Magnetic resonance imaging—guided percutaneous fenestration of a cervical intradural cyst

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.

Recurrence of a symptomatic spinal intradural arachnoid cyst 29 years after fenestration

Symptomatic arachnoid cysts are relatively rare, and no case reports have described recurrence of such cysts almost 30 years after surgery. We herein report a case in which a symptomatic intradural arachnoid cyst recurred 29 years after fenestration of the primary lesion. The patient was a 64-year-old woman who presented with paralysis of the left lower limb. She had undergone surgical treatment for an intradural arachnoid cyst at the T12 level 29 years previously. Magnetic resonance imaging (MRI) revealed an intradural mass at the T12–L1 level. The mass was compressing the spinal cord and cauda equina. Its localization and shape on MRI were similar to those of the primary cyst 29 years previously. Partial resection was performed under a diagnosis of a recurrent intradural arachnoid cyst. After surgery, the patient’s left lower limb paralysis improved. The pathological findings were suggestive of an intradural arachnoid cyst. The MRI findings 29 years previously provided useful information. The possibility of very late recurrence should be considered in patients who undergo surgical removal of intradural arachnoid cysts.

Postarachnoiditis Anterior Spinal Arachnoid Cyst Formation with Compressive Myelopathy: Report of 2 Cases

BACKGROUND

Spinal cystic arachnoiditis is a rare complication of a subarachnoid haemorrhage or infectious meningitis. The inflammatory process leads to fibrosis, adhesions, and in severe cases cyst formation. Large arachnoid cysts are an uncommon cause of compressive myelopathy. The majority are located posterior of the spinal cord at the thoracic level. Anterior cyst formation is exceptional, especially at the cervical region.

CASE DESCRIPTION

We present 2 cases of progressive myelopathy secondary to anterior arachnoid cyst formation. In a 54-year-old female a large anterior symptomatic thoracic cyst arose 4 years after rupture of a posterior inferior cerebellar artery aneurysm. The other 59-year-old-patient, however, developed an anterior cervical cyst only weeks after a varicella meningoencephalitis. Both female patients were treated with a decompressive laminectomy and wide fenestration of the cysts. Partial recovery was obtained in 1 patient, but there was no improvement in the other case.

CONCLUSIONS

Spinal cystic arachnoiditis with anterior cyst formation is an extremely rare complication of subarachnoid haemorrhage and infectious meningitis but can cause severe neurologic deficits. Clinicians should be aware of this rare complication. Due to the risk of irreversible spinal cord injury, rapid surgical intervention is recommended in most cases.

Symptomatic spinal cord compression from an intradural arachnoid cyst with associated syrinx in a child: case report

Symptomatic intradural extramedullary arachnoid cysts in children are rare, and of the previously reported pediatric cases in the current literature, none to our knowledge were associated with a spinal cord syrinx. We describe an 8-year-old child who presented with paraparesis and regression of bowel and bladder control. An intradural extramedullary arachnoid cyst was identified on preoperative magnetic resonance imaging, with an associated spinal cord syrinx. We describe the preoperative imaging, surgical management, and clinical course of this patient, who had improvement in his paraparesis. This paper reviews relevant pediatric literature and the etiology of arachnoid cysts and associated spinal cord syrinx formation.

A modified "far-lateral" approach for safe resection of retroodontoid dural cysts

Cystic mass lesions at the ventral craniocervical junction have been described only rarely in the past, however, they have received more attention with improved imaging modalities in recent years. These lesions have been approached by various operative procedures. A modified "far-lateral" approach combined with a C1 hemilaminectomy without fusion was used to safely remove the cyst and decompress the cervical medulla in a 72-year-old woman with cervicooccipital pain and paresthesia in both arms. Following surgery, complete resolution of symptoms was achieved, and no recurrence at 1 year follow-up was detected. A modified "far-lateral" approach offers several advantages when compared with other operation techniques.

Spinal cord compression caused by idiopathic intradural arachnoid cysts of the spine: review of the literature and illustrated case

Intradural spinal arachnoid cysts with cord compression are rare. When becoming symptomatic they cause variable symptoms involving gait disturbance, paraparesis or tetraparesis and neuropathic pain, decreasing significantly the patients' life quality. The extension of such cysts averages 3.7 vertebral bodies. The diagnosis is clinical and radiological with the use of MRI, CT myelography or a combination of both. The best treatment option is complete removal of the cyst. However, even when paresis is regressing there is no good recovery from neuropathic pain. Laminectomy approach can cause postoperative complications especially when the cyst(s) expand(s) in more than one level. Alternatively, a cyst fenestration can be performed, including the levels of the maximal spinal cord compression. The clinical outcome is as good as after the cyst resection enabling the patient to walk again. The neuropathic pain may persist and require medication. A clinical case is presented, and the literature is reviewed. In the present case we report a patient with intradural arachnoid cysts extending from T6 to L2 and causing severe gait ataxia as well as neuropathic pain and hypaesthesia. The spinal-cord was compressed at T8 and T12. Surgical treatment with partial cyst resection in the compressed levels with an interlaminar approach brought similar results as complete resection. The patient was able to walk without help which was not possible before surgery. The cysts' extension is impressive as well as the minimal operative procedure.

Percutaneous aspiration of spinal terminal ventricle cysts using real-time magnetic resonance imaging and navigation

STUDY DESIGN

Clinical case series.

