Intradural extramedullary cysts of the spinal canal: clinical presentation, radiographic diagnosis, and surgical management

TRANSVERSE DORSAL ARACHNOID WEB AND SYRINGOMYELIA

OBJECTIVE

We present a case of syringomyelia attributed to a transverse thoracic arachnoid web at T4. The cerebrospinal fluid pressure caudal to the web was higher than the cerebrospinal fluid pressure rostral to the web, causing a syrinx in the thoracic and cervical spinal cord above the web.

CLINICAL PRESENTATION

A 43-year-old man presented with numbness and a burning pain in his left upper back and extremities. Magnetic resonance imaging showed a cervical-thoracic syrinx that terminated relatively abruptly at T4. Because of the abrupt termination of the syrinx at T4 and the slight ventral displacement of the spinal cord at this level, a dorsal arachnoid web was suspected.

INTERVENTION

A T4 laminectomy was performed. Intraoperative ultrasound before opening of the thecal sac showed a pulsating transverse dorsal arachnoid web. The dura was opened and the web resected, thus widely communicating the dorsal subarachnoid space. The syrinx dramatically decreased in size and the patient's pain improved but did not resolve completely.

CONCLUSION

In patients with presumed idiopathic syringomyelia, imaging studies should be closely inspected for the presence of a transverse arachnoid web. Surgical resection of a transverse thoracic arachnoid web with syringomyelia can result in resolution of the syringomyelia and improvement in neurological function. Syrinx formation in patients with these webs may occur in the area of the spinal cord where there is lower cerebrospinal fluid pressure, which may be either rostral or caudal to the arachnoid web. We evaluate this hypothesis by comparing our case with other published cases.

Intradural Extramedullary Arachnoid Cyst Presenting as Arteriovenous Malformation in the Thoracic Spinal Cord

We report the case of a 57-year-old man who was admitted on the basis of worsening paraplegia and incontinence. This patient had developed similar neurologic symptoms 15 previously but fully recovered after conservative medical therapy with corticosteroids. At that point, he was diagnosed with a thoracic spinal arteriovenous malformation (AVM); yet, no focal spinal lesion was identified. During this second presentation, the patient was initially worked up at an outside institution, where MR imaging revealed serpiginous flow voids along with anterior displacement or atrophy of the cord at the T5-T6 level. Edema of the mid and lower thoracic cord was also noted. While under our care, spinal arteriography and CT angiography failed to conclusively detect an underlying AVM. The patient underwent a second MR study, which showed no major interval change in the pathology. Subsequently, CT myelography of the thoracic spine demonstrated a large intradural extramedullary arachnoid cyst (or arachnoid adhesions resulting in the formation of an entrapped cystic collection). The flow voids that were seen on MR imaging were attributed to venous congestion and dilation arising from chronic compression by the cyst. Cord edema was also found to be secondary to increased interstitial pressure in the setting of this cord compression superiorly. Since surgery was not indicated for this patient at the time of diagnosis, no surgical or pathohistologic assessment was obtained to further characterize the nature of this cystic collection.

Is total excision of spinal neurenteric cysts possible?

Spinal neurenteric cysts are intradural cystic lesions. These represent a part of the spectrum of developmental anomalies. These are rare lesions. Most of the data in literature is review of case reports. This made us evaluate our results of 23 cases and review the literature. This is a retrospective study of 23 patients managed at our institute over 20 years. The slides were retrieved and histopathological features studied. Twenty patients were less than 30 years old and 21 were males. Follow-up was available for 21 patients with mean duration of 71 months (range 2 months to 23 years). The typical presentation was backache with progressive neurological deficits pertaining to the level. Atypical presentations as acute onset, recurrent episodic events and aseptic meningitis were also noted. The cervicothoracic region was the most common site. 16 patients had cyst in intradural extramedullary plane and seven had intramedullary location. Associated vertebral anomalies as hemivertebrae, Klippel-Feil and spina bifida were noted in seven patients. There were two histological types of cysts with no correlation between the type of cysts and associated vertebral anomalies and extent of outcome. Partial excision though had higher risk of recurrence, was not associated with poorer outcome. Dorsal approach is an acceptable route with reasonably good results for this lesion. Spinal neurenteric cysts present at younger age with varied clinical presentations. These are commonly located intradurally ventral to the cord. Histological types have no effect on the outcome. Total excision is the choice of treatment. However, partial excision is a feasible option in intramedullary lesions and when significant adhesions occur. Although associated with higher risk of recurrence, the outcome is still good in these patients on re-excision.

