Multiple extradural arachnoid cysts as a cause of spinal cord compression in a child. Case report

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.

Thoracic spinal extradural arachnoid cyst: A case report and literature review

Background:

Spinal extradural arachnoid cysts (SEDACs) are rare and are variously attributed to congenital, traumatic, or inflammatory etiologies. Here, we report a 70-year-old male who presented with a T11-T12 SEDAC and an incidental craniovertebral junction (CVJ) meningioma.

Case Description:

A 70-year-old male presented with progressive bilateral lower limb weakness and paresthesias. The thoracic MRI identified an extradural arachnoid cystic lesion at the T11-T12 level. In addition, the brain/ cervical MR documented an incidental meningioma at the CVJ. The patient underwent T11-T12 laminectomy for fenestration/removal of the extradural arachnoid cyst resulting in immediate cord decompression and neurological recovery. The histologic examination was consistent with a SEDAC who underwent successful resection of the SEDAC that resulted in symptom resolution.

Conclusion:

We presented a 71-year-old male with a thoracic SEDAC and an incidental CVJ meningioma, where resection of the SEDAC resulted in symptom resolution.

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.

A Rare Case of Spinal Extradural Arachnoid Cyst with Cord Compression

Spinal extradural arachnoid cysts are rare lesions which typically involve the thoracic spine and are an asymptomatic condition of unknown origin. They may also produce symptoms by compressing the spinal cord or nerve roots. Surgery is the treatment of choice in such lesions, but asymptomatic patients can be managed conservatively. We present a case of symptomatic, probable traumatic origin, spinal arachnoid cyst at our center in Hospital Kuala Lumpur, Malaysia. Magnetic resonance imaging spine showed well-defined, nonenhancing extradural cystic lesion from T5 to T6 vertebrae level compressing spinal cord anteriorly. The patient underwent T5, T6 laminoplasty, T4 partial laminectomy and excision of the cyst. Histologically, the cyst wall comprised of collagen and meningothelial cells. This surgical intervention achieved neurological improvement in terms of motor power in our follow-up of this patient.

[A rare cause of spinal cord compression: spinal epidural arachnoid cyst (about 3 cases)]

Spinal epidural arachnoid cyst (SEAC) is a benign condition whose pathophysiology is still uncertain. It is most commonly asymptomatic but it can cause severe neurological sequelae especially when treatment is not received in time. We conducted a retrospective study of three patients treated for SEAC conducted in the Neurosurgery Department, Hassan II University Hospital, Fez. We report the case of two male patients and a woman, with an average age of 35 years (range: 16-56 years), admitted with slow progressive spinal cord compression. All patients underwent spinal cord MRI showing epidural fluid collection, having the same signal as that of cerebrospinal fluid, compressing the opposite marrow. The collection was located in the chest in all cases. All patients underwent surgery via posterior approach for cyst resection and cyst neck ligation in two cases and dural plasty in a single case. Anatomo-pathologic examination showed arachnoid cysts. Postoperative outcome was simple in all cases. This study aims to update the current understanding of this pathology while insisting on the need for early management given its tendency toward gradual worsening in the absence of adapt therapy. It also aims to review the clinical, paraclinical and therapeutic features of this condition.

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.

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.

FOXC2 mutations in familial and sporadic spinal extradural arachnoid cyst

Spinal extradural arachnoid cyst (SEDAC) is a cyst in the spinal canal that protrudes into the epidural space from a defect in the dura mater. Most cases are sporadic; however, three familial SEDAC cases have been reported, suggesting genetic etiological factors. All familial cases are associated with lymphedema-distichiasis syndrome (LDS), whose causal gene is FOXC2. However, FOXC2 mutation analysis has been performed in only 1 family, and no mutation analysis has been performed on sporadic (non-familial) SEDACs. We recruited 17 SEDAC subjects consisting of 2 familial and 7 sporadic cases and examined FOXC2 mutations by Sanger sequencing and structural abnormalities by TaqMan copy number assay. We identified 2 novel FOXC2 mutations in 2 familial cases. Incomplete LDS penetrance was noted in both families. Four subjects presented with SEDACs only. Thus, SEDAC caused by the heterozygous FOXC2 loss-of-function mutation should be considered a feature of LDS, although it often manifests as the sole symptom. Seven sporadic SEDAC subjects had no FOXC2 mutations, no symptoms of LDS, and showed differing clinical characteristics from those who had FOXC2 mutations, suggesting that other gene(s) besides FOXC2 are likely to be involved in SEDAC.

