Surgical Management of Spinal Arachnoid Cysts in Adults

Extradural spinal cyst in a pediatric patient: A case report

Background

Spinal extradural arachnoid cysts comprise <1% of all spinal lesions and are rare findings in pediatric patients. The pathogenesis of spinal extradural arachnoid cysts is not well known but is thought to most commonly be due to congenital dural defects. Other origins include trauma, inflammation, or infection, such as arachnoiditis. Spinal magnetic resonance imaging is the gold standard for diagnosis, showing a fluid-filled space dorsal to the spinal cord with signal intensity akin to cerebrospinal fluid (CSF) and often the site of dural defect with CSF leak. While most spinal extradural arachnoid cysts are asymptomatic, large cysts can compress the spinal cord or nerve roots, leading to myelopathy, radiculopathy, or focal pain symptoms. In such cases, surgical management is indicated.

Case Description

Here, we present a case of a 15-year-old female who presented with lower back pain radiating to her bilateral posterior thighs and knees, with imaging indicating a thoracolumbar spinal extradural arachnoid cyst. After failed conservative treatment, surgical intervention in the form of laminectomy, fenestration of the arachnoid cyst, and repair of the dural defect was required, resolving the patient's symptoms with no recurrence of the cyst.

Conclusion

Complete resolution of pain in our patient following surgical management of spinal arachnoid cyst suggests that treatment of the arachnoid cyst can be achieved through minimal exposure to the site of the CSF leak to fenestrate the cyst and repair the leak.

Long-term outcomes following surgical treatment of spinal arachnoid cysts: a population-based consecutive cohort study

BACKGROUND CONTEXT

Spinal arachnoid cysts (SACs) are rare, cerebrospinal fluid-filled sacs lined by an arachnoid membrane in the spinal canal. Symptoms can develop due to pressure on the spinal cord or adjacent spinal nerves by the cyst itself or by interrupted flow of cerebrospinal fluid. If noninvasive management fails or neurological deterioration occurs, surgical treatment is recommended. However, data is lacking on long-term outcomes after surgery.

PURPOSE

To determine long-term outcomes in patients surgically treated for SACs.

STUDY DESIGN

Population-based cohort-study.

PATIENT SAMPLE

All consecutive patients treated for either intra- or extradural SACs with surgery between 2005 and 2020 at the author's institution were included.

OUTCOME MEASURES

American Spinal Injury Association Impairment Scale (AIS) and modified Japanese Orthopedic Association score (mJOA).

METHODS

Data was primarily extracted from electronic patient medical notes. Telephone interviews were performed to assess long-term postoperative outcomes. All analyses were conducted using the statistical software program R version 4.0.5. Statistical significance was set at p<.05.

RESULTS

Thirty-four patients were included. Cyst excision was performed in 11 (32%) cases, and fenestration in the remaining 23 (68%). The median follow-up time was 8.0 years. Surgery resulted in a significant long-term improvement in both AIS (p=.012) and mJOA (p=.005). Sensory deficit was the symptom that most often improved (81%), followed by pain (74%) and motor function (64%). AIS deteriorated in two patients, of which one case was attributed to a surgical complication. Local cyst recurrence requiring reoperation was seen in 4 (12%) cases, all of them following cyst fenestration. One patient (3%) required reoperation for progression of the cyst progression at a different level.

CONCLUSION

This study reports outcomes of surgically treated SACs with the longest follow-up time to date. Microsurgical cyst excision or fenestration were safe treatment options, and the neurological improvements seen in the immediate postoperative phase were maintained at long-term follow-up.

Diagnostic dilemma in acute neurological presentation of spinal arachnoid cysts: A case report

Background

Spinal arachnoid cysts are relatively uncommon, cerebrospinal fluid-filled sacs formed by arachnoid membranes that can be either idiopathic or acquired. The neurological presentation of these cysts is varied. Advances in imaging techniques have allowed an improved characterization of these entities and excluded other possible causes of clinical manifestation. Their presentation remains varied, ranging from pain to progressive neurological deficits. Here, we present two cases of patients with thoracic arachnoid cysts that posed a diagnostic dilemma at initial presentation because of their acute neurological deficit, and their eventual recovery after surgical intervention.

Case description

The first case is of a patient with end-stage renal failure, which prevented the administration of contrast during the workup. The differential diagnosis ranged from intradural abscess to arachnoid cyst. The second patient presented with non-remitting back pain that progressed to an acute neurological deficit. Both patients recovered well after decompression of the cyst.

Conclusion

The decision to intervene is still patient-dependent and based on the extent of neurological deterioration at the time of presentation due to the relatively benign nature and lack of understanding of the temporal presentation of neurological symptoms, which are rapidly and almost completely reversed after surgery. However, further studies need to be done to understand the acute presentation of these cysts, which are apparently long-standing.

Pathogenesis, management strategies, and outcome of non-communicating extradural spinal arachnoid cyst (NEAC): a systematic review

OBJECTIVE

Non-communicating extradural spinal arachnoid cysts (NEACs) are extremely rare aetiology of symptomatic spinal cord compression. The aim of this study was to address their pathogenesis, optimum management strategy and outcome through systematic review of existing published studies.

MATERIALS AND METHOD

We have found 13 eligible publications by searching through PubMed, ScienceDirect, and Google Scholar databases, published from inception to December 2020. We have analysed the data of 21 patients extracted from those 13 publications by IBM SPSS version 23.

RESULTS

According to our analysis congenital predisposition, trauma, and previous surgery history are the aetiology of NEAC. Clinical presentation of cyst depends upon the location and extent of compression or involvement of the neurovascular structures. Paraparesis with variable degree of sensory disturbance was seen among patients. Based on neuroimaging findings, NEACs are most commonly found at dorsal and dorsolumbar region. Magnetic resonance imaging (MRI) is the diagnostic modalities of choice and CT myelography can demonstrate the communication with the subarachnoid space. Recurrence rate of cyst after surgery is very low as only one out of twenty patients showed recurrence. If dural defect is not accurately addressed, the recurrence rate increased significantly.

CONCLUSIONS

Our study has highlighted aetiology, treatment strategies, and neurological outcome of NEAC. These findings may help neurosurgeons to manage this rare surgical entity for favourable outcome.

Spinal Intradural Arachnoid Cysts in Adults: An Institutional Experience and Literature Review

BACKGROUND

Adult spinal intradural arachnoid cysts are rare pathologic entities with an unclear etiopathogenesis. These lesions can be dichotomized into primary (idiopathic) or secondary (related to inflammation, intradural surgery, or trauma) etiologies. Limited series have depicted optimal management strategies and clinical outcomes.

OBJECTIVE

To illustrate our experience with spinal intradural arachnoid cysts and to present a literature review of surgically treated cysts to elucidate the clinical and anatomic differences between etiologies.

METHODS

Institutional review revealed 29 patients. Various data were extracted from the medical record. Initial and follow-up symptomatologies of the surgical cohort were compared. The literature review included case series describing cysts managed surgically.

RESULTS

From patients treated surgically at our institution (22), there was a significant reduction in thoracic back pain postoperatively ( P = .034). A literature review yielded 271 additional cases. Overall, primary and secondary lesions accounted for 254 and 39 cases, respectively. Cysts of secondary origin were more likely localized ventral to the spinal cord ( P = .013). The rate of symptomatic improvement after surgical intervention for primary cysts was more than double than that of secondary cysts ( P < .001). Compared with primary etiologies, the rates of radiographic progression ( P = .032) and repeat surgery ( P = .041) were each more than double for secondary cysts.

CONCLUSION

Surgical intervention for spinal intradural arachnoid cysts improves thoracic back pain. The literature supports surgical intervention for symptomatic primary spinal intradural arachnoid cysts with improved clinical outcomes. Surgery should be cautiously considered for secondary cysts given worse outcomes.

Spinal extradural arachnoid cysts: A novel formation mechanism and dural defect location technology

Purpose

The formation mechanism of spinal extradural arachnoid cysts (SEACs) remains unclear. There are several hypotheses for the formation of SEACs, but none of them can fully explain its pathological findings and surgical procedures. In this study, we retrospectively analyzed the cases of SEACs, aiming to clarify the formation mechanism of SEACs. In addition, we summarize a concise method for locating dural defects preoperatively and formulate a putative explanation of this method.

Methods

The clinical data of 14 patients with SEACs underwent surgery in our hospital from January 2017 to December 2021 were retrospectively analyzed.

Results

Fourteen patients were identified during the study period. The cysts all spanned the T12/L1 segment, and dural defects were also located at the T12/L1 level (2 cases not recorded) as well as the middle or the upper-middle level of the cysts. Nine cases were treated with total cyst excision, 2 cases were treated with dural defect closure only, and 3 cases were treated with total cyst excision and dural defect closure. Histopathological examination demonstrated that the cyst wall contained both the arachnoid epithelial and compact fibrous connective tissue. The symptoms were relieved in all patients, and no recurrence was observed.

Conclusions

According to intraoperative and pathological findings, the dural outer layer cyst (DOLC) is a more reasonable hypothesis about SEACs formation. When CT myelography or cinematic MRI cannot determine the location of the dural defect preoperatively, it can be located according to the middle level of the SEACs with high accuracy.

Impact of Surgical Timing on Neurological Outcomes for Spinal Arachnoid Cyst: A Single Institution Series

Objective

Spinal arachnoid cysts (SACs) are rare lesions that often present with back pain and myelopathy. There is a paucity of literature evaluating the impact of surgical timing on neurological outcomes for primary SAC management. To compare long-term neurological outcomes in patients who were managed differently and to understand natural progression of SAC.

Methods

We conducted a retrospective analysis of adult patients treated for SAC at our institution from 2010 to 2021, stratified into 3 groups (conservative management only, surgical management, or conservative followed by surgical management). Study outcome measures were neurological outcomes as measured by modified McCormick Neurologic Scale (MNS), postoperative complications, and cyst recurrence. Nonparametric analysis was performed to evaluate differences between groups for selected endpoints.

Results

Thirty-six patients with SAC were identified. Eighteen patients were managed surgically. The remaining 18 patients were managed conservatively with outpatient serial imaging, 7 of whom (38.9%) ultimately underwent surgical treatment due to neurological decline. Most common presenting symptoms included back pain (50.0%), extremity weakness (36.1%), and numbness/paresthesia (36.1%). Initial/preoperative (p = 0.017) and 1-year postoperative (p = 0.006) MNS were significantly different between the 3 groups, but not at 6 weeks or 6 months postoperatively (p > 0.05). Additionally, at 1 year, there was no difference in MNS between patients managed surgically and those managed conservatively but ultimately underwent surgery (p > 0.99).

Conclusion

Delayed surgical intervention in minimally symptomatic patients does not seem to result in worse long-term neurofunctional outcomes. At 1 year, postoperative MNS were significantly higher in both surgical groups, when compared to the conservative group highlighting worsening clinical picture regardless of preoperative observational status.

Spinal arachnoid cysts: A case series & systematic review of the literature

INTRODUCTION

Spinal arachnoid cysts (SACs) are rare lesions with challenging and controversial management.

RESEARCH QUESTION

We analyzed our experiences from a case series and provide a systematic review to determine 1) Demographic and clinical features of SACs, 2) Optimal imaging for diagnosis and operative planning, 3) Optimal management of SACs, and 4) Clinical outcomes following surgery.

MATERIALS AND METHODS

A single-institution, ambispective analysis of patients with symptomatic SACs surgically managed between May 2005 and May 2019 was performed. Data were collected as per local ethics committee stipulations. A systematic review of SACs in adults was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and a preapproved protocol.

RESULTS

Our series consisted of 11 patients, M:F 8:3, mean age 47.8 years (range 18-73 years). Mean follow-up was 19 months (range 5-36 months). SACs were excised or marsupialised (7), fenestrated (3) or partially excised (1). Eight patients had expansile duroplasty, 3 primary dural closure. One patient had a cystoperitoneal shunt. All patients were AIS D preoperatively; 4 remained unchanged and 7 improved to AIS E at follow-up. Our systematic search retrieved 725 citations. Fourteen case series met the inclusion criteria. There was no evidence to support superiority of one surgical strategy over another. Surgery for symptomatic patients resulted in positive clinical outcomes.

DISCUSSION AND CONCLUSIONS

Symptomatic SACs require surgical intervention. Limited evidence suggests that decompressing the cord, breakdown of arachnoid adhesions, and establishing CSF flow by consideration of expansile duroplasty are important for positive outcomes.

Surgical management and outcomes in spinal intradural arachnoid cysts: the experience from two tertiary neurosurgical centres

PURPOSE

Evaluation of the presentation and outcomes of different surgical treatment approaches for spinal intradural arachnoid cysts (SIAC).

METHODS

Cases were identified from electronic records of two major neurosurgical centres in London over the last 10 years (October 2009-October 2019) that have been surgically treated in both institutions. Clinical findings, surgical technique, and recurrence by procedure were statistically analysed. Statistical analysis was performed with STATA 13.1 Software.

RESULTS

A total of 42 patients with SIAC were identified for this study with a mean age at the time of surgery of 53.6 years and a male:female ratio of 8:13. There were 31 patients with primary SIACs and 11 with secondary SIACs. The most common presenting symptom was paraesthesia (n = 27). The most common location of the cyst was in the thoracic region (n = 33). Syrinx was present in 26.2% of SIACs (n = 11). Resection was associated with significantly better postoperative pain compared to other surgical techniques (p = 0.01), significantly poorer postoperative urinary function (p = 0.029), and lower rates of sensory recovery in patients who presented preoperatively with sensory deficit (p = 0.041). No significant difference was seen in symptomatic outcomes between patients with primary and secondary SIACs.

CONCLUSION

Resection and drainage are both effective methods of managing SIACs. In this observational study, resection was associated with significantly reduced pain postoperatively when compared with drainage, however also with significantly less improvement in postoperative urinary function. Therefore, resection should be the gold standard management option for SIACs, with drainage as an option where resection is unsafe, and drainage should also be considered in patients presenting with urinary dysfunction.

Surgical techniques used in the management of intra-arachnoid diverticula in dogs across four referral centres and their immediate outcome

OBJECTIVES

To report the surgical techniques being used to treat single focal spinal intra-arachnoid diverticula in dogs, their complications and immediate postoperative outcomes.

MATERIALS AND METHODS

Retrospective multi-centre case series across four referral centres.

RESULTS

Fifty-seven dogs were included in the study. The most common type of surgery was durectomy (28 dogs) followed by marsupialisation (11 dogs), durotomy alone (seven dogs), shunt placement (six dogs) and stabilisation (five dogs). A higher proportion of intra-arachnoid shunt dogs became unable to walk in the immediate postoperative period (24 hours postsurgery) (4/6, 66%) compared to all dogs five of 57, 9% (2/7 durotomy alone, 3/28 durectomy alone). Of the nine dogs with immediate postoperative deterioration, seven had improved, walking without assistance, by 3 to 5 weeks postoperatively.

CLINICAL SIGNIFICANCE

This study does not identify an influence of surgical technique on short-term outcome. Dogs with a thoracolumbar intra-arachnoid diverticulum that undergo a shunt placement are likely to deteriorate neurologically in the immediate 24-hour postoperative period but appear to improve by 3 to 5 weeks after surgery. Further work is required to evaluate whether one surgical technique is superior for preventing or reducing long-term relapse.

Early microsurgery on thoracolumbar spinal extradural arachnoid cysts: Analysis of a series of 41 patients

BACKGROUND

We designed this study to share our management experiences on spinal extradural arachnoid cysts (SEACs) to add more to the body of evidence for their treatment.