Characterization of magnetic resonance images for spinal cord tumors

Study Design

Retrospective study MR images for spinal cord tumors.

Purpose

To analyze the characteristics of MR images for spinal cord tumors, which were then verified at surgery or biopsy.

Overview of Literature

MR images are often used as the primary diagnostic imaging tool and the preoperative study of choice. The need for biopsy may be obviated because of increasingly accurate preoperative histologic diagnosis by MR images.

Methods

The study group consisted of 39 patients who had undergone MR imaging for preoperative evaluation of spinal cord tumors between September 1989 and February 2008. All patients had operations for spinal cord tumors, which were confirmed at biopsy. Of the 39 patients, 18 were men, and 21 were women. The average follow-up period was 23.8 months. The mean patient age was 46.6 years.

Results

Diagnoses included neurilemmoma (19 cases), neurofibroma (4 cases), meningioma (5 cases), hemangioma (3 cases), giant cell tumor (1 case), ganglioneuroma (1 case), lymphoma (1 case), neuroblastoma (1 case), and metastatic tumor from the prostate (1 case). The remaining 3 cases were composed of arachnoid cysts (2 cases) and a vascular malformation (arteriovenous malformation, 1 case).

Conclusions

MR images are the preoperative modality of choice in the evaluation of spinal cord tumors. MR images can narrow the differential diagnosis and guide surgical resection.

Intradural extramedullary arachnoid cyst of the thoracic spine associated with cord compression

In this report, a 55-year-old Caucasian women with an arachnoid cyst of the thoracic spine is presented. This cyst remained undiagnosed because of the nonspecific nature of her symptoms over approximately three months. Only when she started to complain of ataxia, a posterior fluid collection compressing the spinal cord was found in MRI. Even though preoperative diagnosis remained uncertain, this additional neurological dysfunction warranted surgical treatment. Surgery was successful with respect to in-toto removal of the intradural, extramedullary cyst, reversal of cord compression and symptoms. Histological diagnosis was of an arachnoid cyst.

Differentiation between pediatric spinal arachnoid and epidermoid-dermoid cysts: is diffusion-weighted MRI useful?

BACKGROUND

Appropriate differentiation between epidermoid-dermoid and arachnoid cysts is important for patient management. MRI has had limitations in differentiating these two types of cysts, especially in the region of the spinal cord.

OBJECTIVE

To evaluate the role of diffusion-weighted (DW) MRI for differentiation between spinal arachnoid and epidermoid-dermoid cysts.

MATERIALS AND METHODS

Four children underwent conventional and DW MRI. Turbo spin-echo imaging was used to obtain DW images.

RESULTS

On conventional MRI, low T1-W and high T2-W signal was present in all lesions. DW imaging showed restricted diffusion in two patients with epidermoid-dermoid cysts and no water restriction in two patients with arachnoid cysts. Three of four children had extramedullary lesions and one patient had an intramedullary lesion. Three children had surgery, two with epidermoid-dermoid cysts and one with arachnoid cyst. Diagnosis was confirmed by histopathology. One child with a thoracic arachnoid cyst had stable clinical imaging findings during a follow-up of 21 months.

CONCLUSION

On conventional MRI, epidermoid-dermoid and arachnoid cysts have similar signal characteristics. Initial experience with spine DW imaging shows promise in differentiating epidermoid-dermoid cysts from arachnoid cysts. Preoperative differentiation is important because it changes management and surgical approach.

