Recurrent intraspinal arachnoid cyst treated with a shunt procedure

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.

Minimally invasive endoscopic fenestration of a spinal arachnoid cyst in a child with tetrasomy 18p: illustrative case

BACKGROUND

Spinal arachnoid cysts (SAC) are rare, especially in children. Patients can be asymptomatic or present symptoms of spinal cord compression. In this latter case, surgery is indicated to relieve the compression. Different surgical techniques have been described to treat these cysts, endoscopic or endoscopy-assisted fenestration being the least invasive. Tetrasomy 18p describes the condition in which two copies of the short arms of chromosome 18 are present. It is an extremely rare pathology with a variable phenotype, including 100% of cases cognitive impairment and developmental delay. Different central nervous system (CNS) abnormalities have been found in these patients.

OBSERVATIONS

The authors describe the case of a 3-year-old boy with a tetrasomy 18p and a wide spinal arachnoid cyst that received an endoscope-assisted treatment with a significantly improved motor outcome.

LESSONS

Tetrasomy 18p is an extremely rare pathology and different CNS abnormalities have been described in association with, but to date spinal arachnoid cyst has never been reported. These children typically show global hypotonia and cognitive impairment. The authors recommend a thorough neurological assessment with cranio-spinal magnetic resonance imaging to rule out any possible malformation that could be improved by surgery.

Surgical management and outcomes in spinal intradural arachnoid cysts: the experience from two tertiary neurosurgical centres

PURPOSE

Evaluation of the presentation and outcomes of different surgical treatment approaches for spinal intradural arachnoid cysts (SIAC).

METHODS

Cases were identified from electronic records of two major neurosurgical centres in London over the last 10 years (October 2009-October 2019) that have been surgically treated in both institutions. Clinical findings, surgical technique, and recurrence by procedure were statistically analysed. Statistical analysis was performed with STATA 13.1 Software.

RESULTS

A total of 42 patients with SIAC were identified for this study with a mean age at the time of surgery of 53.6 years and a male:female ratio of 8:13. There were 31 patients with primary SIACs and 11 with secondary SIACs. The most common presenting symptom was paraesthesia (n = 27). The most common location of the cyst was in the thoracic region (n = 33). Syrinx was present in 26.2% of SIACs (n = 11). Resection was associated with significantly better postoperative pain compared to other surgical techniques (p = 0.01), significantly poorer postoperative urinary function (p = 0.029), and lower rates of sensory recovery in patients who presented preoperatively with sensory deficit (p = 0.041). No significant difference was seen in symptomatic outcomes between patients with primary and secondary SIACs.

CONCLUSION

Resection and drainage are both effective methods of managing SIACs. In this observational study, resection was associated with significantly reduced pain postoperatively when compared with drainage, however also with significantly less improvement in postoperative urinary function. Therefore, resection should be the gold standard management option for SIACs, with drainage as an option where resection is unsafe, and drainage should also be considered in patients presenting with urinary dysfunction.

Endoscopic treatment of spinal arachnoid cysts

Background/objective

Spinal arachnoid cysts (SAC) are intradural lesions, which may provoke a compression of the spinal cord and roots. Endoscopic techniques are increasingly used to minimize the surgical access and the postoperative scar tissue. Shunts may also represent an option. The aim of this paper is to illustrate the technique of endoscopic-assisted fenestration and positioning of a cysto-peritoneal diversion in a thoracic SAC using a flexible endoscope and to perform a systematic literature review on this subject.

Material and methods

We reported our case and we performed a review of the literature, searching for all the adult cases of Type III SACs in English language treated through endoscopic procedures.

Results

We found 5 articles matching our search criteria and we included 9 adult patients in our analysis. Six patients were females and the most common localization was the thoracic spine. Six patients underwent selective laminectomies followed by endoscopic fenestration without cyst wall resection. Three patients had a percutaneous endoscopic inspection of the cyst and in two cases a cysto-subarachnoid shunt space was performed. Improvement of pre-operative neurological deficit was reported in six patients, no patients experienced clinical deterioration. The mean follow-up was 22 months and no progression or recurrence was reported.

Conclusion

The implementation of endoscopy allows a minimally invasive treatments with good visualization of cyst anatomy and precise shunt positioning under real-time guidance. Endoscopy is technically demanding but it can offer similar clinical outcomes when compared to microscopic procedures with a limited rate of post-operative complications.

