Excision of an asymptomatic cervical intradural neurenteric cyst through the anterior approach: a study of two cases and a review of the literature

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.

A case of neurenteric cyst of spine mimicking an arachnoid cyst

BACKGROUND

Intradural cysts of the spine are arachnoid cysts, neuroenteric cysts, and ependymal cysts. The usual finding in case of a neurenteric cyst is a ventrally located non-contrast-enhancing lesion that is isointense on T1-weighted sequence and hyperintense on T2-weighted imaging. An arachnoid cyst is hypointense in T1-weighted image and hyperintense in T2-weighted image, mimicking cerebrospinal fluid(CSF), and the location is dorsal to the cord. But a neurenteric cyst can mimic an arachnoid cyst in appearance.

CASE

A 48-yr old autorikshaw driver presented with weakness of fingers and lower limbs. All sensations were decreased below xiphisternum(T6). The gait was spastic. Magnetic Resonance Imaging(MRI) showed an extramedullary intradural cyst at C7-T1 level. It was hypointense on T1-weighted image and hyperintense on T2-weighted image. There was no enhancement with contrast. C7/T1 Laminectomy was done. On gentle retraction of the cord, a whitish cyst was seen. Some clear fluid was aspirated and cyst was excised en toto. Myelopathy improved over two weeks. Histopathological examination showed a cyst wall composed of fibrocollagenous tissue, and lined by pseudostratified epithelium containing many goblet cells and having focal ciliation. The findings were consistent with neurenteric cyst. Follow-up MRI after five years showed no recurrence.

CONCLUSION

To our knowledge, the peculiarities of the case are that the radiological features mimicked arachnoid cyst in having the intensity of CSF. But the ventral location was suggestive of a neurenteric cyst. Total excision could be done through the posterior approach after decompressing the cyst by aspiration.

Antenatally diagnosed intraspinal-posterior mediastinal neurenteric cyst - what is the optimal management?

Neurenteric cyst is a rare congenital anomaly that belongs to the spinal dysraphism spectrum. It is classically a disease of late childhood, with some rare reports of intrauterine and adult presentation. The increase in incidental antenatal diagnosis raises new management questions. We present a case of an asymptomatic combined intraspinal-posterior mediastinal neurenteric cyst. The cyst was diagnosed on antenatal ultrasound and was initially treated with image-guided aspiration in early infancy. However, the cyst recurred and the patient developed recurrent episodes of bacterial meningitis. Two-stage surgical resection was performed, although the infection prohibited complete excision. We caution against image guided aspiration of neurenteric cysts, and suggest a management algorithm based on the available literature.

Rare morbidity of permanent quadriplegia caused by neurenteric cyst of the cervical cord

The incidence of neurenteric cyst (NC) is rare, accounting for 0.3%–1.3% of all spine tumors. The occurrence of quadriplegia caused by NC is even scarcer. Herein we report on a young girl with a rare NC over the C2-C5 spinal cord, which led to the morbidity of permanent quadriplegia despite early surgical intervention. This case highlights the rare morbidity of cervical cord NC presenting with permanent quadriplegia that failed to respond despite early surgical excision.

Cord Splitting Access to Ventral Intradural Cysts of Cervicothoracic Junction and Thoracic Spine

OBJECTIVE

Surgical treatment of ventrally located intradural cysts is difficult and controversial. Laminectomy with division of the denticulate ligaments and gentle cord mobilization remains the standard approach but risks further neurologic deterioration secondary to cord manipulation. Our purpose is to evaluate the safety and effectiveness of a midline cord-splitting approach as an alternative for treating ventral thoracic intradural cysts.

METHODS

We describe 2 patients who were treated for ventral intradural cysts causing progressive and severe myelopathy. Under general anesthesia and continuous neurophysiologic monitoring, laminectomy, durotomy, and cord splitting through a midline approach gave direct access to both lesions. Cyst drainage was supplemented by a cystopleural shunt in 1 case.

RESULTS

Cyst collapse and cord reexpansion were documented in both patients with a magnetic resonance imaging scan 1 week after surgery. In both cases there was a significant neurologic improvement, which was maintained 2 years postoperatively. Intraoperative monitoring recorded no loss of somatosensory or motor potentials during surgery. Follow-up magnetic resonance imaging scans 2 years postoperatively showed no evidence of cyst recurrence, and both patients remained neurologically improved and stable.

