.The controversy in this condition has revolved around the indication and timing of surgery. Some authors have proposed that surgical detethering guarantees a good long-term outcome.[567] Others have questioned the wisdom of prophylactic release, stating that progression of symptoms will occur in spite of surgical release.[89] This is a review of the current thoughts on the matter, and to question whether there is a debate at all today.Yamada and Won[10] categorized tethered lesions into three categories: (1) True TCS, associated with an inelastic filum with or without cord elongation or filum thickening, caudal lipomyelomeningoceles (LMMCs) and sacral myelomeningoceles (MMCs); (2) a combination of the lesion above the cord fixation (TCS) and additional local lesion related to MMCs or dorsal and large transitional LMMCs; (3) patients without typical signs and symptoms of TCS despite the anatomical appearance of cord tethering.{Figure 1}The same author later[11] proposed a clinical classification: (1) True TCS, (2) partial TCS, (3) nonstretch-induced disorder with symptomatology and anomalies similar to TCS, and (4) a large MMC in the high lumbar area. Category 1 patients had the best surgical outcome, Category 2 only had recovery in deficits which correlated with stretch-induced dysfunction, Category 3 patients had pain relief but no neurological improvement, and Category 4 patients after surgery had no change in neurological signs. Clearly, it would appear that Category 1 and 2 would benefit from surgery, Category 3 would lead to unpredictable results, and in Category 4, surgery would be unpredictable as much as it would be impossible to hazard a guess as to the results of such a release. Extrapolating to the classification of congenital lipomas proposed by Pang, these are classified into the following types: Dorsal, terminal, transitional, and chaotic. Hence, the terminal would represent Type 1 with good surgical results in terms of neurological recovery, the dorsal and transitional would represent Type 2 with unpredictable recovery of function, and the chaotic would definitely be Type 3 where untethering may make no difference to outcome.The problem is, however, a little more, as two more considerations enter into the equation: (1) How much of the pathophysiological changes are reversible after surgery and (2) what is the morbidity of the surgical intervention itself?To understand the first question, we have to appreciate that in lipomas, like in other tethering lesions, there is impairment of the oxidative metabolism and there is electrophysiological dysfunction.[121314] Hence, how much of the cord changes are reversible after surgery is difficult to be certain about. Regarding the second question, Pierre-Kahn[15] demonstrated that in asymptomatic lipomas of the conus, 25% of the patients deteriorated within a mean period of 4.4 years after surgery. At 9 years, the actual risks of deterioration, as determined by the Kaplan-Meier method, were 33% for conservatively treated patients and 46% for the surgically treated patients. The suggestion by this group was clear risks of surgical intervention for asymptomatic conus lipomas, which was higher with the so-called “prophylactic” intervention! Yet, publications by Pang et al. have recommended prophylactic surgery for all dorsal, terminal, and transitional lipomas.[16]Although at the outset there may seem to be a debate between the two groups on either side of the Atlantic, a little analysis reveals the following facts about the two publications: (1) Pierre-Kahn group from Paris performed partial resection of lipomas with considerable morbidity and neurological deterioration, whereas in Pang's own series, the results of this treatment were also very poor. What was different in Pang's later series? First, he performed “total” resection of the lipomas, using the “white line” as a guide to the plane between the cord and the lipoma. Second, he always recommended intraoperative neurophysiological monitoring. Hence, in case of dorsal and terminal lipomas, it would appear that complete resection of the lipoma provides the best results, and indeed, the best insurance against delayed retethering! The current data from Paris suggest that their results are better with total removal of the lipomas.[17] In another recent publication, Talamonti et al.[18] seem to also favor prophylactic surgery in all but transitional lipomas.Neurological signs are often used as a guide to prognosis and treatment as in the grading system of lipomas described by Hoffman et al.[19] Here, Grade 0 and Grade 1 patients who have large conus lipomas which are difficult to completely remove are often best treated with supervised neglect. Fat is soft and elastic, but when the fibrous component of fibroadipose tissue in the filum increases, this may result in excessive cord traction. As regards the growth rate of the spinal cord vis-à-vis that of the vertebral column, if the cord is anchored by an inelastic filum at or below L3 level at the age of 4 or more years, the growth rate of the lumbosacral cord may not match that of the vertebral column, and it is likely to result in unacceptable levels of cord traction.[2021]Where does all this lead us to in the great asymptomatic lipoma debate? The following deductions can be readily made: (1) Asymptomatic lipomas of the filum need early untethering surgery as this procedure carries minimal morbidity. (2) prophylactic is best performed for dorsal and transitional lipomas, provided total removal may be carried out, and for this, intraoperative monitoring is mandatory. (3) If total removal of a lipoma cannot be performed, for example, in a chaotic lipoma, it is best to leave well alone! The same applies to those who are unable to remove in totality any of the other types of lipomas as well. Hence, the great asymptomatic debate seems to be fizzling out today….