Pterion Prep CraniPro VUMC Case Prep
2026-06-27

Case Prep: Intramedullary Spinal Cord Tumor Resection (Ependymoma / Astrocytoma / Hemangioblastoma)

Case / Approach Snapshot

One-Liner

[Age]yo [M/F] with a [cervical/thoracic] intramedullary spinal cord tumor ([ependymoma / astrocytoma / hemangioblastoma]) at [levels] presenting with [pain / sensory changes / weakness] planned for laminectomy/laminoplasty and midline myelotomy for microsurgical resection.

Figures, Imaging & Video

🎥 Operative video — search operative video on YouTube ▸ · The Neurosurgical Atlas ▸

🧭 Operative approach: Posterior thoracolumbar approach — detailed corridor setup, step-by-step technique & figures

Neurosurgical Atlas · AO Spine / Surgery Reference · Radiopaedia · PubMed Central — operative figures © linked; see media-sources.md

High-Yield Literature

Curated Image Set

Open-access figures are embedded from PubMed Central articles and kept unique to this guide.

Intramedullary Spinal Cord Tumor Resection — Fig. 1 Fig. 1. (a) T2 MRI and (b) Gd-enhanced MRI before the initial surgery (nine years ago), showing the presence of an intramedullary tumor. Source: Tuberculous meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection — Nagoya Journal of Medical Science 2015; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — Fig. 2 Fig. 2. (a) T2 MRI after the first surgery, showing total resection of the tumor. (b) T2 MRI four years after the first surgery, showing regrowth of the tumor. (c) T2 MRI and (d) Gd enhanced MRI… Source: Tuberculous meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection — Nagoya Journal of Medical Science 2015; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — Fig. 3 Fig. 3. (a) Normal chest X-ray. (b) Brain CT showing slight ventricle enlargement. (c) Brain MRI showing ventricle enlargement. Source: Tuberculous meningitis with dementia as the presenting symptom after intramedullary spinal cord tumor resection — Nagoya Journal of Medical Science 2015; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — FIG. 1. FIG. 1.. Preoperative cervical spine MR images demonstrating an intramedullary mass extending from C6 to T2. A: T2-weighted image showing an associated syringomyelia with cranial extension of the… Source: Anterior intradural CSF collection causing postoperative neurological deterioration after intramedullary tumor resection and associated syringomyelia: illustrative case — Journal of Neurosurgery: Case Lessons 2026; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — FIG. 2. FIG. 2.. Cervical spine MR images demonstrating an anterior intradural fluid collection resulting in dorsal displacement of the spinal cord (arrow). A and B: T2-weighted images showing a… Source: Anterior intradural CSF collection causing postoperative neurological deterioration after intramedullary tumor resection and associated syringomyelia: illustrative case — Journal of Neurosurgery: Case Lessons 2026; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — FIG. 3. FIG. 3.. Intraoperative findings and ultrasound images. A: Intraoperative ultrasound demonstrating a prominent anterior CSF space compressing the spinal cord posteriorly, consistent with a… Source: Anterior intradural CSF collection causing postoperative neurological deterioration after intramedullary tumor resection and associated syringomyelia: illustrative case — Journal of Neurosurgery: Case Lessons 2026; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — FIG. 4. FIG. 4.. Postoperative cervical spine MR image demonstrating restoration of the spinal cord to its normal position (arrow) with a marked reduction in the associated syrinx (arrowheads) compared… Source: Anterior intradural CSF collection causing postoperative neurological deterioration after intramedullary tumor resection and associated syringomyelia: illustrative case — Journal of Neurosurgery: Case Lessons 2026; CC BY-NC-ND.

Intramedullary Spinal Cord Tumor Resection — Figure 1: Figure 1:. (a and b) Preoperative images – T1 pre- and postcontrast of thoracic spine and (c) one year postoperative – T1 postcontrast of thoracic spine. Source: Primary thoracic intramedullary spinal cord tumor with likely metastases of glial origin to the lumbosacral vertebrae: Illustrative case — Surgical Neurology International 2023; CC BY-NC-SA.

Intramedullary Spinal Cord Tumor Resection — Figure 2: Figure 2:. (a) 18 months postoperatively – T2 noncontrast of thoracic spine, (b) 20 months postoperatively – T1 with contrast of thoracic spine, and 3 years postoperatively showing progression (c)… Source: Primary thoracic intramedullary spinal cord tumor with likely metastases of glial origin to the lumbosacral vertebrae: Illustrative case — Surgical Neurology International 2023; CC BY-NC-SA.

Intramedullary Spinal Cord Tumor Resection — Figure 3: Figure 3:. (a) Three years postoperatively – T1 with the contrast of cervical spine, (b) 3 years postoperatively – T1 with the contrast of lumbar spine, and (c) X-ray-guided biopsy of L4 vertebral… Source: Primary thoracic intramedullary spinal cord tumor with likely metastases of glial origin to the lumbosacral vertebrae: Illustrative case — Surgical Neurology International 2023; CC BY-NC-SA.

