Microsurgical Resection of an Intramedullary Ependymoma at the Cervicomedullary Junction: A Two-Dimensional Operative Video.

Ependymomas are the most common adult intramedullary spinal tumors. Although uncommon in the brainstem, ependymomas make up a large proportion of tumors of this location. We present an operative video case report of an intrinsic ependymoma at the cervicomedullary junction. The purpose of this report is to present the clinical picture, operative setup, and surgical technique involved in resection of an intramedullary tumor of this region. For best outcome for intramedullary ependymomas, the goal should be gross total resection. These tumors have a relatively distinct plane between tumor and normal parenchyma, making a gross total resection more probable than cases of infiltrative intramedullary astrocytomas. Despite this, significant morbidity can be associated with treatment. Proper microsurgical technique with use of operative adjuncts can maximize resection while minimizing neurologic injury to optimize outcomes in patients. We present the case of a 42-year-old man presenting with neck and shoulder pain, upper extremity paresthesias, and gait instability. Magnetic resonance imaging of the neuroaxis revealed a heterogeneously enhancing expansile lesion in the lower medulla and multiple lesions in the thecal sac, representing drop metastases. Due to symptoms and mass effect from the lesion, the patient underwent a suboccipital craniotomy for tumor resection. We highlight operative techniques in our case, including use of neurophysiologic monitoring, intraoperative ultrasound, ultrasonic aspirator, and dissection with microcottonoid pledgets and bimanual technique. Pathology revealed a World Health Organization grade II ependymoma. Postoperative magnetic resonance imaging revealed a small amount of residual. He underwent full craniospinal proton beam therapy with boost to the residual and metastases with good outcome. Patient provided consent for this report.