Syringomyelia associated with intradural arachnoid cysts

Object

Intradural arachnoid cysts are relatively uncommon pouches of cerebrospinal fluid (CSF) found within the subarachnoid space. The authors present a series of eight symptomatic patients in whom syrinx cavities were associated with arachnoid cysts, and they discuss treatment strategies for this entity.

Methods

The population comprised eight men whose mean age was 50 years (range 35–81 years). All patients experienced gait difficulty, and it was the chief complaint in seven; arm pain was the primary complaint in one. No patient had a history of spinal trauma, meningitis, or previous spinal surgery at the level of the syrinx cavity or arachnoid cyst. In each patient imaging revealed a syrinx cavity affecting two to 10 vertebral levels. Posterior thoracic arachnoid cysts were found in proximity to the syrinx cavity in each case. There was no evidence of cavity enhancement, Chiari malformation, tethered cord, or hydrocephalus.

All patients underwent thoracic laminectomy and resection of the arachnoid cyst wall, and postoperative neurological improvement was documented in each case. The mean follow-up duration was 19 months (range 4–37 months). Follow-up magnetic resonance imaging demonstrated the disappearance of the arachnoid cyst and a significant decrease in syrinx cavity size in each patient.

Conclusions

Spinal arachnoid cysts can be associated with syringomyelia, likely due to alterations in normal CSF dynamics. In symptomatic patients these cysts should be resected and the normal CSF flow restored. The results of the present series indicate that neurological improvement and reduction in syrinx cavity size can be achieved in patients with syringomyelia associated with intradural arachnoid cysts.

Spinal intramedullary neuroepithelial (ependymal) cyst. A rare cause of treatable acute para paresis

An 8-yr-old female child presented with acute onset of severe pain in the lower limbs and difficulty in walking. Spine MRI showed hyperintense signals on T2 weighted images at T2-T3 level, which was intramedullary in location. The patient was operated and histopathology reported as neuroepithelial cyst. Spinal intramedullary neuroepithelial cysts are rare. Spinal cord compression due to the cyst is very uncommon and because of its rarity the present case is being reported. The clinical features, embryogenesis and literature were reviewed briefly.

Compression médullaire par kystes arachnoïdiens

Spinal arachnoid cysts are considered to be rare entities, intradural locations are even less common. We report two cases of patients (two women aged 77- and 21-year-old) who presented spinal cord compression by intradural arachnoid cysts. For the second patient, repeated surgical procedures were necessary to improve the neurological status. After presenting the case reports, we expose the pathophysiological mechanisms and clinical features, and the surgical difficulties of treating this rare cause of spinal cord compression.

Syringomyelia associated with intradural arachnoid cysts

Object

Intradural arachnoid cysts are relatively uncommon pouches of cerebrospinal fluid (CSF) found within the subarachnoid space. The authors present a series of eight symptomatic patients in whom syrinx cavities were associated with arachnoid cysts, and they discuss treatment strategies for this entity.

Methods

The population comprised eight men whose mean age was 50 years (range 35–81 years). All patients experienced gait difficulty, and it was the chief complaint in seven; arm pain was the primary complaint in one. No patient had a history of spinal trauma, meningitis, or previous spinal surgery at the level of the syrinx cavity or arachnoid cyst. In each patient imaging revealed a syrinx cavity affecting two to 10 vertebral levels. Posterior thoracic arachnoid cysts were found in proximity to the syrinx cavity in each case. There was no evidence of cavity enhancement, Chiari malformation, tethered cord, or hydrocephalus.

All patients underwent thoracic laminectomy and resection of the arachnoid cyst wall, and postoperative neurological improvement was documented in each case. The mean follow-up duration was 19 months (range 4–37 months). Follow-up magnetic resonance imaging demonstrated the disappearance of the arachnoid cyst and a significant decrease in syrinx cavity size in each patient.