METHODS

We retrospectively reviewed 41 patients who underwent microsurgery for thoracolumbar SEACs at our hospital from June 2009 to June 2019. All clinical data, including medical history, clinical features, imaging manifestation, operative findings, and prognosis, were extracted from medical records and databases. Perioperative differences of the Visual Analogue Scale (VAS), the Oswestry disability index (ODI) score, and postoperative Odom's criteria were used to assess the surgical outcome.

RESULTS

The most common and very first clinical symptom in the 41 patients was pain (VAS = 2.82 ± 0.89), and the mean ODI value was 61.7 ± 8.9%. Imaging revealed that the cystic lesions in the thoracolumbar spine involved an average of 2.85 segments. Of the 41 patients, 39 underwent total cyst excisions, and 36 had their dural defect repaired by one of three methods. The mean postoperative follow-up time was 52.3 months. Postoperatively, one case developed kyphoscoliosis and two cases experienced a recurrence. The majority of patients showed excellent outcomes according to Odom's criteria, the postoperative VAS (0.80 ± 1.08), and the ODI (15.4 ± 9.3%).

CONCLUSIONS

Themost commonclinicalsymptoms of thoracolumbar SEACs included progressive discomfort and pain around the involved spinal segments. Early surgical intervention relieved the patients from their symptoms. Microsurgery was recommended to resect the complete cyst and to repair the dural defect, but resection of the complete cyst is more necessary than just repairment of the dural defect for providing promising outcomes.

Systematic Review of Surgical Management of Spinal Intradural Arachnoid Cysts

OBJECTIVE

Spinal intradural arachnoid cysts (SIACs) are rare pathological lesions that can arise via outpouchings of the arachnoid layer in the spinal canal that can result in neurological deficits. We performed a systematic literature review regarding the current surgical techniques used in the management of SIACs and discussed the prevailing hypotheses surrounding the etiology of SIACs.

METHODS

A systematic search of the literature was performed in December 2020 using EMBASE and MEDLINE for reports regarding the surgical management of SIACs. Data were collected regarding the demographics of the patients, classification system used, presence or absence of syrinxes, preoperative imaging modality, surgical approach and extent of resection, and postoperative outcomes and follow-up.

RESULTS

Our search yielded 19 reports for inclusion in the present study. The 19 studies included a total of 414 cases, with an overall male/female ratio of 0.93:1. The most common site for the SIACs was the thoracic spinal cord at 77.5%. The symptoms were very similar across the 19 studies. Of the 19 studies, 15 had used resection to manage the SIACs, 10 had used fenestration or marsupialization, and 4 had used cystoarachnoid or cystoperitoneal shunts.

CONCLUSIONS

SIACs are rare and debilitating spinal pathological lesions, with the etiology of primary SIACs still not fully elucidated. Multiple surgical approaches have been effective, with the optimal operative strategy largely dependent on the individual patient and cyst factors on a case-by-case basis.

Multiple extradural spinal arachnoid cysts: A case report

Background:

Extradural spinal arachnoid cysts (SACs) rarely cause neural compression and disability.

Case Description:

A 38-year-old female presented with a history of two episodes of falling due to transient weakness in the lower limbs. The neurological examination showed normal motor and sensory function, but hyperreflexia. The thoracic magnetic resonance imaging revealed multiple extradural SACs between the T3-L1 levels. Following complete surgical resection of the most symptomatic cyst, she did well. The histopathological examination confirmed a Type I extradural SAC.

Conclusion:

Here, we discussed one case and reviewed the literature on the diagnosis and treatment of multiple extradural SACs.

Surgical outcome of primary intradural spinal arachnoid cysts: a series of 10 cases

Background

Primary intradural spinal arachnoid cysts are rare pathologies of uncertain etiology and variable presentation from no symptoms to myelopathy or radiculopathy according to cord or root compression. MRI with diffusion and contrast differentiates them from many pathologies. There is a lot of debate regarding when to treat and how to treat such rare pathologies.

Objective

We present a series of 10 primary intradural arachnoid cysts and evaluate outcome after surgery.