The long-term risk of recurrence should be established by prospective studies.

Syringopleural shunt placement in a pug with a cervical spinal diverticulum and associated syringomyelia

We report persistence of associated syringomyelia and formation of newly caudal spinal arachnoid diverticulum, following marsupialization surgery. We describe syringopleural shunt placement as a novel approach to treat both conditions in a Pug dog.

Percutaneous Fenestration of a Spinal Arachnoid Web Using an Intrathecal Catheter: Effect on Cerebrospinal Fluid Flow and Clinical Status

Background

Spinal arachnoid webs are a rare anatomic entity manifesting as neuropathic back pain, compressive myelopathy, radiculopathy, and hydrocephalus. Typical treatments include hemilaminectomy or full laminectomy with durotomy and microsurgical resection, which can result in secondary scarring and recurrent blockage of cerebrospinal fluid (CSF) flow perpetuating the cycle.

Case Description

A 66-year-old woman presented with progressively worsening gait and memory. Magnetic resonance imaging demonstrated an arachnoid web in the high thoracic region, causing CSF flow obstruction and hydrocephalus. A standard lumbar drainage catheter was introduced percutaneously into the lumbar thecal sac and advanced in a cephalad direction, across the arachnoid web, to the high thoracic region. The patient underwent continuous CSF drainage through this catheter for a total of 3 days, displaying measurable clinical improvement that persisted at the 3-month follow-up visit. Phase-contrast magnetic resonance imaging demonstrated interval reconstitution of dorsal synchronous CSF flow at the second thoracic vertebral level, both on day 3 and at the 3-month control imaging study.

Conclusions

This minimally invasive approach seems useful in achieving restoration of spinal fluid flow at the thoracic region when the underlying blockage results from an arachnoid web and leads to quantifiable clinical improvement.

Occurrence of spinal extradural arachnoid cysts in a child with concomitant intracranial midline abnormalities: case report

Spinal extradural arachnoid cysts (SEACs) are uncommon spinal lesions that may cause myelopathy, most frequently in the 2nd decade of life. There are multiple theories of their pathogenesis, and associated entities include spinal trauma, spina bifida, and the lymphedema-distichiasis syndrome. The authors report the case of an otherwise healthy, developmentally normal 13-year-old boy who presented with multiple SEACs. Upon further neuroimaging workup, he was found to have an asymptomatic retrocerebellar arachnoid cyst, cavum septi pellucidi, and cavum vergae. Three contiguous but separate spinal cysts were identified intraoperatively, and they were completely excised with closure of the dural defects. The patient recovered motor and sensory function of the lower extremities. This collection of uncommon neuroimaging findings provides important clues to the pathogenesis of the disease and guides the optimal management of patients with SEACs. The unusual presentation of SEACs, together with uncommon midline abnormalities, provides further evidence of their congenital, midline origin. Therefore, it is reasonable to pursue imaging of the brain in atypical cases of SEACs.

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.

Surgical treatment of a thoracic ventral intradural arachnoid cyst associated with syringomyelia: case report

The pathogenesis of thoracic ventral intradural spinal arachnoid cyst (ISAC) is unknown due to its extremely low incidence. In addition, its surgical treatment is complicated because of the ventral location, large craniocaudal extension, and frequent coexistence of syringomyelia. The optimal surgical strategy for thoracic ventral ISAC remains unclear and continues to be a matter of debate. In this report, the authors describe an extremely rare case presenting with a compressive thoracic ventral ISAC associated with syringomyelia that was successfully treated with a simple cyst-pleural shunt. The patient's medical history revealed bacterial spinal meningitis along with an extensive spinal epidural abscess, suggesting the incidence of extensive adhesive arachnoiditis (AA) to be a plausible cause for this pathology. Thoracic ventral ISAC reportedly occurs secondary to AA and is commonly associated with syringomyelia. Placement of a cyst-pleural shunt is an effective, safe, and uncomplicated surgical strategy, which can provide sufficient cyst drainage regardless of the coexistence of AA, and thus should be considered as primary surgical treatment. Syrinx drainage could be reserved for a later attempt in case the cyst-pleural shunt fails to reduce the extent of syringomyelia.

