Surgical strategy for multiple huge spinal extradural meningeal cysts

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.

Detection of the communicating hole(s) of spinal extradural arachnoid cysts using time-spatial labeling inversion pulse magnetic resonance imaging

STUDY DESIGN

Report of 2 cases.

OBJECTIVE

To report the usefulness of time-spatial labeling inversion pulse magnetic resonance imaging (T-SLIP MRI) for detection of the communicating hole(s) of spinal extradural arachnoid cysts (SEACs).

SUMMARY OF BACKGROUND DATA

SEACs normally communicate with the subarachnoid space via small communicating hole(s) in the dura. It is necessary to identify the accurate locations of these communicating hole(s) before attempting to close them through limited laminotomy/laminectomy. Myelocomputed tomography or conventional MRI may fail to detect the locations of the hole(s) because they comprise small dural defects.

METHODS

Case 1: A 33-year-old female presented with an SEAC at the T11–L2 vertebral level. Case 2: An 82-year-old female presented with an SEAC at T12–L4 vertebral level.

RESULTS

Case 1: T-SLIP MR image of the left parasagittal plane (not the midsagittal or right parasagittal plane) revealed cerebrospinal fluid flow from the subarachnoid space into the cyst at L1. After limited laminotomy at T12–L1 and partial cyst resection, we identified 2 contiguous dural holes immediately medial to the left L1 pedicle; this corroborated the preoperative T-SLIP MRI findings. The holes were sutured. Postoperative conventional MR image confirmed significant cyst shrinkage. Case 2: T-SLIP MR image revealed a curved line at the L1 pedicle in the right parasagittal plane. After L1 laminectomy and partial cyst resection, a dural hole was identified L1 pedicle, which was in agreement with the preoperative T-SLIP MRI findings. After surgery, the lower extremity pain disappeared. Postoperative conventional MR image revealed significant cyst shrinkage.

CONCLUSION

T-SLIP MRI is useful for detection of the communicating hole(s) of SEACs.

LEVEL OF EVIDENCE

N/A.

Neurosurgical management of patients with lumbosacral myeloschisis

Myeloschisis is the most serious and complex congenital anomaly in spina bifida manifesta (cystica). However, with improvements in medical care and increased understanding of its pathophysiology, the associated long-term morbidity and mortality rates have been significantly reduced. This article reviews various issues associated with the neurosurgical management of patients with myeloschisis, such as perinatal management, repair surgery for myeloschisis, neurosurgical management of hydrocephalus, Chiari malformation type II, tethered cord syndrome and epilepsy, and intrauterine fetal surgery.

A sacral arachnoid cyst causing holocord syringomyelia

Spinal extradural arachnoid cysts (ACs) have an infrequent predilection for the sacrum. As with their counterparts in other regions of the spine, cysts in this location are mostly asymptomatic. Common presentations in symptomatic cases include pain in the low back or perineum, radiculopathy, and sphincteric dysfunction. The authors report a hitherto undescribed presentation in which the predominant symptoms are those related to an associated holocord syrinx. This 15-year-old boy presented with fluctuating, spastic paraparesis and a dissociated sensory loss in the trunk. Admission MR imaging of the spine showed an extradural AC from S-2 to S-4 and a holocord, nonenhancing syrinx. The patient underwent S-2 laminectomy, fenestration of the cyst, and partial excision of its wall. Intradural exploration revealed a normal-looking filum terminale and the absence of any dural communication with the cyst. At a follow-up visit 6 months after surgery, his motor and sensory deficits had resolved. Follow-up MR imaging showed complete resolution of the syrinx in the absence of the sacral AC. This is the first report of a sacral extradural AC causing holocord syringomyelia. Because conventional theories of syrinx formation were not helpful in elucidating this case, a hypothesis is postulated to explain the clinicoradiological oddity.

Huge thoracolumbar extradural arachnoid cyst excised by recapping T-saw laminoplasty

BACKGROUND CONTEXT

Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. Total removal of the cyst and repair of the dural defect is the primary treatment for symptomatic spinal extradural arachnoid cysts.

PURPOSE

To report the usefulness of recapping T-saw laminoplasty in treating huge extradural arachnoid cyst.

STUDY DESIGN

Case report.

