Spinal neurenteric cyst presenting in infancy with chronic fever and acute myelopathy

Retroperitoneal enterogenous cyst combined with teratoma

A 63-year-old man presented with left abdominal pain, abdominal distention, and black stool following emotional stress and strenuous exercise. CT examination revealed a large cystic mass in the left abdominal cavity, as well as the presence of a teratoma in the hepatogastric space and a descending duodenal diverticulum. Subsequently, he underwent surgical resection, and the pathological findings indicated that the cyst wall consisted of mucinous glandular epithelium and smooth muscle, displaying a structure similar to normal intestinal wall tissue. Furthermore, the cyst was lined with ciliated columnar epithelium, confirming the diagnosis of an isolated enterogenous cyst (EC). Due to the potential trauma associated with excising the EC, the patient did not undergo resection of the teratoma, especially given its proximity to a branch of the trunk abdominal artery.

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.

Clinical features and MRI manifestations of intraspinal enterogenous cysts

AIM: To explore the clinical features and magnetic resonance imaging (MRI) manifestations of intraspinal enterogenous cysts.

METHODS: Case reports concerning intraspinal enterogenous cysts were retrieved from CNKI and WanFang Data and screened according to the inclusion and exclusion criteria. The clinical features and MRI manifestations of intraspinal enterogenous cysts were analyzed.

RESULTS: A total of 60 case reports with 80 patients were included. The male to female ratio was 46:33. The mean age was 19.9 years ± 14.6 years. The mean course of disease was 2.87 years ± 5.00 years. There were 37.50% of patients with chief complaint or first symptom of neck-shoulder-back pain or discomfort. Most of the patients (82.50%) had motor dysfunction, and 13 patients had complications. The lesions were mostly located in the cervical (45.00%), ventral (83.33%) and subdural (94.87%) spinal cord. The signal was mostly hypointensity (67.35%) on T1 weighted imaging and hyperintensity (91.84%) on T2 weighted imaging in MRI examination. No enhancement was observed in most post-contrast images. Thinning and displacement can be observed in the corresponding spinal segments due to compression of cysts. All patients underwent surgery, and 95.74% of them recovered well. There were three cases of recurrence.

CONCLUSION: Intraspinal enterogenous cyst is a rare congenital disease. It can be diagnosed early and treated timely based on the clinical features and MRI manifestations. MRI examination provides an important tool for preoperative diagnosis, surgical planning and prognosis evaluation of intraspinal enterogenous cysts.

Intraspinal Neurenteric Cysts in Children

Background:

Neurenteric cysts are rare congenital epithelium-lined cysts of the central nervous system. They are found predominantly in the spinal cord, with lower incidence in the intracranial compartment, and may be associated with various other congenital spinal anomalies. Seven patients with symptomatic intraspinal neurenteric cysts are presented.

Materials and Methods:

Seven patients with intraspinal neurenteric cysts aged from nine months to ten years treated at this hospital from May 2000 to July 2006 were reviewed. The clinical manifestations, imaging and surgical findings of patients were analyzed retrospectively. All patients underwent operation. One patient's cervical neurenteric cyst was resected using the lateral cervical approach, and the other six resections were performed with posterior approach.

Results:

All seven patients presented with neurological involvement. One patient had an intramedullary cyst, while the other six cysts were situated ventrally. Three patients' cysts occurred in the cervical region, two in the cervicothoracic region, one in the thoracic region and one in the lumbar region. One patient had bony anomalies, and one had a lumbar posterior occult spinal dysraphism. Five patients' symptoms improved rapidly after surgery.

Conclusions:

Intraspinal neurenteric cysts in children are rare and most occur ventral to the spinal cord. Magnetic resonance imaging (MRI) is the most effective imaging modality. Earlier diagnosis and surgical resection of spinal neurenteric cysts improves prognosis.