Spinal arachnoid cysts in adults: diagnosis and management. A single-center experience

OBJECTIVEAdult spinal arachnoid cysts (SACs) are rare entities of indistinct etiology that present with pain or myelopathy. Diagnosis is made on imaging studies with varying degrees of specificity. In symptomatic cases, the standard treatment involves surgical exploration and relief of neural tissue compression. The aim of this study was to illustrate features of SACs in adults, surgical management, and outcomes.METHODSThe authors searched medical records for all SACs in adults in the 10-year period ending in December 2016. Radiology and pathology reports were reviewed to exclude other spine cystic disorders. Recurrent or previously treated patients were excluded. Demographic variables (age, sex) and clinical presentation (symptoms, duration, history of infection or trauma, and examination findings) were extracted. Radiological features were collected from radiology reports and direct interpretation of imaging studies. Operative reports and media were reviewed to accurately describe the surgical technique. Finally, patient-reported outcomes were collected at every clinic visit using the SF-36.RESULTSThe authors' search identified 22 patients with SACs (mean age at presentation 53.5 years). Seventeen patients were women, representing an almost 3:1 sex distribution. Symptoms comprised back pain (n = 16, 73%), weakness (n = 10, 45%), gait ataxia (n = 11, 50%), and sphincter dysfunction (n = 4, 18%). The mean duration of symptoms was 15 months. Seven patients (32%) exhibited signs of myelopathy. All patients underwent preoperative MRI; in addition, 6 underwent CT myelography. SACs were located in the thoracic spine (n = 17, 77%), and less commonly in the lumbar spine (n = 3, 14%) and cervical/cervicothoracolumbar region (n = 2, 9%). Based on imaging findings, the cysts were interpreted as intradural SACs (n = 11, 50%), extradural SACs (n = 6, 27%), or ventral spinal cord herniation (n = 2, 9%); findings in 3 patients (14%) were inconclusive. Nineteen patients underwent surgical treatment consisting of laminoplasty in addition to cyst resection (n = 13, 68%), ligation of the connecting pedicle (n = 4, 21%), or fenestration/marsupialization (n = 2, 11%). Postoperatively, patients were followed up for an average of 8.2 months (range 2-30 months). Postoperative MRI showed complete resolution of the SAC in 14 of 16 patients. Patient-reported outcomes showed improvement in SF-36 parameters. One patient suffered a delayed wound infection.CONCLUSIONSIn symptomatic patients with imaging findings suggestive of spinal arachnoid cyst, surgical exploration and complete resection is the treatment of choice. Treatment is usually well tolerated, carries low risks, and provides the best chances for optimal recovery.

Resection of an extensive thoracic arachnoid cyst via less-invasive targeted laminoplasties

OBJECTIVE

Spinal arachnoid cysts are a known cause of spinal cord compression. When symptomatic, treatment of choice entails laminectomies over the length of the cyst in order to achieve complete cyst removal and fenestration.

METHODS

A 60-year-old woman presented with a one-year history of progressive pain between the shoulder blades, exacerbated by sitting up or standing, and relieved by lying supine. MRI imaging revealed a T3-T7 dorsal intradural arachnoid cyst. Due to extant spinal deformity and medical comorbidity, the decision was made to proceed with selective laminoplasties at the superior and inferior limits of the cyst.

RESULTS

After the dura was opened to reveal the margins, the cyst was sharply fenestrated and drained. Irrigation was passed through the cyst to ensure open communication, and a lumbar drain catheter was passed from the inferior to superior margin. The catheter was removed before closure. Postoperatively, MRI of the thoracic spine revealed decompression of the spinal cord and the patient noticed improvement in her symptoms. At 7-month follow-up, the patient remained free of symptoms and MRI demonstrated near-complete resolution of the cyst.

CONCLUSION

Although open exposure and complete resection are considered the treatment of choice for spinal arachnoid cysts, cyst fenestration through selective bony windows at the margins of the cyst represents a viable, less invasive alternative approach to effective cyst decompression, and can be considered in patients in whom a full exposure would be prohibitive.