CONCLUSIONS

We have been able to drain 2 ventral intradural cysts using a cord-splitting technique. This has allowed safe access to purely ventrally located lesions, which were inaccessible dorsally or dorsolaterally. By using this method we have been able to avoid a more invasive ventral transthoracic approach necessitating vertebrectomy and reconstruction and risking serious complications.

A Recurrent Cervical Neurenteric Cyst Treated Anteriorly: Safe, Gross-Total Excision Facilitated by Prophylactic Unilateral Vertebral Artery Exposure, Microdissection, and Spinal Cord Monitoring-A Case Report and Technical Note

This study reports on a 67-year-old woman with partial Brown-Séquard syndrome due to a recurrent cervical neurenteric cyst at C3 to C4. The myelopathic symptoms reappeared 22 years after a previous shunting operation performed posteriorly with a silicone tube connecting the intradural cervical cyst cavity to the subarachnoid space. We have now succeeded in removing the cyst nearly completely with the anterior approach. The surgical procedure consisted of right vertebral artery exposure at C3 and C4 and a subtotal corpectomy of C3 followed by microdissection of the cyst, duraplasty, and iliac strut graft fusion. Spinal cord monitoring with motor-evoked potential studies helped us safely dissect the cyst wall tightly adhering to the spinal cord. Duraplasty with Gore-Tex patch-grafting in conjunction with postoperative lumbar subarachnoid drainage worked well in preventing a spinal fluid fistula. At two years after surgery, the patient showed a nearly complete return of function without any recurrence of the cyst.

Spinal neurenteric cyst in a dog

CASE DESCRIPTION An 11-year-old English Cocker Spaniel was evaluated because of chronic progressive ataxia of the hind limbs. CLINICAL FINDINGS The dog had no history of previous illness, and findings of physical examination and laboratory tests were unremarkable. Neurologic examination revealed that the dog was ambulatory with severe ataxia of the hind limbs. Proprioception was decreased in the right and left hind limbs (right affected more than left), and spinal reflexes were bilaterally unremarkable. Moderate signs of pain were detected during palpation of the lumbar portion of the vertebral column. Findings suggested a lesion within the thoracolumbar or lumbar segments of the spinal cord. Magnetic resonance imaging revealed extradural spinal cord compression attributable to an extradural space-occupying lesion originating from or infiltrating the L4 lamina on the right side. TREATMENT AND OUTCOME Hemilaminectomy was performed to remove the extradural lesion. Histologic findings for tissue samples collected during the procedure were consistent with a neurenteric cyst. The late onset and progression of clinical signs of this rare congenital malformation were suspected to have been the result of enlargement of the neurenteric cyst through continuous production of mucus by goblet cells. The dog responded favorably to surgical decompression and was clinically normal 1 year after surgery. It was euthanized 2 years after surgery for an unrelated reason (end-stage heart disease), and no neurologic deficits were evident before that point. CLINICAL RELEVANCE Congenital neurenteric cysts should be considered as a differential diagnosis for neoplastic disease in dogs in which results of diagnostic imaging indicate the presence of an extradural mass affecting vertebral structures.

Intramedullary and Extramedullary Cervical Neurenteric Cyst Requiring Fixation and Fusion

BACKGROUND

Spinal neurenteric cysts are rare in the literature, described by sporadic case reports and small case series. In the vast majority of cases, these lesions are intradural extramedullary. We report the novel case of a cervical neurenteric cyst that was simultaneously intramedullary and extramedullary.

CASE DESCRIPTION

A 47-year-old man underwent C2 through C7 laminectomies for microsurgical resection of a large cystic intradural mass, with C1 through T1 instrumentation and fusion. Gross total resection was obtained. Fusion was necessary after removal of the posterior elements because the vertebrae were thinned extensively and remodeled around the tumor, a treatment paradigm that has not been described adequately for neurenteric cysts previously.

CONCLUSIONS

A novel case of cervical intramedullary and extramedullary neurenteric cyst is presented with clinical, radiographic, and histologic details. Given the potential for bony remodeling around these developmental tumors, the possibility exists for instability after certain neurenteric cysts are resected. Thus, the present case adds fixation and fusion to the potential treatment paradigm for select spinal neurenteric cysts.

Two-stage approach in the management of thoracic neuroenteric cyst with spinal extension: thoracoscopic excision following dorsal laminectomy

BACKGROUND

Neuroenteric cysts (NC) are rare pathologies and localized generally in posterior mediastinum or abdomen where they may extend to spinal canal through a vertebral defect. Isolated spinal lesions require dorsal/ventral laminectomy and thoracic ones thoracotomy or thoracoscopy. Posterolateral approach via thoracotomy is generally performed for lesions with both thoracic and spinal components. Minimal invasive excision of a thoracic NC with spinal extension in an infant is presented herein.

CASE REPORT

A term female newborn with an antenatal (26th week) diagnosis of congenital diaphragmatic hernia (CDH) was admitted. On physical examination, she was normal except mild dyspnea and CDH were excluded on radiogram. Left parenchymal opacity necessitated thorax tomography that revealed lobulated cystic lesion (6 × 3.5 × 4.5 cm) in posterior mediastinum. MRI showed intraspinal extension of the lesion through a hemivertebrae (6th). Two-stage procedure was planned for suspected neuroenteric cyst. First, intraspinal component was excised with dorsal laminectomy and the connection was closed. Then, the thoracic component was excised thoracoscopically. Histopathological evaluation confirmed the diagnosis. Total parenteral nutrition and high dose somatostatin analog was needed due to transient left chylothorax on postoperative course. She was well and symptom-free in postoperative period.

CONCLUSION

Neuroenteric cysts may lead to misdiagnoses in antenatal period. MRI is critical to show spinal and vertebral pathologies in suspected cases. Thoracoscopy may safely be performed for thoracic lesions with spinal extension in two-stage approach following closure of the connection and excision of the spinal component.

Silent neurenteric cyst with split cord malformation at conus medullaris: Case report and literature review

Split cord malformations (SCM) are a common pediatric abnormality where children present with features of tethering and backache along with varying neurological deficits. Multiple neural tube defects may co-exist in children having defects of primary and/or secondary neurulation. Co-existent neurenteric cysts along with type 1 SCM have been described very rarely in the literature. We report a case of silent neurenteric cyst at conus medullaris with SCM type 1 where the cyst was missed in the preoperative imaging. Until date, only 8 such cases of neurenteric cysts with SCM at lumbar region have been reported. We review the literature regarding co-existing dual pathologies of neurenteric cysts and type 1 SCMs in light of limited capacity of imaging modalities to detect small neurenteric cysts in presence of co-existent neural tube defects. Multiple spinal neural tube defects in children need more attention and precise microneurosurgical skills as management differs in each of them. Co-existence of such pathologies detected intra-operatively may need modifications in preoperative planning to achieve the best possible outcomes.

Anterior cervical arachnoid cyst

This report is composed of two patients with anteriorly located cervical intradural arachnoid cyst and review of 24 cases in Englishlanguage literature. Both of our patients were in the first two decades of life with neck pain and motor weakness. With suspicious diagnosis of anterior arachnoid cyst surgery was carried out in both cases, though laminectomy in one and laminoplasty in the other. The cyst wall was widely fenestrated with subsequent subtotal excision of the cyst. Both cases had good long-term outcome. The review disclosed male predominance. 73% of the patients were diagnosed within the first two decades of life. Neck pain and motor weakness were the dominant signs and symptoms of this pathology. Magnetic resonance imaging showing a cerebrospinal fluid (CSF) containing cyst was the best mode of diagnosis. Wide cyst fenestration with waying CSF into subarachnoid cyst was the most appropriate and applied surgery with optimal outcome.

Neurosurgical management of neurenteric cysts in children

OBJECT

Neurenteric cysts (NCs) are endothelium-lined structures of presumed endodermal origin. There have been few pediatric series of intracranial NCs reported previously. The authors present their experience in the management of these lesions.

METHODS

A retrospective chart review of all cases of NCs identified between 1977 and 2007 was carried out. Demographics, details of clinical presentation, surgical therapy, and outcome data were extracted.

