Multiple spinal extradural arachnoid cysts occurring in a child

Multiple spinal extradural arachnoid cysts presenting as compressive myelopathy in a teenager: case report and literature review with special emphasis on postoperative spine deformity in the current minimally invasive era

INTRODUCTION

Multiple synchronous spinal extradural arachnoid cysts are extremely rare in children and can lead to cord compression and disability. Multiple spinal extradural arachnoid cysts (SEDACs) in children with immature and growing spine need to be studied separately from multiple SEDACs in adults with mature and fully grown spine because of multiple surgical limitations in children (blood loss, surgery duration, long-term spinal stability after long segment exposure, etc.).

MATERIAL AND METHODS

We planned a non-systematic literature review of similar cases described in literature to analyse the pattern of presentation, management, and outcome of this surgically curable disease.

RESULTS

A total of 28 cases of paediatric multiple SEDACs in the age range of 5 months to 17 years and mean age of 11.54 years were analysed. Exposure was achieved by laminectomy in 9, laminoplastic laminotomy in 13, laminectomy in first surgery followed by laminoplasty in second surgery (re-exploration) in 1, hemilaminectomy in 2, and technique "not reported" in 3 children. Complete/near-complete recovery was seen in 27 (96.42%) children. Postoperative spine deformity was reported in 7 (25%) children and was progressive in 2 children during serial follow-up.

CONCLUSIONS

Symptomatic multiple synchronous SEDACs in children is a rare surgically curable condition. Sincere attempt to find out a dural defect in all cysts is a very important step in multiple SEDAC surgery. Total cyst wall excision with closure of all dural defects is the gold standard treatment for symptomatic cases. Laminoplasty is preferred for excision of multiple SEDACs in children to prevent postoperative spine deformity during long-term follow-up. Long serial follow-up for postoperative spine deformity is necessary.

Transforaminal endoscopic excision of bi-segmental non-communicating spinal extradural arachnoid cysts: A case report and literature review

BACKGROUND

Spinal extradural arachnoid cysts (SEACs) are a rare cause of spinal cord compression. Typically, these cysts communicate with the intradural subarachnoid space through a small defect in the dural sac. For symptomatic SEACs, the standard treatment is to remove the cyst in total with a (hemi)laminectomy or laminoplasty. We present a rare case of bi-segmental non-communicating SEACs and describe our experience of using an endoscopic minimal access technique to remove bi-segmental non-communicating SEACs.

CASE SUMMARY

A 79-year-old female presented with pain related to bi-segmental SEACs at the T11-L1 segments. She underwent sequential transforaminal percutaneous endoscopic thoracic cystectomy of the SEACs. Following her first procedure, spinal magnetic resonance imaging demonstrated complete excision of the cyst at the T12-L1 segment. However, the cyst at the T11-T12 segment was still present. Thus, a second procedure was performed to remove this lesion. The patient’s right-sided lumbar and abdominal pain improved significantly postoperatively. Her Japanese Orthopaedic Association score increased from 11 to 25, her visual analogue scale score was reduced from 8 to 1. The physical and mental component summary of the 36-item short-form health survey (SF-36) were 15.5 and 34.375 preoperatively, and had increased to 79.75 and 77.275 at the last follow-up visit, respectively.

CONCLUSION

Bi-segmental non-communicating SEACs are extremely rare. Endoscopic surgery is a safe, effective, and reliable method for treating these cysts. In the event of bi-segmental SEACs, it is important to identify whether both cysts are communicating before surgery, and if not, to remove both cysts separately during the index surgery to avoid re-operation.

How to Find Dural Defect of Spinal Extradural Arachnoid Cyst

Spinal extradural arachnoid cysts (SEACs) are rare and usually asymptomatic, and they usually do not require surgical treatment. If symptoms manifest, however, surgical treatment is required. A 25-year-old male patient complained of impotence upon admission. Magnetic resonance images (MRIs) of his lumbar spine showed a SEAC located longitudinally from the T11 to L3, which was accompanied by thecal sac compression. Verifying the location of the dural defect is crucial for minimizing surgical treatments. Cystography, myelography, and lumbar spine MRI were conducted to locate the leak in real-time; however, it was not found. Hence, the location of the cerebrospinal fluid leak was estimated based on cystography, computed tomography, myelography, and MRI findings. We suggest that the region with the earliest contrast-filling, as well as the middle and widest area of the cyst, may correspond to the location of the dural defect.

