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Introduction and Aim: Separating the spinal cord while separating spine sharing conjoined twins may have long-lasting implications for the survivors. We aim to study the role of neurophysiological monitoring in delineating the spinal anatomy as an important component to pre-operative planning and twin separation, thereby improving neurological outcome. Case Report: Study involves two pairs of pyopagus conjoined twins with a shared spine. The twins were subjected to neurophysiological monitoring under general anesthesia to identify the neuronal supply and cross-innervation of various organs including lower limbs and anal sphincters with respective brain. Pre-operatively, the spinal cord was seen to be joined terminally with varying degree in both set of twins. Neurophysiological monitoring done preoperatively on the first set of twins revealed cross innervation from twin B to twin A, although twin A had its independent complete innervation. The sphincter was predominantly controlled by twin A. In the second set of twins, there was no cross innervation, both twins had equal control of sphincter hence the sphincter allocation was done using other general and anatomical factors. Neurophysiological monitoring was also utilized intraoperatively to divide the cord in its functional midline instead of anatomical midline thereby preserving neural outflow and function. Post-operatively, both set of twins retained motor and sensory supply to lower limbs and mobilize both limbs well, aided with physiotherapy. Conclusion: Better functional outcomes are possible with the use of neurophysiological monitoring during the workup and management of spine-sharing conjoined twins.