Intraspinal neurenteric cysts--report of three paediatric cases

Spinal Neurenteric Cyst of the Ventral Cervicothoracic Junction With Klippel-Feil Syndrome as a Symptom of Progressive Myelopathy: A Case Report

Neurenteric cysts are rare and account for only 0.7%-1.3% of all spinal tumors. Spinal neurenteric cysts are associated with spina bifida, split-cord malformations, and Klippel-Feil syndrome, a rare congenital disorder characterized by fusion of two or more cervical vertebrae. Klippel-Feil syndrome is rarely accompanied by neurenteric cysts. In this case report, we describe a cervicothoracic junction neurenteric cyst associated with Klippel-Feil syndrome in a 30-year-old man who presented with a 2-month history of neck pain with radiation of pain into both arms and a 1-month history of weakness in the left arm. Magnetic resonance imaging (MRI) of the spine revealed an expansive intradural extramedullary cystic lesion anterior to the spinal cord at the cervicothoracic junction. The neurenteric cyst was removed using an anterior approach, accompanied by C5-C6 corpectomy. The patient's condition improved postoperatively, and he was discharged after postoperative MRI. Spinal neurenteric cysts should be considered in the differential diagnosis in cases of vertebral developmental abnormalities concurrent with intraspinal cysts.

Computed Tomographic Evaluation of Mediastinal Masses - An Experience at a Tertiary Care Centre in Bareilly, India

BACKGROUND Mediastinal lesions are one of the most common lesions of the chest in children and adults. Multidetector computed tomography (MDCT) is the most common investigation done in patients with suspected abnormalities on X-ray. Crosssectional imaging visualises complex anatomy, helps in predicting the tissue of origin, characterises lesions and depicts the extent of involvement of adjacent structures. Complications of mediastinal lesions and emergent conditions, for example, sealed pneumo-mediastinum, tracheoesophageal / pulmonary fistula, a peri-lesional abscess can be well assessed on CECT. The possibility of the lesion as benign or malignant and can be well predicted. Vascular lesions like aneurysms, dissections, and embolism can be evaluated and stable lesions requiring to follow up and unstable lesions requiring emergent treatment are differentiated using MDCT. The objectives of the study were to characterize and identify features pathognomic of specific mediastinal masses on computed tomography and find out diagnostic accuracy of MDCT in mediastinal masses and compare them with pathological results wherever possible. METHODS A prospective study was done in the Department of Radiodiagnosis, Rohilkhand Medical College and hospital, Bareilly for a span of 1 year from November 2018 to October 2019. Our study included 51 patients. Mediastinal lesions were assessed based on size, compartmental localisation, and attenuation and enhancement patterns. RESULTS In our study with 51 patients, 16 lesions were non-neoplastic and 35 were neoplastic lesions. Anterior mediastinal lesions constituted maximum lesions followed by middle and posterior mediastinal lesions. Lymph nodal masses were the commonest lesions out of which 4 cases were tubercular in origin, 4 were lymphomatous and 4 were metastatic. Neurogenic tumours were most common in the posterior mediastinum consisting of 6 cases. 2 vascular lesions were seen, 1 of aortic aneurysm and 1 aortic dissection. The diagnostic accuracy of MDCT was 93 % compared to histopathological results. Computed tomography (CT) plays a major role in evaluating mediastinal masses by virtue of its excellent multiplanar reconstruction capabilities and demonstration of exact anatomic relationships. However, in many situations, histopathological examination is needed to know the exact tissue of origin and for further management. CONCLUSIONS We conclude that CT has a major role in evaluating mediastinal masses regarding location, extent and tissue characterization. It can display certain features pathognomic for particular masses thus obviates the need for invasive procedures. KEY WORDS Mediastinal Lesions, MDCT, Imaging Modality, Histopathology

Concurrent Thoracic Spinal Intradural Extramedullary Epidermoid and Neurenteric Cyst in a Spinal Dysraphism Child

INTRODUCTION

Intraspinal epidermoid cysts are congenital or acquired in origin; whereas intraspinal neurenteric cysts (NECs) are of congenital origin. Their individual association with spinal dysraphism and vertebral segmentation anomalies is very well known.

CASE PRESENTATION

We hereby report a case of concurrent intradural extramedullary epidermoid and NEC at adjacent vertebral levels in a spinal dysraphism child, not reported in English Literature till now.

