The patient came to the clinic 27-March-2013 complaining of limping during walking due to weak right leg for 1 year.

MRI cervical spine done 24-March-2013 showing intramedullary tumor at the level of C4 and C5 with syrinx extending from C2 down to mid-dorsal level. MRI of the brain was normal.

On examination: The patient is limping. There is slight pain when turning the head toward the right shoulder. Hypotrophy of the interossii muscles right hand. The grip and extension of the right hand 4/5, so the right triceps muscle. Hoffmann positive right side  with the deep reflexes exaggerated in the right side. SLRS was 80 degrees both sides without pain. There is weak dorsi and planterflexion right  foot -4/5  and right quadriceps femoris 4/5. There is hypalgesia right leg below the knee joint. Babinski is positive in the right with brisk clonus right foot.

Using IOM Inomed ISIS, cervical tumor scenario with MEP SEP. D-wave proximal and distal with running EMG was setup, to keep real time monitoring of the neurological status of the patient. Laminectomy of C4 and C5 was done. The dura was opened longitudinally. The tumor is seen under the arachnoid of the spinal cord and dissection of the spinal cord over the tumor was carried out at the area where there was no fibers with preservation of the smallest arteries and veins. Biopsy was done: ependymoma. The tumor was followed with its border and practical total resection of the tumor was achieved. The cleavage was proper in the right side, but at the left side it was more adherent to the spinal cord. The spinal cord became lax and the CSF coming from all directions and the spinal cord regained normal shape. The D-waves, MEP and SEP were acceptable to the end of the total resection. Water-tight closure of the dura with routine closure of the wound. Before extubating the patient, another MEP, SEP and running EMG confirmed the integrity of the spinal cord.

Routine closure of the wound. Smooth postoperative recovery. The weakness of the right lower leg became more pronounced, but moving and feeling them

The lesion before surgery looking as ependymoma, because of syrinx formation. It is hard to tell exactly if it is ependymoma or glioma.

For more details about ependymomas, please visit ependymomas.com.

For more details about D-wave, SEP and MEP please visit iomonitoring.org.