Sodium Fluorescein-Guided Microsurgery for Intramedullary Spinal Ependymomas: Technical Nuances, Surgical Workflow, and Operative Video.

Abstract

Intramedullary ependymomas represent the most common histological subtype among intramedullary spinal cord tumors (IMSCTs). Early microsurgical resection remains the treatment of choice, as functional outcomes are strongly associated with preoperative neurological status and the presence of a favorable tumor-cord cleavage plane, often allowing gross total resection. Intramedullary tumor surgery is currently supported by several intraoperative adjuncts, including high-magnification microscopy, intraoperative ultrasound, and neurophysiological monitoring, all aimed at maximizing safe resection while preserving neurological function. Among emerging adjuncts, fluorescence-guided surgery using Sodium Fluorescein (SF) may provide additional intraoperative anatomical guidance during tumor resection. While SF has been extensively investigated in brain tumor surgery, its application in intramedullary spinal tumors remains limited. Fluorescence patterns generally correlate with areas of blood-spinal cord barrier disruption and contrast enhancement on preoperative MRI, potentially facilitating intraoperative visualization of the tumor-cord interface. Between December 2023 and October 2025, five consecutive patients with WHO grade 2 intramedullary spinal ependymomas underwent fluorescein-guided microsurgical resection. Fluorescence was detectable in all cases, gross total resection was achieved, and early neurological outcomes were favorable. This technical note describes the surgical workflow and technical nuances of Sodium Fluorescein-guided resection of intramedullary spinal ependymomas, illustrated by a representative case and operative video. Within a multimodal surgical strategy, SF may represent a useful adjunct to microsurgical dissection, although further experience and prospective studies are needed to better define its role in intramedullary tumor surgery.