Conclusions

Spinal arachnoid cysts can be associated with syringomyelia, likely due to alterations in normal CSF dynamics. In symptomatic patients these cysts should be resected and the normal CSF flow restored. The results of the present series indicate that neurological improvement and reduction in syrinx cavity size can be achieved in patients with syringomyelia associated with intradural arachnoid cysts.

Giant cervicothoracic extradural arachnoid cyst: case report

The pathogenesis, etiology, and treatment of the spinal arachnoid cyst have not been well established because of its rarity. A 57-year-old male was presented with spastic quadriparesis predominantly on the left side. His radiological examination showed widening of the cervical spinal canal and left neural foramina due to a cerebrospinal fluid - filled extradural cyst that extended from C2 to T2 level. The cyst was located left anterolaterally, compressing the spinal cord. Through a C4–T2 laminotomy, the cyst was excised totally and the dural defect was repaired. Several features of the reported case, such as cyst size, location, and clinical features make it extremely unusual. The case is discussed in light of the relevant literature.

Spinal intradural juxtamedullary cysts in the adult: surgical management and outcome

OBJECTIVE

Intradural nonneoplastic cysts compressing the spinal cord are rare lesions. We retrospectively analyzed a series of patients harboring this entity with regard to clinical and radiological features, surgical management, and follow-up results.

METHODS

In a retrospective study, we reviewed the medical charts, radiological investigations, and follow-up data of 11 women and 10 men (mean age, 43.6 yr) with intradural juxtamedullary spinal cysts, which were consecutively treated microsurgically at our institutions between January 1995 and January 2003. All lesions were approached via a laminectomy, hemilaminectomy, or laminoplasty at the corresponding vertebral levels and histopathologically verified. The patients were routinely scheduled for clinical follow-up 2 and 6 months after surgery. Baseline postoperative magnetic resonance imaging (MRI) was ordered 6 months after surgery. Thereafter, follow-up was performed at 1-year intervals, with neurological examination and MRI.

RESULTS

According to presenting symptomatology, two main patient groups could be differentiated: one group with a myelopathic syndrome (10 patients) and another group with a predominant radicular pain syndrome (8 patients). Histopathological examination revealed 16 arachnoid cysts, 4 neuroepithelial cysts, and 1 cervical nerve root cyst. Most arachnoid cysts (12 cases) were located on the dorsal aspect of the thoracic spinal cord. The mean craniocaudal extension of these cysts was 3.7 vertebral levels, and complete resection was performed. In four patients, the arachnoid cyst was situated ventral to the spinal cord and involved up to 17 vertebral levels. These patients had a history of major spinal trauma, and the cyst was generously fenestrated at its greatest circumference as depicted on preoperative MRI scans. The four neuroepithelial cysts and the cervical nerve root cyst were located on the ventral or ventrolateral aspect of the spinal cord, and their maximum sagittal extension was two spinal vertebral levels. Symptoms in all but two patients demonstrated major improvement; in particular, radiating pain disappeared immediately after surgery. There was no cyst recurrence on MRI after a mean follow-up period of 3.2 years.

CONCLUSION

Intradural cysts should be considered in the differential diagnosis of lesions causing myelopathy and/or a radicular pain syndrome. Microsurgical resection or generous fenestration in cysts with large craniocaudal extensions effectively ameliorated patients' symptomatology. A description of the first documented case of a surgically treated intradural cervical nerve root cyst is provided.

Intraspinal epidermoid cyst successfully treated with radiotherapy: case report

OBJECTIVE AND IMPORTANCE

Epidermoid cysts are benign lesions that account for 0.7% of all intraspinal tumors. Standard treatment is complete resection. The recurrence rate after surgery cannot be estimated from the scarce literature, but it has been acknowledged that, in some patients, curative surgery may be impossible and temporary relief of symptoms is the only aim.

CLINICAL PRESENTATION

In 1996, a 59-year-old woman presented with a 30-year history of a spinal epidermoid cyst, for which she had previously undergone eight operations. Spastic paraplegia of the lower limbs had been present from initial diagnosis, and the neurological level had moved upward to C6. At the time of presentation, paresthesia in her arms and hands had developed. A magnetic resonance imaging scan revealed typical sequelae of previous surgery and a fibrotic region starting at the level of C5-C6 with formation of a cyst that extended to the conus terminalis. The spinal cord could not be visualized caudally at C7.

