Intramedullary neurenteric cyst presenting as infantile paraplegia: a case and review

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.

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.

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.

Unique Imaging Features of Spinal Neurenteric Cyst

A 50-year-old male presented with acutely progressed paraplegia. His magnetic resonance imaging demonstrated two well-demarcated components with opposite signals in one cystic lesion between the T1- and T2-weighted images at the T1 spine level. The patient showed immediately improved neurological symptoms after surgical intervention and the histopathological exam was compatible with a neurenteric cyst. On operation, two different viscous drainages from the cyst were confirmed. A unique similarity of image findings was found from a review of the pertinent literature. The common findings of spinal neurenteric cyst include an isointense or mildly hyperintense signal relative to cerebrospinal fluid for both T1- and T2-weighted images. However, albeit rarer, the signals of some part of the cyst could change into brightly hyperintensity on T1-weighted images and hypointensity on T2-weighted images due to the differing sedimentation of the more viscous contents in the cyst.

Clinical presentation and surgical outcomes of intramedullary neurenteric cysts

OBJECT

Intramedullary neurenteric cysts (NECs) are exceedingly rare lesions and have been previously reported in case reports. The aim of this study was to determine the clinical manifestations, radiological features, and long-term prognosis of patients with such lesions.

METHODS

The authors retrospectively reviewed the records of 13 patients with an intramedullary NEC. Each patient underwent MRI, laminotomy, and microsurgery. The accurate diagnosis was based on imaging and pathology findings. Each patient's follow-up status was determined through individual office visits and a structured telephone interview.

RESULTS

The series included 7 male and 6 female patients. Progressive or intermittent motor deficit was the main symptom associated with or without pain or sensory disturbance. Five cysts were located in the cervical cord, 1 in the cervicothoracic cord, 3 in the thoracic cord, and 4 in the conus medullaris. Concurrent malformations included scoliosis (3 cases), fusion of rib (1 case), enlarged spinal canal (1 case), tethered spinal cord (1 case), and ectocardia (1 case). Gross-total resection of the cyst was achieved in 8 cases, and subtotal resection (STR) was achieved in 5 cases. All patients were followed up, with a mean duration of 66.5 months. Cyst recurrence was observed in 4 cases after STR. In 2 cases the patients underwent reoperation; the other 2 patients remained clinically stable and did not undergo reoperation. At the last evaluation, neurological function was improved in 11 patients and remained stable in 2 patients.

CONCLUSIONS

Intramedullary NECs should be considered in the differential diagnosis of a middle-aged patient with intermittent neurological symptoms and concurrent malformations. Early surgery is advocated to prevent permanent neurological deficits. When gross-total resection cannot be achieved, maximally safe removal under the protection of intraoperative neuromonitoring is advised. Because of the high risk of cyst recurrence, routine follow-up MRI is needed. If a residual cyst shows obvious regrowth and results in neurological deficits, timely reoperation with a goal of STR should be performed.

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.

Spinal dysraphism: A challenge continued to be faced by neurosurgeons in developing countries

OBJECTIVES

The incidence of spinal dysraphism has significantly decreased over the last few decades, all over the world; however, still the incidence is much higher in developing countries with poor socioeconomic status.

MATERIALS AND METHODS

The present study includes all patients managed for spinal dysraphism over a period of one year (January 2011-December 2011). Details including demographics, antenatal care history, site and type of lesion, neurological examination, imaging finding, associated congenital anomalies, management offered, and outcome were recorded.

RESULTS

A total of 27 children were operated for spinal dysraphism during the study period (17 males and 11 females). Median age was 120 days (age range, 1 day to 6 years). Mothers of 15 children did not seek any regular antenatal checkup and only 13 mothers received folic acid supplementation during pregnancy. Fourteen children were delivered at home and 13 were at hospital. The most common site was lumbosacral region (67.8%). Seven patients had rupture of the sac at the time of presentation, one child had local infection, and four patients had hydrocephalus (requiring shunt before surgical repair). Two patients developed hydrocephalus at follow up, needing shunt surgery. The mean hospital stay was 7 days (range, 5 days to 31 days; median, 10 days).

