To describe the first case of a thoracic perineural cyst successfully treated using a direct thoracic transforaminal endoscopic approach./r/nCase report./r/nA 66-year-old male presented with right-sided radicular pain in a T4 distribution. MRI of the thoracic spine revealed a right T4 perineural cyst caudally displacing the root in the T4-5 foramen. He had failed attempts at nonoperative management. The patient underwent an all endoscopic transforaminal perineural cyst decompression and resection as a same-day surgical procedure. Postoperatively, the patient noted near complete resolution of the preoperative radicular pain. A thoracic MRI with and without contrast was performed 3 months after surgery and showed no evidence of the preoperative perineural cyst and no symptom recurrence was noted by the patient./r/nThis case report presents the first safe and successful report of an all endoscopic transforaminal decompression and resection of a perineural cyst in the thoracic spine.