History of Present Illness

Imaging Review

MRI (T1±Gad, T2) entire cord

Angiography

Labs

Neurological Examination

Surgical Planning

Case Logistics, OR Needs & Orders

Diagnosis & Indication

Position

Key Surgical Steps

  1. Level localization (fluoroscopy), laminectomy or laminoplasty over tumor + 1 level above/below
  2. Ultrasound — confirm tumor extent, syrinx, choose myelotomy length
  3. Midline durotomy, tack-up, preserve arachnoid then open
  4. Inspect cord — identify midline (dorsal median sulcus/raphe between dorsal columns), often widened cord, may see discoloration/vessels
  5. Midline myelotomy through the dorsal median sulcus (minimizes dorsal column injury) over tumor length; pial sutures gently retract
  6. Tumor resection:
    • Ependymoma: identify cleavage plane, internally debulk (CUSA), circumferentially dissect from cord, coagulate ventral feeders, deliver en bloc/piecemeal — aim gross total
    • Astrocytoma: internally debulk, no clear plane — partial resection/debulk, avoid aggressive pursuit (motor loss)
    • Hemangioblastoma: do NOT enter nodule (vascular); circumferential pial dissection, coagulate feeders, remove nodule en bloc; drain associated syrinx
  7. Continuous IONM — stop/pause if MEP/D-wave drop
  8. Hemostasis (gentle — bipolar near cord), do NOT pack cavity tightly
  9. Watertight dural closure, sealant, ± laminoplasty reconstruction
  10. Closure

Critical Anatomy & Structures at Risk

  1. Spinal cord parenchyma — dorsal columns (myelotomy → proprioceptive/sensory loss), corticospinal tracts (motor)
  2. Anterior spinal artery / sulcal arteries (ventral) — cord infarction
  3. Pial vessels, syrinx
  4. Dura (CSF leak)

Equipment

Monitoring

Anesthesia

Potential Complications

  1. Neurological decline — dorsal column (sensory/proprioception, common transient), motor (worse with astrocytoma/aggressive resection)
  2. CSF leak/pseudomeningocele
  3. Cord infarction (anterior spinal artery), hemorrhage
  4. Spinal deformity (post-laminectomy, esp. children — laminoplasty mitigates), recurrence

Operative Note Template

Preoperative Diagnosis: [Cervical/thoracic] intramedullary spinal cord tumor ([ependymoma/astrocytoma/hemangioblastoma]) at [levels]

Postoperative Diagnosis: Same (pending pathology)

Procedure: [Levels] laminectomy/laminoplasty with midline myelotomy and microsurgical resection of intramedullary tumor

Surgeon / Assistant: Anesthesia: Total IV anesthesia (IONM-friendly), no paralytic EBL / Fluids: Adjuncts: Microscope, ultrasound, CUSA (low), ICG (hemangioblastoma), pial sutures; MEP/SSEP/D-wave; MAP > 85–90 Implants: Dural substitute, sealant; [laminoplasty hardware] Complications: None

Indications: [Age]yo [M/F] with an intramedullary spinal cord tumor at [levels] causing [progressive myelopathy/sensory change]. Maximal safe resection under IONM guidance was planned. Risks (dorsal-column/motor deficit, CSF leak) discussed.

Description of Procedure: After consent and time-out, total IV anesthesia was induced (MAP > 85–90, no paralytic) and MEP/SSEP/D-wave monitoring established. The patient was positioned prone; a laminectomy/laminoplasty was performed over the tumor plus a level above/below, and ultrasound defined the extent. A midline durotomy was made and the cord exposed.

A midline myelotomy through the dorsal median sulcus was performed and the tumor addressed [ependymoma: cleavage plane developed, internally debulked, dissected circumferentially and removed for gross-total; astrocytoma: internally debulked without an aggressive pursuit of indistinct margins; hemangioblastoma: pial dissection with feeder coagulation and en-bloc nodule removal without entering it]. The anterior spinal artery and pial vessels were preserved; resection was paused/limited per MEP/D-wave changes. A watertight dural closure was performed with sealant [and laminoplasty reconstruction].

Closure was completed in layers. The patient was transferred with MAP support and CSF-leak precautions; transient dorsal-column dysfunction was anticipated.

Postoperative Plan

Chief-Level Case Review

Use these as the senior-level mental model for Intramedullary Spinal Cord Tumor Resection (Ependymoma / Astrocytoma / Hemangioblastoma):

Common Pimp Questions

Use these to pressure-test preparation for Intramedullary Spinal Cord Tumor Resection (Ependymoma / Astrocytoma / Hemangioblastoma):

  1. What neurologic level and root are responsible for the presenting deficit?
  2. What is the decompression target and how will you know it is adequately decompressed?
  3. What instability, deformity, bone-quality, or fusion variable changes the construct?
  4. What vascular, visceral, dural, or neural structure is the main structure at risk?
  5. What postop brace, drain, mobilization, MAP, antibiotic, and DVT plan should be ordered?

Attending Preference Variables

Items that commonly vary by surgeon or institution: