Long-term outcomes following surgical treatment of spinal arachnoid cysts: a population-based consecutive cohort study

BACKGROUND CONTEXT

Spinal arachnoid cysts (SACs) are rare, cerebrospinal fluid-filled sacs lined by an arachnoid membrane in the spinal canal. Symptoms can develop due to pressure on the spinal cord or adjacent spinal nerves by the cyst itself or by interrupted flow of cerebrospinal fluid. If noninvasive management fails or neurological deterioration occurs, surgical treatment is recommended. However, data is lacking on long-term outcomes after surgery.

PURPOSE

To determine long-term outcomes in patients surgically treated for SACs.

STUDY DESIGN

Population-based cohort-study.

PATIENT SAMPLE

All consecutive patients treated for either intra- or extradural SACs with surgery between 2005 and 2020 at the author's institution were included.

OUTCOME MEASURES

American Spinal Injury Association Impairment Scale (AIS) and modified Japanese Orthopedic Association score (mJOA).

METHODS

Data was primarily extracted from electronic patient medical notes. Telephone interviews were performed to assess long-term postoperative outcomes. All analyses were conducted using the statistical software program R version 4.0.5. Statistical significance was set at p<.05.

RESULTS

Thirty-four patients were included. Cyst excision was performed in 11 (32%) cases, and fenestration in the remaining 23 (68%). The median follow-up time was 8.0 years. Surgery resulted in a significant long-term improvement in both AIS (p=.012) and mJOA (p=.005). Sensory deficit was the symptom that most often improved (81%), followed by pain (74%) and motor function (64%). AIS deteriorated in two patients, of which one case was attributed to a surgical complication. Local cyst recurrence requiring reoperation was seen in 4 (12%) cases, all of them following cyst fenestration. One patient (3%) required reoperation for progression of the cyst progression at a different level.

CONCLUSION

This study reports outcomes of surgically treated SACs with the longest follow-up time to date. Microsurgical cyst excision or fenestration were safe treatment options, and the neurological improvements seen in the immediate postoperative phase were maintained at long-term follow-up.

An unusual cause of chronic neuropathic pain: report of a case of multiple intradural spinal arachnoid cysts and review of the literature

Spinal arachnoid cysts (SACs) arise either intra- or extradurally and are usually solitary, while cases of multiple SACs have been scarcely reported in the literature. Herein, we report on a rare case of multiple and recurring intradural spinal arachnoid cysts (SACs) causing severe spinal cord compression and neuropathic radicular pain, in a 35-year-old female with a 10-year follow-up. Two separate attempts at surgery were performed but only provided temporary relief since the cysts recurred and new ones formed along the entirety of the spinal cord. Finally, a conservative approach with physiotherapy and a combination of analgesic medications was pursued.

Spinal arachnoid cysts: A case series & systematic review of the literature

INTRODUCTION

Spinal arachnoid cysts (SACs) are rare lesions with challenging and controversial management.

RESEARCH QUESTION

We analyzed our experiences from a case series and provide a systematic review to determine 1) Demographic and clinical features of SACs, 2) Optimal imaging for diagnosis and operative planning, 3) Optimal management of SACs, and 4) Clinical outcomes following surgery.

MATERIALS AND METHODS

A single-institution, ambispective analysis of patients with symptomatic SACs surgically managed between May 2005 and May 2019 was performed. Data were collected as per local ethics committee stipulations. A systematic review of SACs in adults was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and a preapproved protocol.

RESULTS

Our series consisted of 11 patients, M:F 8:3, mean age 47.8 years (range 18-73 years). Mean follow-up was 19 months (range 5-36 months). SACs were excised or marsupialised (7), fenestrated (3) or partially excised (1). Eight patients had expansile duroplasty, 3 primary dural closure. One patient had a cystoperitoneal shunt. All patients were AIS D preoperatively; 4 remained unchanged and 7 improved to AIS E at follow-up. Our systematic search retrieved 725 citations. Fourteen case series met the inclusion criteria. There was no evidence to support superiority of one surgical strategy over another. Surgery for symptomatic patients resulted in positive clinical outcomes.