CONCLUSION

Spinal dysraphism is still a major public health problem in developing countries. Management of patients with spinal dysraphism is complex and needs close coordination between pediatrician, neurologist, neurosurgeon, and rehabilitation experts. A large number of factors influence the outcome.

Intramedullary neurenteric cyst associated with a tethered spinal cord: Case report and literature review

Background:

Neurenteric cysts are benign tumors of the central nervous system (CNS) that represent 0.3% to 0.5% of all spinal cord tumors. They are usually extramedullary and found in the lower cervical and thoracic spine. Only 12.2% of neurenteric cysts are documented to be intramedullary.

Case Description:

The authors report a case of a 35-year-old female that presented with progressive weakness and loss of coordination in her legs. Magnetic resonance imaging (MRI) showed an intramedullary cystic lesion in the thoracolumbar region and a low-lying conus medullaris suggesting tethered cord. The patient was taken to the operating room for detethering of her spinal cord and resection of the lesion. Pathologic examination of the tissue confirmed the diagnosis of a neurenteric cyst.

Conclusion:

A search of the literature since the advent of MRI showed 29 published cases of intramedullary neurentic cysts. Of the 24 published cases with a follow-up MRI, the average recurrence rate was 25% with a mean follow up of 51 months.

A case of split notochord syndrome: an adult with a spinal endodermal cyst mimicking an intramedullary tumor

Intraspinal endodermal cysts are very rare congenital cysts, usually composed of a thin-walled cyst the lining of which mimics gastrointestinal or respiratory epithelium. Diagnosis is usually established during the first or second decade of life. These cysts are frequently associated with vertebral or spinal cord abnormalies and dual malformation with mediastinal or abdominal cysts. Collectively, they are called split notochord syndrome. The authors describe their experience in the treatment of a 57-year-old man having an endodermal cyst mimicking an intramedullary tumor at the level of Th1-2. He was admitted to our institution for evaluation of an intraspinal mass diagnosed by MRI at a local hospital after experiencing temporary numbness and weakness of the lower left extremity. T1-weighted sagittal MRI demonstrated the lesion with signal intensity iso- to slightly hypointense to the spinal cord without enhancement after administration of gadolinium. Although T2-weighted sagittal images demonstrated as hyperintense to the spinal cord, axial images revealed a passage between the mass and subarachnoid space. We could not completely rule out the presence of an intramedullary tumor and undertook a laminectomy with a posterior approach. Histopathological analysis revealed an endodermal cyst and the authors found syringomyelia, which was clearly separated from the cyst in the preoperative sagittal MRI and intraoperative ultrasonography study. To the best of our knowledge, this is the first report in the English literature of a thoracic endodermal cyst requiring differential diagnosis from a spinal cord tumor.

Isolated spinal neurenteric cyst presenting as intramedullary calcified cystic mass on imaging studies: case report and review of literature

Intramedullary neurenteric cysts (NEC) without associated malformations are extremely rare and, to our knowledge, have never been reported in association with calcification. We report a unique imaging presentation as a partially calcified mass of an isolated intramedullary neuroenteric cyst of the lower thoracic spinal cord with pathologic correlation. The literature for isolated forms of intramedullary NEC since the advent of magnetic resonance imaging is also reviewed.

Intramedullary cervical neurenteric cyst mimicking an abscess

We describe a cervical intramedullary neurenteric cyst in a 12-year-old male patient who presented with gradual onset and progressively worsening neck pain, spastic quadriparesis and impaired sensation in the C(2) dermatome. MR imaging revealed a well-defined peripherally enhancing cystic intramedullary lesion with a posteroinferior enhancing nodule at the C(2)-C(3) level mimicking an abscess. There was no evidence of spinal dysraphism. The lesion was completely resected through a posterior approach and the patient showed radical improvement in his symptomatology. At follow-up after 3 years, he was asymptomatic and the MR imaging showed no evidence of any residual or recurrent cyst. The case presented here is unique, since a spinal neurenteric cyst showing intense peripheral contrast enhancement mimicking an abscess is unusual. The radiological features, pathogenesis and surgical considerations in cervical intramedullary neurenteric cysts are discussed and the relevant literature is briefly reviewed.

