Surgical technique for executing an en bloc resection of a multilevel cervical intramedullary ependymoma: A 2D operative video.

Background: We present the case of a 39-year-old female with progressive loss of dexterity, gait imbalance, sensory deficits, and neuropathic pain in her bilateral upper and lower extremities. She presented with hyperreflexia, bilateral Hoffmann's sign, and clonus. Magnetic resonance imaging (MRI) demonstrated a mid-cervical intramedullary mass with polar cysts, distal syringomyelia, and brainstem edema. We therefore performed a C2-C7 laminectomy with posterior instrumentation for tumor resection.

Case description: We showcase a high-definition operative video with a step-by-step demonstration of this procedure. Key steps are detailed, such as the use of dorsal column mapping to confirm the electrophysiological midline. Crucial surgical maneuvers such as techniques of peeling the tumor away from the spinal cord, use of microcottonoids for dissection, and harnessing the spring action of microdissectors all highlight the importance of mitigating neurological injury and preserving the parenchyma of the spinal cord. Critical considerations regarding bleeding are also highlighted when dealing with ependymomas due to their hypervascular nature. The tumor was resected en bloc, with tumor integrity left intact. Gross total resection was confirmed on postoperative MRI.

Conclusion: Postoperatively, the patient experienced transient proprioceptive deficits, which resolved substantially. At 4-year follow-up, she demonstrated neurological improvement, no hardware complications, and no tumor recurrence. This case underscores the utility of en bloc resection for achieving gross total resection of cervical intramedullary ependymomas while optimizing functional outcomes.