OBJECTIVE

To present a new innovative treatment option for cysts of the terminal ventricle.

SUMMARY OF BACKGROUND DATA

Invasive surgery including laminectomy and cyst fenestration has been the sole reported method of treatment for this rare pathology.

METHODS

Four cases of symptomatic cyst of the terminal ventricle of the spinal cord were treated by percutaneous aspiration using real-time guidance with magnetic resonance imaging (MRI) and optically-tracking navigation.

RESULTS

Three patients were treated successfully by this percutaneous method, and for 1 patient the treatment was converted to conventional surgery after a single unsuccessful trial of percutaneous puncture. All patients were relieved of their symptoms without any complication. Follow-up MRI revealed continued shrinkage of the cysts after both surgery and MRI-guided percutaneous fenestration.

CONCLUSION

MRI-navigated percutaneous aspiration can be a minimally-invasive treatment option for symptomatic cysts of the terminal ventricle, and therefore, can be indicated before more invasive surgery might be scheduled.

Compression médullaire par kystes arachnoïdiens

Spinal arachnoid cysts are considered to be rare entities, intradural locations are even less common. We report two cases of patients (two women aged 77- and 21-year-old) who presented spinal cord compression by intradural arachnoid cysts. For the second patient, repeated surgical procedures were necessary to improve the neurological status. After presenting the case reports, we expose the pathophysiological mechanisms and clinical features, and the surgical difficulties of treating this rare cause of spinal cord compression.

Giant cervicothoracic extradural arachnoid cyst: case report

The pathogenesis, etiology, and treatment of the spinal arachnoid cyst have not been well established because of its rarity. A 57-year-old male was presented with spastic quadriparesis predominantly on the left side. His radiological examination showed widening of the cervical spinal canal and left neural foramina due to a cerebrospinal fluid - filled extradural cyst that extended from C2 to T2 level. The cyst was located left anterolaterally, compressing the spinal cord. Through a C4–T2 laminotomy, the cyst was excised totally and the dural defect was repaired. Several features of the reported case, such as cyst size, location, and clinical features make it extremely unusual. The case is discussed in light of the relevant literature.

Percutaneous Biopsy from Blinded to MR Guided: An Update on Current Techniques and Applications

The advent of interventional MR imaging techniques as well as their adoption to guide percutaneous biopsies and aspirations has served as a further step along a series of technical refinements that commenced with the implementation of image-guided approaches for tissue sampling. Nowadays, the practice of and the expectations from these procedures are quite different from those of the blind percutaneous thrusts performed in the late nineteenth and early twentieth centuries. As the field of interventional MR imaging continues to flourish and to attract more radiologists who realize the many opportunities that this technology can offer to their patients, there is a need for a full comprehension of the concepts, techniques, limitations, and cost-effectiveness of MR imaging guidance to present this service to clinical partners in the appropriate setting. Radiologists should also recognize the need for their significant involvement in the technical aspects of MR-guided procedures, because several user-defined parameters and trajectory decisions can alter device visualization in the MR imaging environment and hence affect procedure safety.

Spinal intradural juxtamedullary cysts in the adult: surgical management and outcome

OBJECTIVE

Intradural nonneoplastic cysts compressing the spinal cord are rare lesions. We retrospectively analyzed a series of patients harboring this entity with regard to clinical and radiological features, surgical management, and follow-up results.

METHODS

In a retrospective study, we reviewed the medical charts, radiological investigations, and follow-up data of 11 women and 10 men (mean age, 43.6 yr) with intradural juxtamedullary spinal cysts, which were consecutively treated microsurgically at our institutions between January 1995 and January 2003. All lesions were approached via a laminectomy, hemilaminectomy, or laminoplasty at the corresponding vertebral levels and histopathologically verified. The patients were routinely scheduled for clinical follow-up 2 and 6 months after surgery. Baseline postoperative magnetic resonance imaging (MRI) was ordered 6 months after surgery. Thereafter, follow-up was performed at 1-year intervals, with neurological examination and MRI.

RESULTS

According to presenting symptomatology, two main patient groups could be differentiated: one group with a myelopathic syndrome (10 patients) and another group with a predominant radicular pain syndrome (8 patients). Histopathological examination revealed 16 arachnoid cysts, 4 neuroepithelial cysts, and 1 cervical nerve root cyst. Most arachnoid cysts (12 cases) were located on the dorsal aspect of the thoracic spinal cord. The mean craniocaudal extension of these cysts was 3.7 vertebral levels, and complete resection was performed. In four patients, the arachnoid cyst was situated ventral to the spinal cord and involved up to 17 vertebral levels. These patients had a history of major spinal trauma, and the cyst was generously fenestrated at its greatest circumference as depicted on preoperative MRI scans. The four neuroepithelial cysts and the cervical nerve root cyst were located on the ventral or ventrolateral aspect of the spinal cord, and their maximum sagittal extension was two spinal vertebral levels. Symptoms in all but two patients demonstrated major improvement; in particular, radiating pain disappeared immediately after surgery. There was no cyst recurrence on MRI after a mean follow-up period of 3.2 years.

CONCLUSION

Intradural cysts should be considered in the differential diagnosis of lesions causing myelopathy and/or a radicular pain syndrome. Microsurgical resection or generous fenestration in cysts with large craniocaudal extensions effectively ameliorated patients' symptomatology. A description of the first documented case of a surgically treated intradural cervical nerve root cyst is provided.