INTERVENTION

Because both patient and surgeons did not want further surgical interventions that might comprise upper limb function, radiotherapy was performed. A dose of 46 Gy was delivered to the cervicothoracic spine (C4-T1) by opposing anteroposterior high-energy photon beams. The treatment was well tolerated, and after treatment, the patient's clinical symptoms improved slightly, without evolution on magnetic resonance imaging.

CONCLUSION

Irradiation was effective in stabilizing the patient's disease. Although radiotherapy is not established in the treatment of epidermoid cysts, it should be considered as an alternative to palliative surgery and in patients who cannot undergo operations.

Magnetic resonance imaging—guided percutaneous fenestration of a cervical intradural cyst

✓ The authors describe the case of a high cervical, intradural extramedullary cyst located anterior to the spinal cord in a 13-year-old boy. The lesion was fenestrated percutaneously by using real-time magnetic resonance (MR) imaging guidance and a local anesthetic agent. The patient's symptom, severe exercise-induced headache, immediately resolved after treatment. Nine months later, complete disappearance of the cyst was confirmed on MR imaging and computerized tomography myelography. Magnetic resonance imageing—guided fenestration can be considered a minimally invasive option for intradural cystic lesions.

[Prognostic factors in the treatment of the intradural extramedullary tumors: a study of 44 cases]

Between 1993 and 1999, 44 patients submitted to resection of an expansible intradural extramedullary lesion who filled protocol requirements of appropriate follow up were studied. Patients were constituted by 43.2% female and 56.8% male. The mean age was 32.9 years old. Lesion most common location was at the thoracic spine, with 45.5% of the cases, followed by the lumbar level with 18.2%. Tumor extension varied from 1 to 7 vertebral segments, with an average of 2.5 levels. Schwannoma, with 65,9% of the cases, was the most frequent lesion, followed by meningioma with 20.5%. There were 2 cases of neurofibroma and 1 case of paraganglioma, neuroenteric cyst, metastasis and malignant schwannoma. The evolution was of improvement in 56.8%, stability in 31.8% and of worsening in 11.4%. There was no mortality related to the surgical procedure. All cases of worsening had total resection and they had lesions located in the thoracic segment. Total resection is the ideal modality of surgical treatment. However, at the thoracic level, where the peculiarities of spine irrigation prevail, surgical morbidade may be higher (p=0.014).

Symptomatic spinal arachnoid cysts: report of two cases with review of the literature

STUDY DESIGN

Two unusual cases of intradural extramedullary noncommunicating arachnoid cysts are presented, with a review of literature.

OBJECTIVE

To assess surgical excision results in the reversal of symptoms and neurologic deficits.

SUMMARY OF BACKGROUND DATA

Most patients harboring arachnoid cysts are asymptomatic. Noncommunicating intradural extramedullary arachnoid cysts are more rare than communicating intradural extramedullary cysts. Noncommunicating intradural extramedullary arachnoid cysts are a very rare cause of spinal cord compression. Rarely, these cysts can present with bizarre symptoms, such as angina.

MATERIALS AND METHODS

The first case, a 75-year-old woman, presented with progressive paraparesis. The second case, a 40-year-old man, presented with signs and symptoms of angina, with mild spasticity in the lower limbs. In both cases, magnetic resonance imaging revealed compression of the spinal cord as the etiology of presentation. The first patient is the second oldest patient in the literature with an idiopathic spinal arachnoid cyst. The second case has an unusual presentation that has not previously been reported in the literature.

RESULTS

Both cases underwent surgical excision of the arachnoid cyst, with resolution of symptoms and reversal of neurologic deficit.

CONCLUSIONS

Our experience indicates that complete recovery from an arachnoid cyst is possible after surgical excision, even when symptoms are present for a long duration, even in the elderly.