METHODS

We report the case of a 43-year-old man who presented with a 2-year history of progressive muscle weakness and numbness of the lower extremities. Magnetic resonance imaging (MRI) showed a huge extradural arachnoid cyst at the T12-L3 level extending into bilateral neural foramina and severe posterior compression of the spinal cord and cauda equina.

RESULTS

The patient underwent total resection of the cyst and closure of the communication. En bloc recapping T-saw laminoplasty of T12-L2 including the T12-L1 and L1-L2 facet joints was performed to obtain extensive exposure and preserve posterior stability. Postoperatively, the patient achieved complete recovery of neurologic functions. Follow-up MRI demonstrated no recurrence of the cyst. Bone union after laminoplasty was obtained within 6 months.

CONCLUSION

Total resection of the cyst and closure of the communication is curative for this rare lesion. Recapping T-saw laminoplasty provides extensive exposure for removal of a large cyst while allowing complete preservation of the posterior spinal elements.

Three-dimensional constructive interference in steady-state magnetic resonance imaging in syringomyelia: advantages over conventional imaging

OBJECT

Neuroradiology has become indispensable in detecting the pathophysiology in syringomyelia. Constructive interference in steady-state (CISS) magnetic resonance (MR) imaging can provide superior contrast at the sub-arachnoid tissue borders. As this region is critical in preoperative evaluation, the authors hypothesized that CISS imaging would provide superior assessment of syrinx pathology and surgical planning.

METHODS

Based on records collected from a database of 130 patients with syringomyelia treated at the authors' institution, 59 patients were prospectively evaluated with complete neuroradiological examinations. In addition to routine acquisitions with FLAIR, T1- and T2-weighted, and contrast-enhanced MR imaging series, the authors obtained sagittal cardiac-gated sequences to visualize cerebrospinal fluid (CSF) pulsations and axial 3D CISS MR sequences to detect focal arachnoid webs. Statistical qualitative and quantitative evaluations of spinal cord/CSF contrast, spinal cord/CSF delineation, motion artifacts, and artifacts induced by pulsatile CSF flow were performed.

RESULTS

The 3D CISS MR sequences demonstrated a contrast-to-noise ratio significantly better than any other routine imaging sequence (p < 0.001). Moreover, 3D CISS imaging can detect more subarachnoid webs and cavitations in the syrinx than T2-weighted MR imaging with less flow-void artifact. The limitation of 3D CISS imaging is a susceptibility to motion artifacts that can cause reduced spatial resolution. Lengthy acquisition times for axial segments can be reduced with multiplanar reconstruction of 3D CISS-generated sagittal images.

CONCLUSIONS

Constructive interference in steady-state imaging is the MR sequence of choice in the preoperative evaluation of syringomyelia, allowing significantly higher detection rates of focal subarachnoid webs, whereas standard T2-weighted MR imaging shows turbulent CSF flow voids. Constructive interference in steady-state MR imaging enables the neurosurgeon to accurately identify cases requiring decompression for obstructed CSF. Motion artifacts can be eliminated with technical variations.

Neurosurgical management of occult spinal dysraphism associated with OEIS complex

INTRODUCTION

OEIS complex has been described as a combination of defects consisting of omphalocele (O), exstrophy of the cloaca (E), imperforate anus (I), and spinal defects (S). As the first three defects are life-threatening and treated on a priority basis, neurosurgical intervention for spinal defects is deferred until recuperation from abdominogenital repair. However, the best timing for neurosurgical operation has not been precisely described.

MATERIALS AND METHODS

We reviewed our neurosurgical management of three cases (case 1: myelomeningocele; cases 2 and 3: terminal myelocystocele). At 2-6 (3.6 on average) months after birth, neurosurgical procedures, including reduction of the size of the lumbosacral cystic lesion and untethering of the spinal cord, were performed.

RESULTS

During this period, the patients' weights increased from 1,911 to 3,368 g on average, and the lumbosacral cystic lesion was markedly enlarged. In all cases, no neurological deterioration was seen, and ventriculoperitoneal shunt was not indicated.

CONCLUSION

Thus, neurosurgical procedures can be performed in patients weighing 3-4 kg and/or at an age of 3 months, after confirming recuperated conditions from abdominogenital repair. Careful observation should be made of the size of the lumbosacral cystic lesion and neurological deterioration.