Purpose <p>Tethered cord syndrome (TCS) is an important consideration in pediatric scoliosis because it can present with curve progression, pain, and evolving neurologic or urologic dysfunction that may affect deformity evaluation and surgical planning. This state-of-the-art review summarizes the current literature on TCS in pediatric spinal deformity, with emphasis on diagnostic workup, scoliosis natural history, and surgical timing relative to deformity correction.</p> Methods <p>A literature review was performed focusing on pediatric TCS in the setting of spinal deformity, including dysraphism-associated tethering, filum-based tethering, retethering, and occult tethered cord syndrome. Studies addressing diagnosis, neurologic and urologic evaluation, scoliosis progression, outcomes after detethering, and timing relative to deformity correction were synthesized narratively.</p> Results <p>Current evidence supports a clinically driven approach in which imaging findings alone are not sufficient to define clinically active tethering. Decision-making should focus on interval neurologic or urologic change and scoliosis behavior over time. Detethering may improve or stabilize cord-related symptoms, but it does not reliably prevent scoliosis progression, especially in larger curves and skeletally immature patients. Evidence supporting routine prophylactic detethering before deformity correction in asymptomatic patients remains limited. Variation in diagnostic criteria and outcome reporting continues to limit clear treatment recommendations.</p> Conclusion <p>In pediatric deformity care, TCS management should be driven by objective clinical progression rather than imaging findings alone. Detethering should be viewed as treatment for active cord-related dysfunction, while scoliosis treatment should be guided by curve progression and skeletal maturity. Standardized definitions and prospective multicenter studies are needed to improve treatment algorithms and reduce practice variation.</p>