CONCLUSION

Multiple spinal lesions related to any/all of the 3 germ layers can coexist at same or adjacent vertebral levels in the same patient and surgical planning shown to be done accordingly.

Endodermal Cysts of the Central Nervous System: Review of the Literature and a Case Report

Context

Endodermal cysts are rare benign developmental cysts lined by mucin-secreting and/or ciliated, cuboidal, or columnar epithelium of probably endodermal origin.

Aims

Endodermal cysts are rarely intracranial, frequently located in the posterior fossa. Supratentorial location is the most infrequent and only few cases are reported in the literature, included our case.

Settings and Design

The authors report a case of intracranial supratentorial endodermal cyst with a review of the literature.

Subjects and Methods

A 40-year-old woman was admitted to our department because of progressive gait disorder for 3 months due to right brachial and crural motor deficit associated to right crural sensory disorder (tactile hypesthesia) and right Babinski response at neurological examination due to an endodermal cyst located in the left frontoparietal convexity.

Discussion

Total resection of endodermal cysts is recommended, despite their location and adhesion to the surrounding structures, due to its high risk of recurrence. Fenestration of the cystic content into the subarachnoid cistern may cause obstructive hydrocephalus or chemical meningism.

Results

Although rare, surgeons should be aware that these lesions must be differentiated clinically, radiologically, and histologically from other supratentorial cystic lesions.

Congenital Spinal Cysts: An Update and Review of the Literature

Congenital spinal cysts are rare and encompass a wide variety of diseases including arachnoid, enterogenous, teratomatous, neurenteric, foregut, bronchogenic, epithelial, ependymal, dermoid, and epidermoid cysts. Here, we elucidate the epidemiology, pathology, pathogenesis, and diagnostic findings of the most common congenital spinal cysts, followed by a discussion of their presentation and treatment options. Differentiating the cause of each lesion is crucial for targeted clinical and surgical management for the patient. Our review describes how arachnoid cysts can be observed, fenestrated, percutaneously drained, or shunted; however, the primary goal for neurenteric, dermoid, and epidermoid cysts is removal. Further, we discuss how patient presentation is dependent on the rate of growth and location of compression on the spinal cord and nerve roots. However, although many of these lesions are discovered incidentally on imaging, the spectrum of possible symptoms include pain, weakness, ataxia, bladder incontinence, and progressive or acute neurologic deficits. We present and review the histology and imaging of a variety of cysts and discuss how although the goal of treatment is resection, the risks of surgery must be considered against the benefits of complete resection in each case.

Intramedullary spinal tumor-like lesions

The development of magnetic resonance imaging (MRI) has led to an increasingly frequent detection of changes in the spinal cord. The most common intramedullary lesions are: demyelinating; vascular; inflammatory; infectious; and congenital, largely called tumor-like lesions. Spinal cord tumors are relatively rare, as compared with brain tumors. The hardest task is to conclude whether the spinal cord lesion is a tumor or a tumor-like lesion. This review is intended to help evaluate the spinal cord and gives an overview of the tumor-like lesions occurring in the spinal cord along with their characteristic.

Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child: A case report and literature review

RATIONALE

Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder.

PATIENT CONCERNS

A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis.

INTERVENTIONS

He was operated on successfully and the cervical lordosis and pain resolved.

OUTCOMES

The child recovered well with no tumor recurrence and massive improvement of his life.

LESSONS

The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.

Spinal Neurenteric Cyst in Association with Klippel-Feil Syndrome: Case Report and Literature Review

BACKGROUND

Spinal neurenteric cysts, also known as endodermal or enterogenous cysts, are rare epithelium-lined structures of presumed endodermal origin. Congenital vertebral anomalies are frequently seen in patients with neurenteric cysts, most typically anterior spina bifida, butterfly vertebrae, and hemivertebrae. However, few series of intraspinal neurenteric cysts accompanied by Klippel-Feil syndrome have been reported previously.

CASE DESCRIPTION

Our purpose is to present the clinical, radiological, and histological results of a 29-year-old patient with a spinal neurenteric cyst associated with Klippel-Feil syndrome and to review previous reported cases of neurenteric cysts associated with Klippel-Feil syndrome. In our patient, cervical radiography demonstrated C5-T1 vertebral fusion and magnetic resonance imaging revealed a large intradural cystic mass. The cystic lesion was removed successfully, and it was histopathologically diagnosed as a neurenteric cyst.

