The patient  a Yemeni citizen came to the clinic 18-November-2023 complaining of difficult walking for 4 years with more weakness of the left leg with gradual deterioration. In wheelchair for 8 months. MRI cervico-dorsal spine done 19-November-2023 showing intramedullary ependymoma extending from C5 down to D2. MRI of the brain was normal.

On examination, the patient is in wheelchair with weak both hands -4/5 both iliopsoas muscles 1/5 quadriceps femoris 3/5, abduction and knees adduction 2/5 no dorsi or planterflexion both feet. There is hypalgesia D3-D6 both sides and hypalgesia down to the right leg. Micturition and defecation preserved. Deep reflexes lower limbs exaggerated and Babinski more brisk with clonus in the left.

The patient was sent for investigations and MRI cervical and dorsal spine done the same day demonstrating the below figures.

Laminectomy of lower half of C5 down to upper half of D2. The dura was opened and reflected to the sides.  Inspection of the spinal cord with the violet tumor transparently seen at the right upper half of the field. Longitudinal incision above this area without violating the capillaries. The tumor was soft but not suckable, for what piece-meal resection was applied. The spinal cord was gently preserved. Practical total removal of the tumor was achieved, A tiny residual adherent to the vein was coagulated and left to avoid trauma to the vein. The spinal cord became lax and no palpable mass inside it. Water-tight closure of the dura and routine closure of the wound. The patient was put in Reverse Trendelenburg position with Valsalva maneuver and hyperventilation. No CSF leak. Before weaning the patient intraoperative MRI was done. No residual is seen. She was sent to the ward.

Too early now.

The patient has huge ependymoma with plegia of the lower limbs and paresis of the hands. Surgery is mandatory.

Even with practical removal of the tumor, postoperative radiation is mandatory.