Theoften extensive nature of intraspinal lipomas and their complex relationship to neural elements can make spinal cord untethering difficult to achieve. Based on anatomic observations at operation, we have adopted a systematic surgical approach which permits untethering with minimal risk of injury to nervous tissue. By considering the site of attachment of lipoma to cord and the position of the posterior nerve roots in relationship to the mass, the location of neural elements can be predicted. We have used this approach in 14 recently operated cases. Our experience corroborates the views of others that the high incidence of progressive neurologic deficits in these patients warrants prophylactic surgical intervention.