Endoscope-Assisted Resection of Extra-Axial Premedullary Neurenteric Cyst via Far Lateral-Supracondylar Approach: 2-Dimensional Operative Video

Neurenteric cysts are rare congenital lesions that may compress the ventral brainstem.1-9 In this operative video, we illustrate the surgical treatment of an intradural extra-axial neurenteric cyst extending from the lower pons to the craniocervical junction. The patient, an asymptomatic 52-yr-old female, underwent surveillance imaging of the premedullary lesion for 14 yr without progression. However, after developing progressive strain-induced headaches, imaging revealed a significant enlargement of the lesion with brainstem compression and partial obstruction of the foramen magnum. Therefore, surgical resection was pursued. The patient consented to the procedure. The patient underwent a lateral suboccipital craniotomy and C1 laminectomy through a far lateral approach. The lesion was immediately visualized upon opening the dura. After identifying the cranial nerves, we resected the tumor while taking care to preserve the neurovascular elements of the cerebellopontine angle and foramen magnum. During the resection, we unexpectedly encountered a firm nodule that was adherent to the right posterior inferior cerebellar artery. This was meticulously dissected and removed en bloc using intraoperative indocyanine green (ICG) angiography. The cavity was inspected with 0-degree and 30-degree endoscopes to ensure complete resection of the lesion. Gross total resection was confirmed on postoperative magnetic resonance imaging. The patient was neurologically intact with no cranial nerve abnormalities and discharged home on postoperative day 3. This case demonstrates that the far lateral-supracondylar approach affords safe access to the ventral pontomedullary and craniocervical junctions and that intraoperative adjuncts, including ICG angiography and endoscopic visualization, can facilitate complete lesion resection with excellent clinical outcomes.