DISCUSSION AND CONCLUSIONS

Symptomatic SACs require surgical intervention. Limited evidence suggests that decompressing the cord, breakdown of arachnoid adhesions, and establishing CSF flow by consideration of expansile duroplasty are important for positive outcomes.

Spinal intradural extramedullary arachnoid cysts in adults-operative therapy and clinical outcome

BACKGROUND

Spinal arachnoid cysts (SAC) are rare mostly idiopathic intradural lesions with compression of the spinal cord and clinical signs of radiculo- and/or myelopathy. We retrospectively analyzed radiological and clinical characteristics of patients with surgical treatment of SAC including a subgroup evaluation of long-term outcome and QoL.

METHOD

Patients with SAC treated between 1993 and 2017 were evaluated. Craniocaudal (c.c.) and anteroposterior (a.p) cyst diameters were measured pre- and post-OP. McCormick and Odom score for myelopathy, general outcome and QoL (SF-36, EORTC-QLQ30) were recorded.

RESULTS

A total of 72 patients (female:male = 1.9:1) were analyzed with mean FU of 44.8 ± 60 months (long-term data from 25 patients with FU 78.2 ± 63.9 months). All had surgery due to solitary cysts: 10 cervical (13.9%), 45 thoracic (62.5%), and 17 lumbosacral (23.6%), the majority (79.2%) located dorsally. Main symptoms were gait disturbance (80%), dysesthesia (64%) and paresis (80%). Patients had (hemi-)laminectomy with cyst fenestration in 48 (66.7%) and complete resection in 18 cases (25.0%). Four cases (5.5%) were treated by cystoperitoneal shunt, 2 by marsupialization (2.8%). In total, 11 revisions were necessary in 9/72 (12.5%) patients (one patient underwent 3 revisions). Two patients were reoperated for wound revision/epidural hematoma (each n = 1). Seven patients needed additional cyst wall resection after 1.5-31.0 months due to insufficient cyst shrinking and persistent clinical symptoms after first surgery; most of the cysts were multiple septated and of post-hemorrhagic origin. The mean c.c. size decreased from 5.2 ± 3.7 cm pre-OP to 2.7 ± 3.9 cm (p < 0.05); the a.p. diameter decreased from 1.0 ± 0.5 cm to 0.3 ± 0.3 cm (p < 0.0001) without significant differences between fenestration and resection. McCormick and Odom scores revealed improved symptoms, particularly of gait disturbance, sensory deficits, and general performance. Long-term FU displayed satisfying QoL performance without differences of fenestration or resection.

CONCLUSION

SAC mostly affect women and are predominantly located in the thoracic spine, becoming apparent with clinical myelopathy. For cysts without intracystic septae and compartments, both fenestration and resection of the cyst wall provided significant reduction of cyst size and clinical improvement.

[Clinical presentation of a dorsal epidural arachnoid cyst after an epidural anesthesia]

BACKGROUND

Arachnoid cysts are dural diverticula with liquid content similar to cerebrospinal fluid, with 1% occurring in the spinal cord. They locate mainly in the dorsal region of the thoracic spine, and are unusual causes of spinal cord compression.

CLINICAL CASE

The case is presented of a previously healthy 15-year-old boy, with a 20-month history of spastic paraparesis that started apparently after epidural block for ankle osteosynthesis. There was decreased sensitivity and strength of the pelvic limbs and gradually presented with anaesthesia from T12 to L4 dermatomes, L5 and S1 bilateral hypoaesthesia and 4+/5 bilateral strength, in the L2 root and 2+/5 in L3, L4, L5, S1, hyperreflexia, Babinski and clonus, but with no alteration in the sacral reflexes. In the magnetic resonance it was diagnosed as an extradural arachnoid cyst from T6 to T9. The patient underwent a T6 to T10 laminotomy, cyst resection, dural defect suture, and laminoplasty. One year after surgery, the patient had recovered sensitivity, improvement of muscle strength up to 4+/5 in L2 to S1, and normal reflexes.

CONCLUSIONS

After the anaesthetic procedure, increased pressure and volume changes within the cyst could cause compression of the spinal cord, leading to symptoms. Despite being a long-term compression, the patient showed noticeable improvement.