Dorsal Spinal Intradural Intramedullary Epidermoid Cyst: A Rare Case Report and Review of Literature

Isolated thoracic intradural extramedullary epidermoid cyst: A technical note

Background

Congenital, acquired, and iatrogenic spinal epidermoid cysts (EC) are very rare.

Methods

A 62-year-old female patient presented with a 5-month history of progressive paraparesis leading to paraplegia secondary to a posterior compressive intradural extramedullary lesion at the T7 level. The patient underwent a laminectomy/durotomy for gross total tumor excision.

Results

Histopathology confirmed the lesion was an epidermoid cyst. Although her spasticity improved within 5 weeks, she only regained partial lower extremity motion (i.e., 3/5 motor function).

Conclusion

Patients presenting with the acute/subacute onset of paraparesis secondary to spinal EC should undergo timely gross total cyst resections to optimize neurological outcomes.

A Pediatric Case of Spinal Intradural Epidermoid Cyst: A Rare Encounter

Intradural epidermoid cysts of the spine are rare congenital lesions. Their etiology is thought to stem from ectodermal remnants during embryonic development. They result in a diverse clinical presentation, often marked by an insidious onset and variable neurological deficits. Timely diagnosis is crucial for optimizing patient outcomes. We present the case of a 10-year-old male child presenting a six-month history of worsening back pain, intermittent leg weakness, and urinary incontinence. The physical examination revealed tenderness over the lower thoracic and lumbar spine, lower limb weakness, hyperreflexia, and sensory deficits. The diagnostic work-up, including cerebrospinal fluid analysis and magnetic resonance imaging, confirmed the presence of an intradural epidermoid cyst in the lumbosacral region. Surgical excision resulted in complete resection, with subsequent improvement in neurological deficits. This pediatric case underscores the importance of maintaining a high index of suspicion for unexplained neurological deficits. Characteristic imaging findings played a pivotal role in the diagnosis, guiding successful surgical intervention and achieving favorable outcomes.

Intramedullary Epidermoid Cyst of the Conus Medullaris: A Case Report and Literature Review

Background

Central nervous system tumors are usually located in the brain, and spinal cord tumors account for approximately 20% of central nervous system tumors. Epidermoid cysts constitute <1% of all intraspinal tumors. It consists of squamous epithelial-lined cysts containing keratin, cholesterol, and cellular granules. Epidermoid cysts can be classified as congenital, acquired, extradural, extramedullary, or intramedullary according to etiology and location. The intradural intramedullary type is uncommon.

Case Presentation

An 11-year-old female patient had back pain with radiation to both lower extremities but worsened on the left side for 5 years. On neurological examination, motor strength was 3/5 for hip flexion and knee extension bilaterally and 5/5 for other key muscle groups. Contrast-enhanced lumbosacral magnetic resonance imaging (MRI) revealed T1 hypointense and T2 hyperintense lesions in the L2-L4 intramedullary conus and cauda equina. Laminectomy and near total resection were done, and histopathological examination revealed an epidermoid cyst. On the third postoperative day, the patient was discharged with completely resolved back pain and an improvement in lower extremity motor power. At monthly follow-up visits for a further 6 months, her back pain and weakness completely resolved, and she had no neurologic deficits. A postoperative lumbosacral MRI was done and confirmed near total excision of the tumor.

Conclusion

Intramedullary conus epidermoid cysts are rare but not unknown to neurosurgeons. MRI with diffusion-weighted images (DWI) is an imaging modality of choice. Asymptomatic patients can be conservatively treated. Once the patient has progressive symptoms and signs of compression, surgical excision is recommended. Meticulous electrocauterization may help decrease tumor regrowth in the remnant capsule, which is recommended. Avoiding leakage of cyst fluid into the subarachnoid space helps to avoid postoperative chemical meningitis. Radiotherapy is an option for the management of multiple recurrences.

A Shunt Method for the Treatment of Syringomyelia Secondary to Trauma and Tuberculous Meningitis

The pathogenesis and surgical treatment of syringomyelia (SM) secondary to trauma and tuberculous meningitis are not clear. We hypothesize that the main cause of SM is impaired cerebrospinal fluid circulation in the subarachnoid space due to spinal arachnoid adhesion induced by trauma or tuberculous meningitis. Using trans-segmental subarachnoid shuntsurgery, we re-established normal cerebrospinal fluid circulation in the subarachnoid space, which resolved the potential cause of SM formation. This study aimed to evaluate the efficacy of trans-segmental subarachnoid shunt surgery in the treatment of SM secondary to trauma or tuberculous meningitis. A total of 143 patients with SM after trauma and tuberculous meningitis were recruited between September 2014 and February 2017. Among these patients, 64 had posttraumatic SM, including 39 males and 25 females with an age range of 21–65 years and an average age of 40.02 years, and 79 patients had SM secondary to tuberculous meningitis, including 49 males and 30 females with an age range of 23–62 years and an average age of 44.95 years. All patients underwent trans-segmental subarachnoid shunt surgery and were subjected to magnetic resonance imaging (MRI) examination between 6 months and 1 year and between 2 and 2.5 years after surgery. Clinical efficacy was assessed by the Tator method. The main symptoms or signs were evaluated by improvement, stabilizationor aggravation of symptoms. Patients were followed-up twice, once at 6 months to 1 year after surgery and once at 2 to 2.5 years after surgery. A total of 143 patients were followed-up for the first time, among whom, the clinical symptoms were improved in 59 patients(41.26%), stable in 51 patients (35.66%) and aggravated in 36 patients (23.08%). MRI exaination showed that the spinal cord cavities completely disappeared in 27 patients (18.88%), shrank significantly in 71 patients (49.65%), did not change or shrink significantly in 32 patients (22.38%) and expanded in 13 patients (9.09%). A total of 122 patients were followed-up for the second time, and the clinical symptoms were improved in 69 patients (56.56%), stable in 25 patients (20.49%) and aggravated in 28 patients (22.95%). Compared to the condition in the first follow-up, 14 patients who were stable were improved, 5 patients who were aggravated were improved, and the symptoms did not change significantly among other patients. The imaging examination did not show any significant change compared to that of the first follow-up. We suggest that trauma or tuberculous meningitis can induce spinal arachnoid adhesion, leading to impaired cerebrospinal fluid circulation in the subarachnoid space, which then causes SM. Trans-segmental subarachnoid shunt surgery is a noninvasive, safe and effective treatment for SM secondary to trauma and tuberculous meningitis.

Spinal intramedullary epidermoid cysts: Three case presentations and literature review

Background:

True intramedullary epidermoid cysts (IECs) not associated with congenital anomalies or previous spinal procedures are extremely rare. In a review of the literature since 1992, only 29 such cases have been reported. Here, we add three new cases in this category.

Case Description:

Three adults presented with spastic paraparesis attributed to thoracic IECs. Gross total microsurgical removal was achieved in two cases, while one case was a partial resection due to capsular adherence to the cord. In all three cases, patients sustained complete recoveries of neurological function and remained symptom free for an average of 5 years follow-up.

Conclusion:

IECs are rare lesions; here, the three located in the thoracic spine, contributed to slow, progressive spastic paraparesis with/without incontinence, and resolved following total (2 patients) and partial (1 patient) resection.