Spinal neurenteric cyst. Report of 4 cases and review of the literature

Neurenteric cysts are rare congenital lesions of the spine that are lined with entodermal epithelium. We describe 4 unusual cases of neurenteric cysts in patients aged between 3 and 16 years. The cyst was situated anteriorly in 3 patients and posteriorly in 1. All the patients had varied clinical and radiological features. The child with dorsal neurenteric cyst had stigmata of spinal dysraphism along with other vertebral anomalies. Another child had an associated syringomyelia along with evidence of severe arachnoiditis. All 4 patients underwent laminectomy and total microsurgical excision of the cysts through a posterior approach. The patient with diastematomyelia developed early recurrence of the cyst and underwent reoperation. Three patients showed an excellent recovery after surgery. The child with arachnoiditis failed to recover neurologically.

Presacral neuroenteric fistula in a newborn presenting with an epidural abscess: case report and review of the literature

We describe a newborn infant (<24 hours of age) who presented with mild swelling on the back and buttocks attributable to a neuroenteric fistula complicated by an epidural parasacral abscess infected with mixed coliforms. Epidural abscesses in infancy are extremely rare, and one has not been observed previously in the newborn period. The infant was surprisingly mildly affected. Prompt intervention led to an excellent outcome. Coliforms may colonize the infant gut in <24 hours, even in the developed world. Unexplained swellings on the backs of infants should lead to a search for underlying malformations and an early surgical review, which is best conducted with a combined pediatric surgical and neurosurgical approach.

Thoracic neurenteric cyst in a middle aged adult presenting with Brown-Sequard syndrome

STUDY DESIGN

To report an unusual presentation of a thoracic neurenteric cyst.

OBJECTIVES

To increase knowledge about the pathogenesis and treatment of intraspinal neurenteric cyst.

SUMMARY OF BACKGROUND DATA

Intraspinal neurenteric cysts (enterogenous cysts) are very rare congenital cysts of endodermal origin. The diagnosis usually is established during the first or second decade of life. Those cysts are frequently associated with vertebral or spinal cord anomalies and dual malformation with mediastinal or abdominal cysts.

METHODS

A 50-year-old man presented with 1 year of left midthoracic intercostal pain after chest compression injury. Several months before admission, he felt left lower extremity weakness with right-side numbness. Plain radiography of thoracic spine was normal while MRI showed a cystic mass at T7, T8 level ventral to the spinal cord with cord compression. The spinal cord was displaced to the posterior more to the right side, mimicking hemisection of the left side of the spinal cord.

RESULTS

Thoracic laminectomy was performed and the intraspinal cyst was removed. The pathology report indicated neuroenteric cyst. The postoperative course was uneventful and the signs of myelopathy improved immediately. The patient appeared well after 2 years of follow-up.

CONCLUSIONS

Intraspinal neuroenteric cyst without plain vertebral anomaly may occur after trauma in middle aged adult life with Brown-Sequard syndrome. Successful treatment requires early recognition of those cysts and their associated abnormalities.

Intraventricular congenital lesions and colloid cysts

Intraventricular congenital lesions and colloid cysts comprise a rather large spectrum of different pathologic conditions. In most cases, treatment in not warranted unless there is progressive ventricular obstruction with hydrocephalus or growth of the lesion itself, making tissue biopsy and histopathologic diagnosis necessary. Accordingly, a precise neuroradiologic evaluation is of the utmost importance, because most lesions, if not symptomatic, only require clinical and radiologic follow-up.