Intradural spinal arachnoid cyst resection: implications of duraplasty in a large case series

OBJECTIVE Optimal diagnosis and management strategies for intradural spinal arachnoid cysts (SACs) are still unresolved given the rare nature of this entity, with few large case series and virtually no statistical analyses of patient characteristics in the literature. Here, the authors studied a large patient cohort with these lesions to determine whether pre- or postoperative attributes could be used to aid in either diagnosis or prognosis. METHODS A chart review was completed at a single institution for the period from 2002 to 2016 to determine the preoperative characteristics and postoperative outcomes of 21 patients with exclusively intradural SACs. Patients were assessed for symptoms such as weakness, pain, sensory changes, bowel and/or bladder dysfunction, and gait changes. Postoperatively, patients were analyzed for symptom improvement, complication occurrence, and duration of follow-up. RESULTS Approximately two-thirds of the patients in this series had developed SACs idiopathically, and the mean duration of symptoms prior to diagnosis was 15 months among all patients. A slight majority (57%) underwent CT myelography in the course of diagnosis, and a quarter of the patients had a syrinx. There was a statistically significant association between location of the SAC and number of presenting signs and symptoms; that is, patients with cysts in the lumbosacral region had more symptoms than those with cysts at the cervical or thoracic levels (p = 0.031). Overall, outcomes were largely positive, with approximately 60%-70% of patients experiencing postoperative improvement in symptoms, with motor weakness showing the highest response rate (71%) and pain symptoms the least likely to subside (50%). In the cohort with preoperative pain, those who had undergone expansile duraplasty were significantly more likely to experience relief of their pain symptoms (p = 0.028), which may have been a result of the superior restoration of cerebrospinal fluid pathways allowing for more adequate reduction in compression. CONCLUSIONS In this large case series on intradural SACs, new light has been shed on aspects of both pre- and postoperative care for patients with these rare lesions. Specifically, the authors revealed that lumbosacral intradural SACs may be associated with a higher disease burden and that patients who undergo expansile duraplasty may have an increased likelihood of experiencing postoperative pain relief.

Excision of an anterior intradural arachnoid cyst of the cervical spine through central corpectomy approach

Anterior cervical intradural arachnoid cyst is a rare entity which has been mostly approached posteriorly, commonly resulting in incomplete resection. Incomplete resection is associated with recurrence; hence, we describe the anterior central corpectomy approach with complete neurologic recovery in a twenty year old with an anterior cervical intradural arachnoid cyst in front of the third and fourth cervical vertebra, who had presented with spastic quadriparesis.

Scalloping Sacral Arachnoid Cyst as a Cause of Perianal Pain- A Case Report

Introduction:

Scalloping sacral arachnoid cyst though a rare condition, should be suspected in cases of persistent perianal pain without any obvious urological or anorectal pathology. Such difficult cases justify ordering an M.R.I of spine as plain X-Rays and clinical examination may come out to be inconclusive. X-ray in later stages may show changes corresponding to scalloping of bone due pressure effect of cyst on surrounding tissue. Diagnosis may further be confirmed by doing contrast MRI which differentiates arachnoid cyst from other intradural and extradural pathologies. Though anatomically spinal arachnoid cysts are just an out pouching from the spinal meningeal sac or nerve root sheath they may be extradural or intradural in their location, communicating to main C.S.F column through their pedicle or an ostium leading to continuous enlargement in size.

Case Report:

A 32 year old female was admitted under our spine unit with 1.5 year history of chronic pain, swelling and reduced sensation in perianal region. On examination she had tenderness and hypoesthesia over lower sacral region. The pain was continuous, dull aching in nature, not related to activity, localized over lower sacrum and perianal area. The neurological examination of her both lower limbs were unremarkable. Anal tone and anal reflex were normal. No sign of inflammation or tenderness was found over coccyx. Since the X-rays were inconclusive an MRI scan was done which showed a cystic lesion in the sacral area extending from S2 to S4 region with mechanical scalloping effect on the surrounding bone. The lesion had same intensity as C.S.F in both T1 &T2 weighted images. The treatment was done by way of surgical decompression with complete excision of cyst and obliteration of space by a posterior midline approach. Presently the patient is 1 year post operative and no sign of recurrence is there.

Conclusion:

Sacral arachnoid cysts should be considered as a differential diagnosis of perianal pain. Large symptomatic sacral cysts should be treated early with complete removal of the cyst including the cyst wall, to reduce the chances of recurrence. Complete decompression of the cyst cavity should be aimed at, but careful dissection of neural element is of highest importance.

Operative management of idiopathic spinal intradural arachnoid cysts in children: a systematic review

BACKGROUND

Spinal intradural arachnoid cysts are rare with only a few patients reported so far. Idiopathic, traumatic, posthemorrhagic, and postinflammatory causes have been reported in the literature. Especially, idiopathic lesions, in which other possible etiological factors have been ruled out, seem to be rare.