Methods

This retrospective study includes patients having primary intradural spinal arachnoid cysts operated in two tertiary care centers from October 2012 till October 2019. Symptomatic cysts were subjected to microsurgical resection or outer wall excision and inner wall marsupialization under neurophysiological monitoring. The Japanese Orthopedic Association Score was used for clinical evaluation while MRI with contrast and diffusion was used for radiological evaluation before and after surgery.

Results

This series included 10 patients, 4 males and 6 females, with mean age of 40 years. Pain was the most common presentation. The most common location was dorsal thoracic region. Total excision was achieved in 2 cases and marsupialization in 8 cases.

All symptoms improved either completely or partially after surgery. No neurological deterioration or recurrence was reported during the follow-up period in this series.

Conclusion

Treatment of symptomatic primary intradural spinal arachnoid cysts should be microsurgical resection, when the cyst is adherent to the cord, microscopic fenestration can be safe and effective.

Diagnosis and treatment of noncommunicating extradural spinal thoracolumbar arachnoid cyst

Background:

Noncommunicating extradural spinal arachnoid cysts are extremely rare. They are believed to arise from congenital defects in the dura mater and become enlarged as a consequence of increased cerebro-spinal fluid (CSF) pressure within the subarachnoid space. Most retain a communicating pedicle through which the extradural cyst maintains connection with the subarachnoid space, and only rarely does this communication become sealed. The optimal treatment consists of complete surgical removal of the cyst with ligation of the communicating pedicle.

Case Description:

A 29-year-old male presented with a progressive spastic paraparesis of 6 months’ duration. The MRI showed a circumscribed intradural extramedullary cystic lesion located from D11-L2. Notably, peroperatively, the cyst appeared to be entirely extradural, without a communicating intradural pedicle. Further, no CSF leak was observed even after Valsalva maneuvers. Following surgical extirpation of the cyst, the patient sustained an uneventful recovery within 1 postoperative month.

Conclusion:

Noncommunicating extradural arachnoid cysts are extremely rare causes of spinal cord compression and should be fully excised.

Extradural Spinal Arachnoid Cyst as a Cause of Cauda Equina Syndrome in a Child

Although spinal arachnoid cysts are relatively common findings observed incidentally in adults, they are much rarely reported in children. They are usually asymptomatic and are mainly located in the middle and lower thoracic regions. However, in rare circumstances, these cysts can cause mass effects that lead to neurologic symptoms. We report the rare case of a spinal extradural arachnoid cyst in a 12-year-old boy who showed signs and symptoms of cauda equina syndrome. Magnetic resonance imaging of the lumbar spine revealed a huge extradural arachnoid cyst extending from L2 to L5. Emergent laminectomy and repair of dural defect was performed after total resection of the extradural arachnoid cyst. There were no postoperative complications. Total recovery was achieved 6 months after surgery. Here, we report this rare case with a review of the literature.

Intradural symptomatic arachnoid cyst formation following non-instrumented lumbar decompression

PURPOSE

Intradural arachnoid cyst is a rare complication of lumbar puncture, post-trauma or post-intraoperative durotomies. We aim to estimate the incidence of early intradural arachnoid cyst radiologically in non-instrumented posterior lumbar decompression among symptomatic patients, and establish clinical correlation.

MATERIALS AND METHODS

Patients who underwent lumbar decompression without instrumentation at a tertiary spinal service between December 2014 and January 2018 were identified. When MRI scans were performed post-operatively within 14 days, imaging, medical and operative records were reviewed by two consultant neuroradiologists.

RESULTS

488 operations were included. 46 operations were followed by an early MRI scan. 59% were requested to investigate new or ongoing pain. Ten demonstrated an intradural arachnoid cyst - seven had no documented durotomy. Eight were primary operations, three were emergency operations. Statistically, we have not identified durotomy, primary-vs-revision surgery, and elective-vs-emergency surgery as risk factors. Two patients required revision operations, of these, one had a repeat post-operative scan, where the cyst resolved following further decompression at the index level, without intradural exploration.

CONCLUSIONS

Intradural arachnoid cyst may complicate posterior lumbar decompression. To our knowledge, this is the first study to assess its incidence as an early post-operative radiological finding, which is likely to be commoner than we recognise. It may be a cause of persisting post-operative pain.

