Background The spinal intradural mass lesions represent a challenge in microsurgical practices. The intraoperative precise localization and characterization of these lesions must be achieved to avoid excessive exposure and neural tissue damage. This study aims to evaluate the role of intraoperative ultrasound during surgical dealing with spinal intradural mass lesions starting before bony work exposure. Results This prospective study had been done during the period from January 2022 to January 2023 with follow-up at least 6 months on 36 patients, suffered intradural spinal mass lesions and underwent microsurgical interventions aided with intraoperative ultrasound. MRI spine and Klekamp score were used as preoperative and postoperative parameters for assessment of the patients. Intraoperative ultrasound features were analyzed to evaluate its values. All lesions were visualized and characterized by intraoperative ultrasound beside spinal anatomical identification. Laminoplasty, laminectomy, durotomy and myelotomy were determined by IOUS. Gross total eradication was achieved in 28/36 (78%). Intraoperative ultrasonography definition of cystic component, well-defined borders and smooth shape of the masses were associated with significant Klekamp outcome improvement. Conclusion Intraoperative ultrasound can be used safely to detect the spinal intradural mass lesions even before bony work for exposure with anatomical and pathological definition and has the ability to predict the outcome.