Multiple extradural arachnoid cysts: report of two operated cousin cases

STUDY DESIGN

Report of 2 operated cousin cases of the multiple spinal extradural arachnoid cysts.

OBJECTIVE

To report the operative findings of cousin cases of the multiple spinal extradural arachnoid cysts and analyze a genetic etiology with the pedigree of all family members.

SUMMARY OF BACKGROUND DATA

Spinal extradural arachnoid cyst is a relatively rare condition that occupies the intraspinal space and sometimes causes neurologic disturbances. The exact etiology is unknown since most reported cases are sporadic. Minimally invasive treatments have been recently applied to a single extradural arachnoid cyst. However, it is still unknown which minimally invasive treatments can be applied to the multiple extradural arachnoid cysts.

METHODS

We experienced 2 cousin cases of multiple spinal extradural arachnoid cysts. Operative findings were described. The pedigree of all family members was made, and a genetic etiology was discussed.

RESULTS

Minimally invasive treatment was tried in Case 1. However, it failed to remove all cysts completely. Each cyst had each stalk communicating with subarachnoid space in both cases. Pedigree showed that the mode of inheritance was likely autosomal dominant.

CONCLUSION

When the cysts are multiple, it is necessary to identify a dural defect in each cyst. The etiology of the multiple extradural arachnoid cysts may be hereditary.

Kyste arachnoïdien intramédullaire symptomatique. À propos de deux cas et résumé de la littérature

OBJECTIVE

The objective of this work is to present and discuss the rare situation of curable medullary compression with favorable prognosis.

MATERIAL AND METHOD

Two cases of thoracic intramedullary arachnoid cysts are described. Clinical, paraclinical, therapeutics and outcome features are discussed with a review of the literature.

RESULTS

Two children, 4 and 8 years old, with an uneventful history were admitted for progressive spastic paraparesia. MRI demonstrated a thoracic intramedullary cystic lesion at level T3-T4 in both patients. The cyst was emptied with partial cyst wall resection via dorsomedial myelotomy. The pathology examination confirmed the diagnosis of arachnoid cyst. The initial clinical signs resolved completely in both patients.

CONCLUSION

Thought in children, intramedullary arachnoidian cyst is a potential cause of medullary compression. Direct surgery is the treatment of choice.

Sacral epidural noncommunicating arachnoid cyst

✓ The authors examine the natural history of a spinal epidural arachnoid cyst and present their experience with its treatment in a 25-year-old man who presented with progressive cauda equina syndrome. Neuroimaging revealed two neighboring sacral epidural cysts. The cysts were completely removed via a sacral S1–4 laminectomy; no communication with the subarachnoid space could be found. The patient's postoperative course was uneventful. He experienced progressive improvement and, finally, complete resolution of symptoms and no recurrence of the cyst. Nabors Type I sacral epidural arachnoid cysts are rare; in some cases their origins and the mechanism by which they cause deterioration in the patients' clinical condition are debatable. Findings in the present case support the idea that some of these cysts are noncommunicating but progressive in their clinical presentation. This lesion type is also known to occur intracranially. A brief review of the literature is provided.

[Extradural thoracic arachnoid cyst. Case report and review of the literature]

OBJECTIVE

To report an unusual and asymptomatic cause of cord compression treated surgically with good clinical outcome.

METHODS AND MATERIAL

We report a case of extradural arachnoid cyst in the thoracic region and review the literature on the clinical, neuroradiologic and therapeutic features.

RESULTS

A 17-year-old man, with unremarkable past medical history was referred to our institution of Neurosurgery, CHU Mohammed-VI, Marrakech, with progressive spastic paraparesis. Magnetic resonance imaging (MRI) showed a posterior extradural cystic lesion in the thoracic region from T6-T7 thoracic vertebra. The cyst was completely removed by posterior approach. An arachnoid cyst was confirmed at the histological study. Neurological symptoms improved after surgery.

CONCLUSION

Given its infrequency, the diagnosis of arachnoid cyst should be suspected when a cystic lesion causes cord compression. Surgery is the treatment of choice, providing good clinical outcome.

Sacral perineural cysts: imaging and treatment options

Perineural cysts are an uncommon radiological finding and a rare cause of radicular leg pain. We report the clinical findings, imaging and operative appearances of a patient who presented with radicular leg and perineal pain, which was found to be associated with multiple sacral perineural cysts. The diagnostic and treatment options are explored. In particular, the use of percutaneous fine-needle cyst drainage as a guide to the value of surgery is discussed. Postoperative complications, such as pseudomeningocoele can occur, but may be effectively treated with lumbar drainage.