Intramedullary spinal neurenteric cyst with fluid-fluid level

Spinal neurenteric cysts are rare intradural extramedullary lesions of the spine, commonly located in the cervical and thoracic regions. The majority localize ventral to the spinal cord and are associated with other vertebral anomalies. Here, the authors report a rare case of a 3-year-old boy presenting with a 1-week history of meningismus followed by rapid-onset (over a few hours) paraplegia. Magnetic resonance imaging revealed an intramedullary cystic lesion with a fluid-fluid level in the cervicothoracic region of the spinal cord without associated bony or soft tissue abnormalities. To the best of the authors' knowledge, such clinical and radiological presentation of a spinal neurenteric cyst has never been reported. A brief review of the pertinent literature is presented, and the possible pathophysiology of such a presentation is also discussed.

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.

Primary nerve repair following resection of a neurenteric cyst of the oculomotor nerve

Neurenteric cysts are rare congenital lesions of endodermal origin occurring in the spinal canal and infrequently in the posterior cranial fossa. The authors report the case of a 3-year-old child who presented with a recurrent third cranial nerve palsy. Magnetic resonance imaging showed a large cystic mass lesion in the ambient cistern on the right side, with compression of the anterolateral aspect of the brainstem. The patient underwent a craniotomy, complete excision, and a primary third cranial nerve repair. While there have been 3 reported cases of neurenteric cysts arising from the oculomotor nerve, this is the first documented case with a primary nerve repair.

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.

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.

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.

Surgical experience in symptomatic congenital intraspinal cysts

Symptomatic congenital intraspinal cysts are uncommon but not rare. Since these cysts may have various manifestations, a careful differential diagnosis is needed. We retrospectively reviewed findings in 3 women and 2 men (age range, 10-50 years) with 6 symptomatic cysts of the thoracic or thoracolumbar spine. In addition, we statistically analyzed the patients' Nurick myelopathy grades before and after treatment. Pain and spastic paraparesis were the most frequent manifestations. Radiographs showed the widening of the spinal bony canal in 3 patients with extradural arachnoid cysts. All patients received limited laminectomy and appropriate surgical procedures. Pathology reports indicated neurenteric (n = 1), arachnoid (n = 4), and epidermoid (n = 1) cysts. Their functional status significantly improved by a mean of 2.6 Nurick points (p = 0.0002). Our findings confirm that these cysts have various manifestations. Congenital intraspinal cyst should be included in the differential diagnosis for patients with back pain, radiculopathy, cauda equina syndrome, Brown-Sequard syndrome, or myelopathy. The advent of MR imaging and increased knowledge about the pathogenesis of these cysts have improved the ease and accuracy of their early diagnosis; in addition, postoperative prognoses are excellent if surgery is performed early.

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.

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.

Magnetic resonance imaging of spinal dysraphism

Spinal cord development occurs through three consecutive periods. Gastrulation (weeks 2-3) is characterized by conversion of the embryonic disk from a bilaminar to a trilaminar arrangement and establishment of a notochord. Primary neurulation (weeks 3-4) produces the uppermost nine tenths of the spinal cord. Secondary neurulation and retrogressive differentiation (weeks 5-6) result in formation of the conus tip and filum terminale. Defects in these early embryonic stages produce spinal dysraphisms, which are characterized by anomalous differentiation and fusion of dorsal midline structures. Spinal dysraphisms may be categorized clinically into two subsets. In open spinal dysraphisms, the placode (non-neurulated neural tissue) is exposed to the environment. These disorders include myelomeningocele, myeloschisis, hemimyelomeningocele, and hemimyelocele, and are always associated with a Chiari II malformation. Closed spinal dysraphisms are covered by intact skin, although cutaneous stigmata usually indicate their presence. Two subsets may be identified based on whether a subcutaneous mass is present in the low back. Closed spinal dysraphisms with mass comprise lipomyeloschisis, lipomyelomeningocele, meningocele, and myelocystocele. Closed spinal dysraphisms without mass comprise complex dysraphic states (ranging from complete dorsal enteric fistula to neurenteric cysts, split cord malformations, dermal sinuses, caudal regression, and spinal segmental dysgenesis), bony spina bifida, tight filum terminale, filar and intradural lipomas, and persistent terminal ventricle. Magnetic resonance imaging is the imaging method of choice for investigation of this complex group of disorders.

Tethered cord syndrome and occult spinal dysraphism

Tethered cord syndrome is a progressive form of neurological deterioration that results from spinal cord tethering by various dysraphic spinal abnormalities. The syndrome, treatments, outcomes, and current controversies are reviewed.