A recurrent intradural cervical neurenteric cyst operated on using an anterior approach: a case report

The neurenteric cyst is an uncommon congenital lesion. In most reported cases, it has been operated on via a posterior approach using a laminectomy, despite the fact that the cyst is usually located ventral to the spinal cord. Reports have shown that early postoperative results have been good with the posterior approach, but very few studies of the long-term postoperative recurrence of neurenteric cysts have been conducted. Here, we report on a case of recurrent neurenteric cyst that was operated on using an anterior approach.A 42-year-old woman presented with a cervical neurenteric cyst that had recurred eight years after its partial removal via a posterior approach. The patient complained of pain on the lateral side of her upper arms, and an magnetic resonance imaging showed that the recurrent cyst was located ventral to the spinal cord and compressed the cord dorsally at the C4-6 level. The patient was operated on via an anterior approach using a vertebrotomy at the lower half of C5 and the upper half of C6. The cyst was attached to the spinal cord firmly and was subtotally removed, with the thickest portion adhering to the cord not being removed. The caudal end of the cyst was observed with the assistance of a rigid endoscope.A neurenteric cyst may recur after partial removal, and the patient's condition may deteriorate during postoperative follow-up. The anterior surgical approach provides good visualization and facilitates safe removal of the lesion.

Intramedullary arachnoid cyst. Case report

The authors present an unusual case of intramedullary arachnoid cyst diagnosed in a patient after the lesion was resected. A wide decompressive surgery was performed and the lesion removed. Histopathological findings were consistent with the diagnosis of arachnoid cyst. Postoperatively the patient exhibited marked improvement in neurological status. To the best of the authors' knowledge, there is no case report of intramedullary arachnoid cyst reported in the literature. With the advent of newer neuroimaging modalities such as magnetic resonance imaging the number of cases of intramedullary arachnoid cysts encountered in the future may increase.

Intradural arachnoid cyst associated with thoracic spinal compression fracture: 7-year follow up after surgery

STUDY DESIGN

A case report with long-term follow after a surgical procedure.

OBJECTIVES

To describe a case of intradural arachnoid cyst secondary to a compression fracture in the thoracic spine and to report long-term results after surgical treatment with hemilaminectomy.

SETTING

Osaka, Japan.

METHODS

A 68-year-old man who had a traumatic intradural arachnoid cyst following an adjacent compression fracture of T5 underwent surgery. Intraoperatively, after recognition of intradural arachnoid cyst with an echogram following hemilaminectomy, the dural sac was incised and the arachnoid cyst was resected under microscopic observation.

RESULTS

At 7 years after the operation, the low intensity within the vertebral body of the compression fracture had resolved and the spinal cord remained in its normal shape and position. No progression of kyphotic deformity was detected.

CONCLUSION

A compression fracture of the thoracic spine can be associated with an intradural arachnoid cyst. Microscopic resection via hemilaminectomy for the cyst showed a good result in a 7-year follow up.

Dorsal arachnoid web with spinal cord compression: variant of an arachnoid cyst? Report of two cases

Spinal arachnoid cysts are diverticula of the subarachnoid space that may compress the spinal cord; these lesions are most commonly found in the thoracic spine. Two patients who presented with thoracic myelopathy were noted on magnetic resonance imaging to have focal indentation of the dorsal thoracic cord, with syringomyelia inferior to the site of compression. Both patients were found at operation to have discrete arachnoid "webs" tenaciously attached to the dura mater and pia mater. These webs were not true arachnoid cysts, yet they blocked the flow of cerebrospinal fluid (CSF) and caused focal compression of the spinal cord. The mass effect appeared to be the result of a pressure gradient created by the obstruction of CSF flow in the dorsal aspect of the subarachnoid space. Both patients responded well to resection of the arachnoid web. Arachnoid webs appear to be rare variants of arachnoid cysts and should be suspected in patients with focal compression of the thoracic spinal cord.