CONCLUSION

Neurenteric cysts should always be considered in the differential diagnosis of an intraspinal cystic mass seen in the setting of vertebral anomalies.

Mature cystic retroperitoneal teratoma with well differentiated renal elements: relation to spinal dysraphism

Retroperitoneum is a relatively uncommon site for pediatric teratomas. Rarely, such tumors can have an intraspinal extension and few cases of retroperitoneal teratomas associated with spinal dysraphism have been reported. Teratomas consist of tissues arising from all three embryonic layers. However, mature renal tissues in the form of glomeruli and tubules are sparingly found in teratomas. A 15-day-old female presented with spina bifida occulta and on evaluation a cystic presacral mass was detected. Intraoperatively the cyst was found densely adherent to the hemivertebrae but not entering the spinal canal. Histopathological examination confirmed a mature cystic teratoma but also demonstrated presence of mature renal elements in the cyst wall. The teratomas lying in proximity to spine and associated with spinal dysraphism are likely to contain mature renal tissues or even nephroblastic elements. It supports the dysembryogenic model of origin of intradural teratomas from native progenitor cells rather than aberrantly migrated germ cells.

A 3-month-old infant with upper extremity weakness

A detailed history should be obtained for all pediatric patients presenting with acute neurological changes. A thorough physical exam can help narrow the possible etiologies. Prompt imaging can lead to a more precise understanding of the level of neuronal involvement. Neurenteric cysts and fistulas are extremely rare in the pediatric population, with most occurring in the lower cervical and upper thoracic region. Most patients will present with symptoms related to cord or brainstem compression; however, associated infections have been reported. Epidural abscesses are also rare, occurring in the mid-thoracic or lower lumbar region. When there is no communication between the gastrointestinal tract and spinal canal, S. aureus accounts for most of these infections. When gram-negative pathogens, such as E.coli and E. cloacae, are isolated, it is imperative to evaluate for the presence of neurenteric fistulas. Because of numerous anomalies associated with neurenteric cysts, the entire spinal canal should be evaluated completely.

Microsurgical excision of the craniocervical neurenteric cysts by the far-lateral transcondylar approach: case report and review of the literature

Neurenteric cysts in the anterior craniocervical junction (CCJ) region can be found in extremely rare cases. We report one case with craniocervical neurenteric cyst that was excised by the far-lateral transcondylar (FLT) approach. A 43-year-old man presented with a history of recurrent episodes of mild neck pain and dysesthesia in his bilateral hands of 2 years' duration with rapid deterioration 3 weeks prior to admission. Magnetic resonance imaging (MRI) of the CCJ region revealed a well-defined intradural cystic lesion located ventral from the pontomedullary junction to C1 vertebra with medulla and C1 cord compression. This patient underwent total excision of the lesion via the FLT approach without any postoperative neurological deficits, and the histopathologic diagnosis was neurenteric cyst. Follow-up MRI has revealed no evidence of recurrence. The clinical features, imaging studies, and surgical approach options involved in resecting craniocervical neurenteric cysts are discussed, along with a review of the literature.

Giant presacral neurenteric cyst with anomalous sacrum in an adult patient

A rare case of an adult patient with a giant neuro-enteric cyst in a presacral location is reported. It had unique histological features of a stratified squamous epithelial lining with neuro-epithelial and smooth muscle components. There was associated sacral dysgenesis with spina bifida. The possible pathogenesis of this entity is discussed.

Laparoscopic resection of a giant retroperitoneal T-shaped duplication of descending colon

The authors encountered an uncommon case of a retroperitoneal T-shaped duplication that presented with a communication with the descending colon, descending downward along the descending colon posterolaterally, passing through the sigmoid mesocolon and across the midline at the level of L5 to S1 vertebrae, ascending behind the ascending mesocolon, and terminating beneath the third portion of the duodenum. Using a 3-port transperitoneal laparoscopic technique, the duplication was completely resected. On reviewing the literature, T-shaped duplication has occurred in only 4 cases; and all arose from the colon and were not associated with other anomalies. Dense adhesions between the blind end and surrounding tissues, a retroperitoneal location, and the U-shaped loop of the duplication appear to support the theory that it was the result of persistent neurenteric canal during the formation of the alimentary tract before the normal midgut-positioning process.

Congenital Anomalies of the Spine

The complexity of the congenital anomalies of the spine can make the neuroradiologic diagnosis challenging. Knowledge of spinal embryology greatly helps in the understanding and classification of these anomalies. We use the classification devised by Tortori-Donati and Rossi and find it helpful from clinical and imaging standpoints. We believe that most patients who have known or suspected congenital spinal anomalies benefit from MR imaging.

