Surgical Treatment of Ten Adults with Spinal Extradural Meningeal Cysts in the Thoracolumbar Spine

Surgical management of a thoraco-lumbar extradural cyst in a pediatric patient with Klippel-Trenaunay syndrome: a case report

Introduction and importance

Klippel-Trenaunay syndrome (KTS) is a congenital disorder characterized by the abnormal development of blood vessels, soft tissues, bones, and the lymphatic system. The syndrome is rare, with few cases reported worldwide, especially those describing an association between KTS and spinal extradural meningeal cysts (SEMC). This report highlights a rare case of a pediatric patient with KTS who underwent successful surgical decompression of a thoraco-lumbar extradural cyst, highlighting the importance of reevaluating surgical interventions in KTS patients.

Case presentation

A 15-year-old girl diagnosed with KTS 4 days postnatally, was referred to our clinic due to chronic back pain and spastic paraparesis. These symptoms were attributed to a compressive extradural thoraco-lumbar cyst. Diagnostic evaluations confirmed the presence of the cyst, leading to the decision to proceed with surgical intervention.

Clinical discussion

The surgical approach involved a laminoplasty at T11-T12-L1, resulting in the total removal of the cystic lesion. The patient exhibited a complete resolution of symptoms postoperatively, with no significant complications reported during the surgery.

Conclusion

With this case, the authors question the fear of surgical intervention in KTS patients, which is often avoided due to concerns of high-risk complications like excessive bleeding or poor wound healing, and hint at a possible association between KTS and extradural meningeal cysts.

Expanding the Horizons of Minimally Invasive Spine Surgery: Experience of the Destandau Technique for the Treatment of Multiple Spinal Diseases

OBJECTIVE

Minimally invasive spine surgery is rapidly gaining popularity because of its versatile nature. Traditionally, prolapsed disc has been the most common disease targeted using this technique. However, its usefulness for various other diseases has also been shown in studies. We present our experience of using this technique for various spinal diseases apart from prolapsed discs.

METHODS

This is a retrospective study in which patients operated on by a single surgeon from January 2019 to April 2023 were included. Cases that required conversion to open technique were excluded. Intraoperative findings and postoperative courses were obtained from patient records.

RESULTS

A total of 47 patients were included in the study, of whom 29 were male and 18 were female. The various diseases treated comprised intradural extramedullary (IDEM) tumors (n = 23), hypertrophied/ossified ligamentum flavum (n = 9), arachnoid cysts (n = 6), dermoid/epidermoid cysts (n = 4), detethering of cord (n = 3), and posterior cervical decompression for an ossified posterior longitudinal ligament (n = 2). The average duration of surgery was 2.1 ± 1.2 hours and the mean intraoperative blood loss was 138.4 ± 59.1 mL. The mean length of hospital stay was 2.3 ± 0.9 days. Two patients had superficial wound infection and none of the operated patients had cerebrospinal fluid leakage. Re-exploration was not required in any of the operated patients.

CONCLUSIONS

Minimally invasive techniques for dealing with multiple diseases involving the spine are as good as traditional open techniques, with some additional advantages of lesser tissue trauma, early return to work, and so on. However, one must overcome the steep learning curve before adopting them in day-to-day practice.

Spinal extradural arachnoid cysts: A novel formation mechanism and dural defect location technology

Purpose

The formation mechanism of spinal extradural arachnoid cysts (SEACs) remains unclear. There are several hypotheses for the formation of SEACs, but none of them can fully explain its pathological findings and surgical procedures. In this study, we retrospectively analyzed the cases of SEACs, aiming to clarify the formation mechanism of SEACs. In addition, we summarize a concise method for locating dural defects preoperatively and formulate a putative explanation of this method.

Methods

The clinical data of 14 patients with SEACs underwent surgery in our hospital from January 2017 to December 2021 were retrospectively analyzed.

Results

Fourteen patients were identified during the study period. The cysts all spanned the T12/L1 segment, and dural defects were also located at the T12/L1 level (2 cases not recorded) as well as the middle or the upper-middle level of the cysts. Nine cases were treated with total cyst excision, 2 cases were treated with dural defect closure only, and 3 cases were treated with total cyst excision and dural defect closure. Histopathological examination demonstrated that the cyst wall contained both the arachnoid epithelial and compact fibrous connective tissue. The symptoms were relieved in all patients, and no recurrence was observed.

Conclusions

According to intraoperative and pathological findings, the dural outer layer cyst (DOLC) is a more reasonable hypothesis about SEACs formation. When CT myelography or cinematic MRI cannot determine the location of the dural defect preoperatively, it can be located according to the middle level of the SEACs with high accuracy.

How to locate the dural defect in a spinal extradural meningeal cyst: a literature review

Spinal extradural meningeal cysts (SEMCs) are rare lesions of the spinal canal. Although closure of the dural defect can achieve satisfactory therapeutic effects, locating the fistula is difficult. This review summarizes the methods for locating the fistula of SEMCs and the distribution and features of fistula sites.

This was a non-systematic literature review of studies on SEMCs. We searched PubMed for English-language articles to summarize the methods of locating the defect. The search words were “epidural arachnoid cyst,” “dural cyst,” “epidural cyst,” and “epidural meningeal cyst.” For the defect location component of the study, case reports, studies with a sample size less than four, controversial ventral dural dissection(s), and undocumented fistula location reports were excluded.

Our review showed that radiography and computed tomography (CT) may show changes in the bony structure of the spine, with the largest segment of change indicating the fistula site. Occasionally, magnetic resonance imaging (MRI) can show a cerebrospinal fluid (CSF) flow void at the fistula site. The middle segment of the cyst on sagittal MRI, the largest cyst area, and cyst laterality in the axial view indicate the fistula location. Myelography can show the fistula location in the area of the enhanced cyst and subarachnoid stenosis. Digital subtraction or delayed CT can be used to observe the location of the initial cyst filling. Cine MRI and time-spatial labeling inversion pulse techniques can be used to observe CSF flow. Steady-state image construction interference sequence MRI has a high spatial resolution. Neuroendoscopy, MRI myelography, and ultrasound fistula detection can be performed intraoperatively. Moreover, the fistula was located most often in the T12–L1 segment.

Identifying the fistula location is difficult and requires a combination of multiple examinations and experience for comprehensive judgment.

Location Distribution of Fistulas and Surgical Strategies for Spinal Extradural Meningeal Cysts: A Retrospective Analysis of 30 Cases at a Single Center

Objective

This study aimed to illustrate the features of fistula location distribution, surgical strategies, and outcomes in spinal epidural meningeal cysts (SEMCs).

Methods

The authors searched and reviewed the medical records for cases of SEMCs. Imaging features, operative reports, and media were reviewed to accurately describe the surgical techniques employed. We recorded the level and laterality of the fistula according to the operative report and the media. Consistency analysis was performed on the dominant laterality of the cyst on preoperative axial magnetic resonance imaging and laterality of the fistula in the operative media or report. When cyst and fistula lateralities were the same, they were considered consistent. Finally, the Japanese Orthopedic Association (JOA) score was used to obtain patient-reported results at each follow-up.

Results

Thirty patients with SEMCs were identified. Fistula repair was performed in all patients. Two patients experienced cyst recurrence after surgery and were repaired during the second surgery. Based on imaging findings, SEMCs mostly occurred in the thoracolumbar junction. Most of the fistulas (87.88%) were at the T12 or L1 levels. In patients with multiple adjacent SEMCs, the fistula may be at one end of the cyst rather than in the middle level of the cyst. A fistula laterality of 72.72% was consistent with cyst laterality. The JOA improvement rate was 61.84%±26.63%.

Conclusion

Most fistulas were always located at the T12–L1 level as well as the middle level of the cyst, which is always consistent with cyst laterality. In patients with multiple adjacent SEMCs, the fistula may be at one end of the cyst. Cleft closure is key to healing SEMCs.

A Single Vertebral Surgical Approach for Spinal Extradural Meningeal Cysts Spanning Multiple Vertebral Segments by Auxiliary Neuroendoscope

BACKGROUND

Spinal extradural meningeal cysts (SEMCs) are rare lesions, especially those spanning multiple vertebral segments, and the surgical strategy has remained controversial. In the present study, we have described the outcomes of 4 patients with SEMCs treated with dural defect repair alone assisted by neuroendoscopy.

METHODS

From January 2018 to January 2020, 4 patients with SEMCs spanning multiple vertebral segments had undergone single-vertebral laminectomy or hemilaminectomy.

RESULTS

The SEMCs in all 4 patients had spanned multiple vertebral segments, from T11 to L2. Using magnetic resonance imaging, the location of the dural defect was predicted correctly for 3 patients. Single-vertebral laminectomy was used in 2 patients and single-vertebral hemilaminectomy in 2 patients. Intraoperatively, the entire cyst, including the upper pole, lower pole, and middle segment of the cyst, was explored using neuroendoscopy. In each patient, only 1 dural defect was found, which had been located in the middle segment of the cyst (T12-L1). All cyst dural defects had been sutured under a microscope. In all cases, the cyst wall was not removed. Postoperatively, the symptoms for all the patients had improved significantly, and subsequent magnetic resonance imaging studies showed obvious cyst regression. During the follow-up period of 15-44 months, no recurrence was observed.

CONCLUSIONS

For SEMCs spanning multiple vertebral segments, dural defect repair without cyst wall resection through single-vertebral hemilaminectomy or laminectomy can be effective. Intraoperative neuroendoscopy can assist, not only in finding the dural defect, but also in avoiding the omission of multiple dural defects as much as possible.