True Dural Spinal Epidural Cysts: Report of 5 Cases

BACKGROUND

Spinal arachnoid cysts are a rare cause of compressive myelopathy. Spinal extradural arachnoid cysts (SEACs) are even rarer.

METHODS

We retrospectively reviewed the SEACs operated on in our hospital between 2015 and 2019, according to their clinical and radiologic findings, treatments performed, and outcomes.

RESULTS

We identified 5 cases (2 males and 3 females), ranging in age from 21 months to 78 years. Except for the pediatric case, all patients presented with pain and 3 had some grade of neurologic impairment. Preoperative magnetic resonance imaging showed multiloculated cyst in 4 cases, and the communication with the dura was properly identified in only 1 case. The patients were operated through a laminectomy or laminoplasty and total removal of the cyst, and the communication with the dura was identified and repaired in all cases. In all cases, the defect was near the exit of a nerve root, and rootlets were seen through it, producing a ball-like valve mechanism. Histology of the cyst wall showed true dura in every case. One patient needed a reoperation for evacuation of a fluid collection (related to the dural sealant). Following Odom's criteria, 3 patients had an excellent outcome and 2 had a fair outcome.

CONCLUSIONS

Total excision of a symptomatic SEAC through either laminectomy or laminoplasty is a safe and effective treatment option. Although isolated repair of the dural communication without cyst removal may seem appealing, we have found it very difficult to identify the point of communication preoperatively.

Cervical Cerebrospinal Fluid Leakage Concomitant with a Thoracic Spinal Intradural Arachnoid Cyst

We encountered a very rare case of spontaneous spinal cerebrospinal fluid (CSF) leakage and a spinal intradural arachnoid cyst (AC) that were diagnosed at different sites in the same patient. These two lesions were thought to have interfered with the disease onset and deterioration. A 30-year-old man presented with sudden neck pain and orthostatic headache. Diplopia, ophthalmic pain, and headache deteriorated. CSF leakage was confirmed in C2 by radioisotope cisternography, and an epidural blood patch was performed. While his symptoms improved gradually, paraparesis suddenly progressed. Thoracolumbar magnetic resonance imaging (MRI) revealed an upper thoracic spinal intradural AC, which was compressing the spinal cord. We removed the outer membrane of the AC and performed fenestration of the inner membrane after T3-4 laminectomy. Postoperative MRI showed complete removal of the AC and normalized lumbar subarachnoid space. All neurological deficits including motor weakness, sensory impairment, and voiding function improved to normal. We present a case of spontaneous spinal CSF leakage and consecutive intracranial hypotension in a patient with a spinal AC. Our report suggests that if spinal CSF leakage and a spinal AC are diagnosed in one patient, even if they are located at different sites, they may affect disease progression and aggravation.

Utilizing real-time contrast medium to detect the fistula of giant spinal arachnoid cyst and treat with minimal invasive surgery

BACKGROUND

Spinal arachnoid cysts are rare and have varied clinical manifestations depending on the affected spinal region and nerve roots. A complete cyst excision with fistula closure is the first choice of treatment. However, it might be difficult to localize the specific position of the fistula because previous images have no enhancements or the fistula is too tiny to be detected.

CASE PRESENTATION

This case is a giant lumbar extradural arachnoid cyst. We administered a lumbar injection with contrast medium into subarachnoid space under digital subtraction angiography (DSA) and disclosed the fistula. Confirming the location of fistula enabled us to perform minimally invasive surgery to ligate the fistula. Surgical intervention for a spinal arachnoid cyst might encounter the problem of the formation of a postoperative cerebrospinal fluid (CSF) fistula. We propose the option of detecting the fistula preoperatively for minimal invasive surgery. Recurrence depends on the long-term follow-up, and more cases are needed to further evaluate our technique.

CONCLUSIONS

The real-time contrast medium technique for spinal arachnoid cysts contributes to the complete ligation with minimally invasive surgery.