Infantile arachnoid cyst compressing the sacral nerve root associated with spina bifida and lipoma--case report

A 2-year-old boy presented with a rare sacral arachnoid cyst manifesting as gait disturbance. Neuroimaging revealed an intradural cyst in the sacral nerve root sheath associated with spina bifida occulta and a lipoma at the same level. At surgery, the conus medullaris was situated at the L-1 level and not tethered. The highly pressurized arachnoid cyst had exposed the dural sheath of the left S-2 nerve root and compressed the adjacent nerves. An S-2 nerve root pierced through the cyst. There was no communication between the cyst and spinal arachnoid space. We thought the one-way valve mechanism had contributed to the cyst enlargement and the nerve compression. Radical resection of the cyst was not attempted. A cyst-subarachnoid shunt was placed to release the intracystic pressure. Postoperatively, his gait disturbance improved and no deterioration occurred during the 4-year follow up. Both tethered cord syndrome and sacral arachnoid cyst in the nerve root sheath should be considered in pediatric progressive gait disturbance. Cyst-subarachnoid shunt is an alternative method to cyst resection or fenestration to achieve neurological improvement.

Spinal intramedullary ependymal cyst: a case report

BACKGROUND

Spinal intramedullary ependymal cysts are extremely rare. Only seven pathologically proven cases have been reported in the literature.

METHOD

We present an 18-month-old female with thoracic spinal intramedullary ependymal cyst that was diagnosed pathologically.

RESULTS

Histological diagnosis was made by light microscopy after immunostaining. After partially removing the cyst wall and establishing communication between the cyst and the subarachnoid space, the patient improved neurologically.

CONCLUSIONS

For spinal intramedullary ependymal cyst we recommend diagnosis by MR imaging without myelography, then enucleation of the cyst, if possible. Otherwise, we remove the cyst wall as much as possible and create adequate communication between the cyst and the subarachnoid space.

Anterior thoracic intradural arachnoid cysts

Anterior thoracic intradural arachnoid cysts (ATIACs) are a rare cause of spinal cord and nerve root compression, for which different treatment strategies have been proposed. Although ATIAC represents a well-known clinical entity, the choice of surgical method has not been uniform, and no study has been specifically designed to compare the results of the different treatment options adopted.

The authors report the case of a 40-year old man with a 1-year history of dorsal pain, weakness in the lower extremities, gait disturbance, and mild sexual and urinary dysfunction. On neurological examination spastic paraparesis, lower-extremity hypertonia, and hypesthesia below T-2 were demonstrated. Magnetic resonance imaging revealed the presence of an ATIAC at the T-2 level. The patient underwent complete microsurgical removal of the cyst.

The authors conducted a Medline search of the relevant literature from 1966 to 1998 and also obtained data on other cases in which patients underwent surgical treatment of ATIAC. The literature search yielded five such cases. Treatment strategies were complete excision and fenestration followed by placement of a shunt. In addition, one case was characterized by intraoperative cyst rupture during retraction of the spinal cord.

Correct preoperative workup coupled with microneurosurgical technique allow for successful removal of the lesion and excellent outcome. Based on the literature review and the results in our case, the complete excision of ATIAC is associated with an excellent outcome, which is different from results achieved using other surgical strategies.

Cauda equina syndrome due to lumbosacral arachnoid cysts in children

We describe the clinical, neuroradiological and surgical aspects of two children in whom symptoms attributable to cauda equina compression were caused by spinal arachnoid cysts. The first patient presented with recurrent urinary tract infections due to neurogenic bladder dysfunction, absent deep tendon reflexes and sensory deficit in the lower limbs. The second child presented with unstable gait as a result of weakness and diminished sensation in the lower extremities. Spinal magnetic resonance imaging revealed a lumbosacral arachnoid cyst in both patients. During surgery the cysts were identified and excised. Two years after surgery, the sensory deficits of the first patient have disappeared and patellar and ankle reflexes can be elicited, but there is no improvement in bladder function. Neurological examination of the second patient was normal. We conclude that the diagnosis of cauda equina syndrome should prompt a vigorous search for its aetiology. Lumbosacral arachnoid cysts are a rare cause of cauda equina syndrome in children.

