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.

Malignancy arising in adamantinomatous craniopharyngioma: Report of a rare case with unusual morphologic features

Adamantinomatous craniopharyngioma is a grade 1 tumor that arises in a sellar/suprasellar location. Despite being a grade 1 tumor, there is high recurrence and endocrinal insufficiency. Malignancy arising in craniopharyngioma is extremely rare, has a dismal prognosis, and is currently not included as a separate entity in the World Health Organization Classification of Central Nervous System 5th edition. Here we describe a case of adamantinomatous craniopharyngioma and its malignant counterpart. The malignant part had unique histomorphology and basaloid cells with pseudoglandular architecture and a myxoid background. It bore a striking resemblance to adenoid cystic carcinoma. Both the benign and malignant counterparts were beta-catenin and SOX-2 positive, providing proof of the malignant part arising from the benign part. Tumors like squamous cell carcinoma and odontogenic ghost cell carcinoma have been described in cranipharyngioma. This case study is the first to describe this unique morphology of adenoid cystic carcinoma-like features. The possibility of adenoid cystic carcinoma was excluded by immunohistochemistry.

Adjunct role of liquid absolute alcohol intralesional sclerotherapy during the surgical management of spinal primary aneurysmal bone cyst in a child: a technical case report

BACKGROUND

Aneurysmal bone cyst is composed of variable -sized cystic blood-filled spaces separated by connective tissue septae. First-line surgical resection of spinal aneurysmal bone cyst in a child with limited total blood volume can lead to massive intraoperative bleeding, thus limiting extent of resection. Our Centre's has good experience of using absolute alcohol as an effective immediate devascularizing agent during vertebral hemangioma surgery in children.

MATERIAL AND METHODS

We report the first case of pediatric lumbar primary aneurysmal bone cyst in which completely blood-less piecemeal total resection of the lesion was performed after intraoperative absolute alcohol intralesional sclerotherapy.

RESULTS

Completely blood-less piecemeal total resection of the lumbar aneurysmal bone cyst was performed after intraoperative absolute alcohol intralesional sclerotherapy.

CONCLUSION

Intraoperative absolute alcohol intralesional sclerotherapy is a very effective devascularizing adjunct for complete piecemeal resection of spinal aneurysmal bone cyst in children with limited blood volume.

IgG4-Related Disease in Intradural Extramedullary Location- Detailed Case Illustration and Literature Review with Special Emphasis on Role of Surgery in its Management

Background

IgG4-related disease (IgG4RD) is a multisystemic progressive fibroinflammatory and lymphoproliferative autoimmune disorder of unknown etiopathogenesis; and its occurrence in intradural extramedullary (IDEM) location is extremely rare.

Aim and Objective

The aim of this study was to review all IDEM IgG4RD cases described in English literature and to signify the role of surgery in its management at this rare location along with the surgical technique and intraoperative findings.

Methods

An Internet-based search (PubMed) for the published reports describing spinal cases of IgG4RD with IDEM involvement was done using the keyword: spinal IgG4-related disease. An illustration of a case of cranial IgG4-related disease in a young man who developed metachronous cervical involvement in intradural extramedullary (IDEM) location is also presented.

Results

Amongst 45 spinal IgG4RD cases reported in English Literature, only 3 cases were IDEM IgG4RD. In the illustrated case, portion of the cervical lesion causing cervical cord encasement was intradural but extraarachnoidal- located between arachnoid and dura, without any pial involvement. All these 4 cases improved following surgery.

Conclusion

Timely meticulous resection of mass lesion in situations of medical treatment failure or progressive neurological decline can lead to reversibility of mass effect-associated neurological manifestations of IgG4RD.

Neck swelling due to skull base (pseudo)meningocele protruding through a congenital skull base bone defect: a case report

BACKGROUND

Meningocele is defined as a protrusion of the meninges through an opening in the skull or spinal column, forming a bulge or sac filled with cerebrospinal fluid. A pseudomeningocele is defined as a cerebrospinal fluid (CSF) collection formed due to escape of CSF through a dural defect with trapping of CSF into the surrounding soft tissues. We herby report rare occurrence of a large (pseudo)meningocele in a young patient with congenital skull base defect presenting as upper lateral neck swelling.

CASE PRESENTATION

We present the case of a 17-year-old boy who had painless progressive swelling right side of the upper neck without any history of meningitis or CSF leak. He had a history of undergoing cranioplasty using steel plates for nontraumatic boggy swelling right parieto-occipital region at the age of 5 years at another hospital. Clinical examination showed painless swelling right side of the upper neck, with positive cough impulse and transillumination. CT head with cisternography showed a large right skull base defect through which a large pseudomeningocele was herniating, thus producing upper neck swelling and compressing oral cavity. The neck swelling and intraoral bulge reduced in size after the coperitoneal shunt.

CONCLUSION

Differential diagnosis of (pseudo)meningocele should be considered while evaluating a painless progressive upper neck swelling having cough impulse and transillumination in a young patient.