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.

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.

Nonfusion Muscle-Sparing Technique to Treat Long-Segment Thoracolumbar Extradural Arachnoid Cyst in a Child: A Case Report and Review of the Literature

BACKGROUND

Spinal extradural arachnoid cyst is an uncommon cause of spinal cord compression. It results from a small dural defect that leads to cerebrospinal fluid (CSF) accumulation in the cyst and subarachnoid space, and the cyst can compress the spinal cord and nerve roots. Surgery is the treatment of choice in symptomatic patients, and most cases have an immediately satisfying outcome after surgery.

CASE DESCRIPTION

A 10-year-old Thai boy presented with progressive weakness in both legs. Magnetic resonance imaging (MRI) demonstrated a giant cystic lesion 23 cm in length from T1-L2 level. To our knowledge, this is the longest arachnoid cyst that has been reported in children. The operation included unilateral paraspinal muscle dissection with spinous process translation techniques, T1-L4 laminectomy, total cyst excision, and dural defect repair at the T4 level. The symptoms were fully resolved within 2 months after surgery. However, thoracic kyphosis was slightly increased, but the patient still has a normal sagittal profile.

CONCLUSIONS

Spinal arachnoid cyst is rare, especially in children. Early diagnosis and treatment are essential for improving the chance of full recovery, and for avoiding complication and irreparable defect. Total cyst removal with dural repair remains the best treatment alternative; however, potential complications, especially spinal malalignment after extensive laminectomy, must be considered. Postoperative MRI showed normal CSF flow and no spinal cord compression. The muscle-sparing technique with multiple-level laminectomy without spinal fusion that we used in this case provided a satisfying outcome.

Spinal extradural arachnoid cyst in a child-a case report

Extradural spinal arachnoid cysts are rare lesions. They frequently communicate with the subarachnoid space through a defect in the dura. Symptoms result from compression of the spinal cord or nerve roots. The treatment of choice is complete surgical excision. We report the case of a 12-year-old girl with extradural spinal arachnoid cyst who had complete surgical excision with good outcome.

Huge multiple spinal extradural meningeal cysts in infancy

BACKGROUND

Multiple spinal extradural meningeal cysts (SEMCs) are rare lesions. SEMCs communicate with the subarachnoid space through multiple dural defects and expand into the extradural space with progressive spinal cord compression.

CASE PRESENTATION

We report a 5-month-old boy with hydronephrosis involving nine huge SEMCs that were distributed from the T1-L5 levels. Eight SEMCs, except for one small noncommunicating cyst, were exposed through laminoplastic laminotomy at the T10-L5 and T3-5 levels. Five transdural communications with dural defects were packed with a piece of autologous muscle and fibrin glue. Tenting sutures to lift up the dura to the vertebral arch were added to minimize the extradural dead space. Postoperatively, cord compression was relieved and hydronephrosis improved.

CONCLUSION

In conclusion, packing of all dural defects and dural tenting sutures at a one-staged operation is useful in the surgical management of huge and multiple SEMCs in infancy.

Recurrent Caterpillar-like Arachnoid Cysts Following Initial Resection: A Unique Presentation of a Disorder Where the Limits of Modern Medicine Are Reached

Of the many emergent neurological cases presenting to the emergency department (ED) and operating room (OR) for resection, arachnoid cysts are amongst one of the rarer pathologies. The proper resection of arachnoid cysts has substantially decreased the risk of recurrence. Current medicinal and surgical approaches have been refined over the years and prove to be successful for many patients. Where current practices begin to fail is during the treatment of complex and rare cases, such as the one presented in this manuscript. The commonly accepted surgical practices that were utilized to aid in the management of our patient, who initially presented with a simple arachnoid cyst, unexpectedly resulted in the further development of additional arachnoid cysts, a very rare occurrence, and a complication that should be discussed amongst all specialists in the hope of identifying more focused, novel, and less-invasive approaches to cyst removal and recurrence prevention.

