32 Tumors of the Cervical Spine
KEY POINTS
Intramedullary Spinal Tumors
General Information, Clinical Presentation, and Imaging
Ependymomas
Intramedullary ependymomas most commonly occur in the cervical and cervicothoracic regions of the spinal cord. The mean age at presentation is 42 years, and there is a slight female predominance. The most common presenting symptom is neck pain localized to the region of the spine, but patients may also present with dysesthetic pain or numbness and, with larger tumors, with symptoms from neural compression. Given the slow growth and well-circumscribed quality of these tumors, symptoms generally progress slowly, and patients often have a long history prior to diagnosis.
Operative Techniques (See Figures 32-1 and 32-2)
Intramedullary Tumors

FIGURE 32-1 A, Intraoperative illustration of a patient with a C4–C7 ependymoma. The durotomy is completed, and the arachnoid is incised (dashed line)B, Tumor dissection is initiated in the middle portion of the tumor, which is the bulkiest. C, Great caution must be exerted while coagulating branches of the anterior spinal artery supplying the neoplasm along the anterior aspect of the cord to avoid occluding the anterior spinal artery. (a = artery)
(From Neurosurgery 51:1162-1174, 2002.)

FIGURE 32-2 Spinal cord ependymoma. A, Preoperative T1-intensity, gadolinium-enhanced MRI scan of a patient with a thoracic cord intramedullary ependymoma. B, Postoperative T1-intensity, gadolinium-enhanced MRI scan of the same patient showing complete resection of the neoplasm. C, Intraoperative photograph of the same patient showing the spinal cord before the myelotomy. D, Ependymoma mushrooming out of the myelotomy. E, Tumor elevated caudally, with a forceps used to dissect the anterior plane. F, En bloc resected ependymoma.
(From Neurosurgery 51:1162-1174, 2002.)
After tumor resection, we achieve hemostasis, avoiding the temptation to coagulate any of the surface vessels. The tacked sutures on the pia and dura are removed. The dura is closed primarily, in a watertight fashion. The subarachnoid space is irrigated to remove any blood prior to final closure, and a Valsalva maneuver confirms lack of CSF egress. Fibrin glue is placed over the dural closure. The wound is closed in the standard fashion and we leave a subfascial drain until there is limited output. We allow the patient to ambulate and sit up immediately after surgery.