Late-adolescent presentation of tethered cord syndrome secondary to filum terminale lipoma

Background: Filum terminale lipoma (FTL) is a form of occult spinal dysraphism that can cause a spectrum of neurological symptoms, including tethered cord syndrome (TCS). While FTL commonly manifests in infancy and childhood, symptomatic presentations in adolescence and adulthood are increasingly recognized. Case Description: Originally, a 16-year-old Filipino male developed dysuria, hematuria, urinary incontinence, and recurrent lower urinary tract infections. At age 22, the physical examination revealed a hyperpigmented patch with superimposed hypertrichosis located left-superolateral to the intergluteal cleft. The sacral region demonstrated diminished convexity due to a subcutaneous fat pad, displacing the superior portion of the cleft to the right; the sacrum and coccyx were impalpable. The only neurological finding was impaired anal and urinary sphincter function. Despite surgical untethering, he remained dependent on urinary catheterization postoperatively, and also newly developed additional sensory deficits. Conclusion: It is important to recognize late-adolescent onset TCS in patients presenting with unexplained urological dysfunction and sacral cutaneous stigmata. Surgical untethering remains the treatment of choice, but outcomes are often diminished by the more protracted duration of preoperative neurological/sphincteric deficits.