RESULTS

Eleven cases were identified, involving 6 girls and 5 boys. The patients' average age was 4.6 years (range 1 day-14 years). Limb weakness was the most common presenting symptom. The location of the cysts was cervical in 2 cases, cervicothoracic in 4 cases, and thoracic in 3 cases. One cyst was anterior to the pons with extension to the left cerebellopontine angle and 1 cyst was at the craniocervical junction. Five patients had an apparently complete initial excision, with 1 recurrence. Four patients were initially treated with incomplete excision and/or cyst drainage, usually into an Ommaya reservoir. A neonate with a large cervicothoracic cyst died of multiple congenital anomalies without any intervention. All other patients were alive at last follow-up. One patient with a radiologically identified presumed cyst, which remained stable, was simply followed up. Several patients required multiple procedures and 1 patient developed hydrocephalus after aseptic meningitis and was treated with CSF shunting.

CONCLUSIONS

Neurenteric cysts are rare in the pediatric population. Total resection, if possible, provides the best long-term outcome. Incomplete excision may lead to multiple procedures, including cyst drainage, but can lead to long-term stability.

Neurenteric cysts of the spine

Neurenteric cysts account for 0.7-1.3% of spinal axis tumors. These rare lesions result from the inappropriate partitioning of the embryonic notochordal plate and presumptive endoderm during the third week of human development. Heterotopic rests of epithelium reminiscent of gastrointestinal and respiratory tissue lead to eventual formation of compressive cystic lesions of the pediatric and adult spine. Histopathological analysis of neurenteric tissue reveals a highly characteristic structure of columnar or cuboidal epithelium with or without cilia and mucus globules. Patients with symptomatic neurenteric cysts typically present in the second and third decades of life with size-dependent myelopathic and/or radicular signs. Magnetic resonance imaging and computed tomography are essential diagnostic tools for the delineation of cyst form and overlying osseous architecture. A variety of approaches have been employed in the treatment of neurenteric cysts each with a goal of total surgical resection. Although long-term outcome analyses are limited, data available indicate that surgical intervention in the case of neurenteric cysts results in a high frequency of resolution of neurological deficit with minimal morbidity. However, recurrence rates as high as 37% have been reported with incomplete resection secondary to factors such as cyst adhesion to surrounding structure and unclear dissection planes. Here we present a systematic review of English language literature from January 1966 to December 2009 utilizing MEDLINE with the following search terminology: neurenteric cyst, enterogenous cyst, spinal cord tumor, spinal dysraphism, intraspinal cyst, intramedullary cyst, and intradural cyst. In addition, the references of publications returned from the MEDLINE search criteria were surveyed in order to examine other pertinent reports.

Prenatal diagnosis of a large, cervical, intraspinal, neurenteric cyst and postnatal outcome

Neurenteric cysts are rare congenital anomalies derived from the notochord and located in front of the spinal column, mostly at the cervical level. They consist of an intraspinal cystic component that is connected to a mediastinal or thoracic cyst. A case of a cervical, intraspinal, neurenteric cyst, diagnosed at 28 weeks of gestation and operated on at 3 and half months after birth, is reported. Herein, we discuss important features of this case including its rare occurrence, intrauterine diagnosis, and early surgical intervention. In conclusion, the nature of prenatal intradural cysts should be fully evaluated and differentiated between neurenteric cyst and other types of cysts with fetal ultrasonography. Therefore, it is essential to be aware of this potential cyst in fetal ultrasonography in utero. Neurenteric cyst should be considered in the differential diagnosis of cervical intradural cystic lesions. In infants, successful surgery provides a cure in patients with cervical neurenteric cysts.

Cervical anterior intradural arachnoid cyst in a child

Intradural arachnoid cysts involving the spine are uncommon and especially rare in an anterior cervical location. In the literature, among 15 patients, 8 were in the paediatric age group and in 3 patients the cyst was localised to the full length of the cervical spinal canal. Although they occur secondary to trauma, haemorrhage, surgery or inflammation, most of them are known to be idiopathic or congenital. Although the disease shows a dramatic neurological course, early diagnosis and treatment could provide good results. We report a 2(1/2) year-old boy with progressive tetraparesis with a huge anterior intradural arachnoid cyst located from the cervico-medullary junction to the C7 level. In the paediatric age group, cervical anterior intradural arachnoid cyst is an unusual cause of quadriparesis. The rarity of this condition and the relevance of MRI in the accurate and early diagnosis is discussed here. A 2(1/2) year-old boy with a large intradural arachnoid cyst extending from the cervico-medullary junction to C7 situated anteriorly is reported here; diagnosis and treatment modalities are discussed.