Spinal Neurenteric Cysts in the Magnetic Resonance Imaging Era

OBJECTIVE:

Neurenteric cysts are derived from displaced entodermal tissue. They are infrequently found in the ventral spinal canal with varying degrees of success in their removal. Experience with 10 such individuals is critically analyzed to aid in the diagnosis and management.

METHODS:

Ten patients, ages 4 through 55 years, with neurenteric cysts were encountered in the last 20 years. This series included three females and seven males; seven children and three adults. The follow-up periods ranged from 3 to 18 years. Three cysts were located at the ventral cervicomedullary junction, five in the midventral cervical spine, and one thoracic and one lumbosacral. The symptoms reflected the location.

RESULTS:

Six of the 10 patients had associated bony abnormalities such as bifid clivus, hemivertebrae, segmentation failures at the site of the lesion, and blocked vertebra. The patient with the thoracic spinal lesion (age, 55 yr) had symptoms from early childhood. A diplomyelia at the site of the lesion was seen in one individual and tethered spinal cord in the same adult and in a young child. Two patients had undergone laminectomy for aspiration and partial resection before referral to our institution at the time of recurrence. Cervicomedullary junction lesions were approached via the far lateral transcondylar approach; two of the cervical intramedullary lesions were resected via a ventral corpectomy with radical resection and interbody fusion. The goal in each case was complete resection to avoid recurrences.

CONCLUSION:

Spinal neurenteric cysts are ventrally located, usually intradural and extramedullary, but may insinuate into the spinal cord. They are isointense on T1 images and hyperintense on T2-weighted images on magnetic resonance imaging without true enhancement. These lesions may be associated with block and hemivertebrae with a predisposition to the craniocervical region. Partial resections have led to recurrence and arachnoiditis.

Comparative study of complex spina bifida and split cord malformation

OBJECTIVE

To see the difference in clinical profiles, radiological findings and surgical outcome of the group 1 split cord malformation and meningomyelocele (SCM with MMC) from group 2 (SCM without MMC).

METHODS

46 patients of SCM were selected from a total of 138 cases of spinal dysraphism. They were divided into two groups, based on presence or absence of MMC. Group I (SCM with MMC) n =19 patients and Group II (SCM without MMC) n=27 patients. A detail clinical evaluation and MR screening of whole spine of all cases was performed. All patients underwent surgical detethering of cord. After an average follow-up of 1.7 years, the operative results were clinically assessed and statistical significance was calculated.

RESULTS

Male to female ratio was 1:09. Mean age of presentation was 3.6 years. Cutaneous markers like tuft of hair, cutaneous haemangioma, etc, had a higher incidence in group II in comparison to group I (50% vs 10.5%). The incidence of motor deficits was significant in group I in comparison to group II (63% vs 40%). The incidences of sensory loss, trophic ulcers, sphincteric dysfunction and muscle atrophy were relatively more common in group I patients, while neuro-orthopedic deformities such as congenital telepes equinovarus (CTEV), scoliosis and limb shortening were more frequent (67%) in group II children as compared to group I (53%). Type I SCM has higher incidence in group I children. Low lying conus were found in 47% patient of group I, while in group II it was noticed in 69%. The associated cranial anomalies like hydrocephalus, ACM and syrinx, were slightly higher in group I patients. At surgery, dysgenetic nerve roots, neural placode, arachnoid bands and atrophic cord were seen mainly in group I. Postoperative complications like, CSF leak, pseudomeningocele and meningitis were more commonly encountered in group I patients. The patients of group II showed better operative outcome compared to group I cases.

CONCLUSION

Incidence of SCM with MMC amount to 41% of total SCM cases. Progressive neurological deficit was higher in this group (SCM with MMC) in comparison to the group harboring SCM without MMC. In view of a significant association of SCM in MMC cases, associated with other craniospinal anomalies, a thorough screening of neuraxis (by MRI) is recommended to treat all treatable anomalies simultaneously for desired outcome.

Isolated enteric duplication cysts

Two rare cases of completely isolated duplication cysts are reported. A large but asymptomatic tubular cyst hanging from a narrow pedicle arising from the base of the terminal ileal mesentery was removed in a 6-day-old boy along with correction of associated malrotation. Multiple isolated duplication cysts located in the thorax and abdomen were excised in a 10-week-old infant. Both children remained asymptomatic after surgery.