Intramedullary neurenteric cyst without any associated malformation. One case evaluated by RMI and electron microscopic study

A 46 years old woman presented with several years history of low back pain. For five years she suffered from weakness of the left lower limb and three years later she experienced an episode of right foot weakness. She suffered too from occasional urinary urgency. The examination showed decreased power and diminished sensory perception in the left leg. On myelography, a block at L2 level was observed. RMI evaluation showed an intramedullary cyst in the anterior part of the spinal cord without any enhancement of its wall by the Gadolinium. At operation a thin-wall cyst was found containing clear fluid. After a biopsy of the wall, a cystosubarachnoid shunt was performed. Histological examination of the surgical sample showed a simple cuboidal epithelium lying on collagen fibrills. Electron microscopic studies showed ciliated cells with a clearly-visible basement membrane. The diagnosis of neurenteric cyst was confirmed. In the postoperative course the patient complained about sensory loss of the legs and the perineal area. Six months later, she exhibited a sensory disturbance of the feet and the right sacral area, a motor deficit of the distal left leg without urinary disturbance. Neurenteric cysts are dysraphic lesions which can be observed without other abnormalities. They are usually extramedullary and the intramedullary forms are very rare: among 5 cases reported in the literature, one has been evaluated by RMI. In the absence of enhancement by the Gadolinium, the other possible diagnosis seems an ependymal cyst. Contrary to extramedullary forms the postoperative course of intramedullary neurenteric cysts are not always eventful. Because the cyst wall cannot be removed, repeated RMI are desirable in the follow-up.

Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature

STUDY DESIGN

This case report describes the unique occurrence of acquired intradural spinal arachnoid cyst after lumbar puncture, which was proven radiographically and surgically.

OBJECTIVES

To review and explore complications of lumbar puncture in the context of subsequent cyst development and to review the incidence, presentation, pathogenesis, and management of spinal intradural arachnoid cysts.

SUMMARY OF BACKGROUND DATA

The etiology of the spinal intradural arachnoid cyst remains obscure; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and assumed by many authors to be congenital.

METHODS

A 20-Year-old woman with back and leg pain underwent lumbar myelography that yielded normal results with no evidence of arachnoid cyst at that time. Within 5 months, clinical symptoms of cauda equina compression and an S1 radiculopathy developed. Subsequent myelography and magnetic resonance imaging revealed a lumbar spinal arachnoid cyst. There was no history of intervening trauma or arachnoiditis. The lumbar puncture was thought to be the cause of the arachnoid cyst.

RESULTS

A laminectomy was performed with complete excision of the arachnoid cyst. The patient had an unremarkable postoperative course with excellent relief of her symptoms.

CONCLUSIONS

This case provides supporting evidence for the traumatic etiology of spinal intradural arachnoid cyst. The development of an intradural spinal arachnoid cyst should be included as a possible complication of lumbar puncture.

Multiple communicating intradural arachnoid cysts: usefulness of myelography and myelo-computed tomography using both lumbar and cervical punctures. Case report

We report a case of multiple communicating intradural cystic lesions. Magnetic resonance imaging did not demonstrate the lesions. Neuroradiological diagnosis of the intradural arachnoid cysts was made from myelography and myelo-computed tomography using both lumbar and cervical punctures. These procedures give us useful information about flow dynamics in the spinal subarachnoid space.

Intradural bronchogenic cysts

The pathological findings of an intradural and extramedullary cyst in the mid cervical spinal canal are described in a 55 year old woman who presented with a short history of pain and paraesthesia of the right arm. Intradural well defined solitary cystic lesions in the spinal canal are uncommon, their pathogenesis is poorly understood, and their nomenclature is confusing. In this case the cyst was a bronchogenic cyst; these are a rare form of such cysts and they are thought to be a malformation arising from a split notochordal syndrome and not a teratoma.