Symptomatic Large Spinal Extradural Arachnoid Cyst: A Case Report

Spinal extradural arachnoid cysts (SEACs) are relatively rare cause of compressive myelopathy. SEACs can be either congenital or acquired, but the etiology and the mechanism for their development are still unclear. A number of cases have been reported in the literature, and the one-way valve mechanism is the most widely accepted theory which explains the expansion of cysts and spinal cord compression. We report two cases of SEAC in this article. Patients had intermittent, progressive cord compressing symptoms. MRI image showed large SEAC which caused compression of the spinal cord. Pre-operative cystography and CT myelography were performed to identify the communicating tract. Pre-operative epidural cystography showed a fistulous tract. The patients underwent primary closure of the dural defect which was a communicating tract. The operative finding (nerve root herniation through the tract) suggested that the SEAC developed through a checkvalve mechanism. Postoperatively, the patients had no surgical complications and symptoms were relieved. Based on our experience, preoperative identification of the communicating tract is important in surgical planning. Although surgical excision is the standard surgical treatment, primary closure of the dural defect which was a communicating tract can be an acceptable surgical strategy.

A symptomatic spinal extradural arachnoid cyst with lumbar disc herniation

Spinal epidural arachnoid cyst (EAC) is a rare, usually asymptomatic condition of unknown origin, which typically involves the lower thoracic spine. We report a case of posttraumatic symptomatic EAC with lumbar disc herniation. A 22-year-old man experienced back pain and sciatica after a traffic accident. Neurological examination revealed a right L5 radiculopathy. Magnetic resonance imaging demonstrated a cystic lesion at the L3 to L5 level and an L4-5 disc herniation; computed tomography myelography showed that the right L5 root was sandwiched between the cyst and the herniation. A dural defect was identified during surgery. The cyst was excised completely and the defect was repaired. A herniation was excised beside the dural sac. Histology showed that the cyst wall consisted of collagen and meningothelial cells. Postoperatively the symptoms resolved. Lumbar spinal EACs are rare; such cysts may arise from a congenital dural crack and grow gradually. The 6 cases of symptomatic lumbar EAC reported in the literature were not associated with disc herniation or trauma. In this case, the comorbid disc herniation was involved in symptom progression. Although many EACs are asymptomatic, comorbid spinal disorders such as disc herniation or trauma can result in symptom progression.

Spinal extradural arachnoid cyst: a case report

Spinal arachnoid cyst is a rare cause of myelopathy secondary to spinal cord compression. We report a case presenting extradural arachnoid cyst of probable traumatic origin leading to irreversible neurological deficits including paraparesis and neurogenic bladder. The patient presented progressive paraparesis and voiding difficulty. Magnetic resonance imaging (MRI) of the spine revealed long segmental cystic lesion of cerebrospinal fluid (CSF) signal intensity at dorsal extramedullary space of T11 to L3 level suggesting arachnoid cyst with diffuse cord compression. On the operation, an ovoid shaped dural defect was identified at right sided dorsolateral aspect of the dura mater between nerve root sleeves at T11 and T12 level. The patient was treated by microsurgical repair of the dural defect and intraoperative findings revealed no further leakage of CSF. The neurological status of the patient was stationary on follow-up examination postoperatively. We postulate that delayed-onset post-traumatic extradural arachnoid cyst should be taken into consideration on the differential diagnosis of intrapinal cysts.

Extradural giant multiloculated arachnoid cyst causing spinal cord compression in a child

BACKGROUND

Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. Enlargement may cause progressive signs and symptoms caused by spinal cord compression. They are associated with trauma, surgery, arachnoiditis, and neural tube defects. Most nontraumatic spinal extradural arachnoid cysts are thought to be congenital.

DESIGN

Case report and literature review.

FINDINGS

A 9-year-old boy with mild paraparesis was found to have an extradural multiloculated arachnoid cyst with fibrous septa at T4-L3 levels and anterior compression and displacement of the spinal cord.

CONCLUSIONS

Definitive treatment of arachnoid cyst entails radical cyst removal and dura cleft repair. Formation of a postoperative cerebrospinal fluid fistula may require external lumbar drainage.