Multiple neurenteric cysts in the posterior fossa and cervical spinal canal--case report

A 46-year-old woman presented with multiple neurenteric cysts in the posterior fossa and spinal canal. Neuroimaging demonstrated neurenteric cysts in the interspace between the left cerebellar hemisphere and vermis, the lateral side of the right cerebellar hemisphere, and the ventral side of the spinal cord at the C-2 and C-4 levels. Total resection of the paravermian cyst and partial removal of the spinal cyst at the C-4 level were performed. Histological examination showed the cyst wall consisted of single or multiple layers of columnar epithelial cells with secretory granules, with mucin secretion verified by periodic acid-Schiff staining. Immunohistochemical staining showed the walls were positive for the cytokeratin, epithelial membrane antigen, and carcinoembryonic antigen, and negative for glial fibrillary acidic protein and S-100 protein. These findings confirmed the endodermal origin. The diagnosis was neurenteric cyst. The paravermian cyst disappeared, but the spinal cyst at the C-4 level recurred 8 months later. Reoperation became necessary 16 months later. The other two cysts also showed enlargement at 6 or 15 months. Total removal of neurenteric cyst is recommended if possible.

Iso-intense neuroenteric cyst in the lower cervical spine treated with ventral resection and anterior fusion utilising sternal notch exposure: case report, technical note and literature review

A 36-year-old female patient with a long-standing asymptomatic lower thoracic scoliosis presented with sensory symptoms involving all limbs. MRI scan demonstrated a rounded ventral intradural mass causing major deformity of the cervical cord at C6 and C7 levels. Unlike most previously reported neurenteric cysts, the MRI signal characteristics of this mass were such that it could not be determined if it is cystic or solid, being iso-intense on T1- and hyperintense T2-weighted images. Resection was performed through a median corporectomy of C6 and C7, the lesion being found to be a neurenteric cyst with an attachment to the anterior median fissure of the cord. Strut graft and cervical locking plate fixation from C5 to C6 was facilitated by extending the cervical incision into the sternal notch, with detachment of left-sided strap muscle insertion. The patient made an excellent recovery with complete resolution of neurological symptoms and solid fusion. The postoperative course was complicated by an anterior cervical CSF collection which resolved spontaneously within 2 months. The literature regarding this rare condition and its management is reviewed. Although the majority of intraspinal neurenteric cysts are situated ventral to the cord, most reports of excision have been from a dorsal approach. Drainage and subtotal excision of neurenteric cysts have been previously advocated; however, the recurrence rate is such that complete excision is advocated. This is facilitated by a ventral approach. A simplified method of utilising the sternal notch exposure is reported. The literature regarding the anatomical peculiarities pertinent to the sternal notch approach, and the reported literature regarding spinal neurenteric cysts is reviewed.

[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).

Lateral approach to a neurenteric cyst of the cervical spine: case presentation and review of surgical technique

STUDY DESIGN

The lateral cervical spinal approach is illustrated by a case of neurenteric cyst.

OBJECTIVES

To present a case of a neurenteric cyst resected the lateral cervical approach, and to review the approach in detail.

SUMMARY OF BACKGROUND DATA

Intradural lesions located anterior to the high cervical spinal cord may present a difficult surgical problem. Neurenteric cysts are unusual lesions found in the brain and spinal cord. This report presents a case of cervical neurenteric cyst causing anterior cord compression that was resected using the lateral cervical approach.

METHODS

A 32-year-old woman presented with chronic headaches and worsening nausea, tinnitus, dizziness, and hyperreflexia and clonus in her lower extremities. Magnetic resonance imaging of the cervical spine showed a mass compressing the anterior spinal cord at C3. Pathology showed that this lesion was a neurenteric cyst. The lesion was resected using the lateral cervical approach.

RESULTS

At this writing, 36 months after surgery, the patient has continued resolution of her symptoms, and no cyst recurrence has been shown on repeat MRI imaging. She has no evidence of postlaminectomy kyphosis.

CONCLUSIONS

The lateral cervical approach is useful for surgeons attempting to resect lateral and anterior intradural lesions of the cervical spine. It also gives excellent cranial-to-caudal access to the thecal sac, spinal cord, and the lesion to be resected. The neck incision preserves cosmesis, and neuromuscular function is maintained. Spinal fusion was avoided in the reported case.