PATIENTS AND METHODS

We systematically reviewed the literature in regards to localization within the spinal canal, treatment options, complications, and outcome. Additionally, we present management strategies in two progressively symptomatic children less than 3 years of age with idiopathic intradural arachnoid cysts.

RESULTS

In total, 21 pediatric cases including the presented cases have been analyzed. Anterior idiopathic spinal arachnoid cysts are predominantly located in the cervical spine in 87.5 % of all cases, whereas posterior cysts can be found at thoracic and thoracolumbar segments in 84.6 % of the patients. Most children presented with motor deficits (76.2 %). Twenty-five percent of anterior spinal arachnoid cysts caused back pain as the only presenting symptom. Open fenestration by a dorsal approach has been used in the vast majority of cases. No major surgical complications have been reported. Ninety-four percent of all patients did improve or showed no neurological deficits. Recurrence rate after successful surgical treatment was low (9.5 %).

CONCLUSION

Idiopathic spinal intradural arachnoid cysts can present with neurological deficits in children. Pathologies are predominantly located in the cervical spine anteriorly and in thoracic and thoracolumbar segments posteriorly to the spinal cord. In symptomatic cases, microsurgical excision and cyst wall fenestration via laminotomy are recommended. Our radiological, intraoperative, and pathological findings support the cerebrospinal fluid obstruction and vent mechanism theory of arachnoid cysts.

Spinal extradural arachnoid cysts

OBJECTIVE: Extradural arachnoid cysts (EACs) are rare causes of spinal cord compression and cauda equina. These benign lesions appear in the literature mainly as single case reports. In this article, we present the largest series found in literature, with four new cases of spinal extradural arachnoid cysts. The characteristic imaging features, details of surgical steps and strategies to prevent postoperative kyphosis in this cystic pathology will be discussed.

Surgical treatment of spinal intradural arachnoid cysts using endoscopy

Object

Spinal intradural arachnoid cysts are a rare cause of spinal cord compression. Since 2000, the authors have treated patients using 2- or 3-level hemilaminectomy or laminectomy followed by partial cyst wall resection as well as endoscopic inspection and fenestration of the cyst wall. They evaluated the usefulness and reliability of endoscopic treatment for this clinical entity based on long-term follow-up results.

Methods

Between 1997 and 2003, 11 patients (3 males and 8 females) with spinal intradural arachnoid cysts were treated, and the authors conducted a retrospective review of these cases. Before 2000, 5 patients were surgically treated without the use of endoscopic techniques. During that time, more than 4 levels of hemilaminectomy were performed to expose and remove cyst walls that extended longitudinally over the spinal axis. Beginning in 2000, endoscopy was used in all 6 cases. Up to 3 levels of hemilaminectomy or 2 levels of laminectomy were performed, and the cyst wall was resected through the bone window. An endoscope was inserted into the cyst cavity and moved in the cranial and caudal direction to fenestrate the cyst wall, resulting in communication of the cyst cavity with the subarachnoid space.

Results

Postoperatively, the neurological symptoms of all patients improved. During long-term follow-up (mean 114.8 months), none of the patients treated with or without endoscopy experienced recurrent cyst formation.

Conclusions

Endoscopic techniques allow neurosurgeons to treat spinal intradural arachnoid cysts less invasively than with standard surgical approaches. Although the number of cases reviewed in this report is small, the data suggest that the use of endoscopy can be an important option in the surgical treatment of spinal arachnoid cysts.

Syringomyelia associated with a spinal arachnoid cyst

While syringomyelia is not a rare spinal disorder, syringomyelia associated with a spinal arachnoid cyst is very unusual. Here, we report a 62-year-old man who suffered from gait disturbance and numbness of bilateral lower extremities. Spinal magnetic resonance imaging (MRI) showed the presence of a spinal arachnoid cyst between the 7th cervical and 3rd thoracic vertebral segment and syringomyelia extending between the 6th cervical and 1st thoracic vertebral segment. The cyst had compressed the spinal cord anteriorly. Syringomyelia usually results from lesions that partially obstruct cerebrospinal fluid flow. Therefore, we concluded that the spinal arachnoid cyst was causing the syringomyelia. After simple excision of the arachnoid cyst, the symptoms were relieved. A follow-up MRI demonstrated that the syringomyelia had significantly decreased in size after removal of the arachnoid cyst. This report presents an unusual case of gait disturbance caused by syringomyelia associated with a spinal arachnoid cyst.

Differentiation between pediatric spinal arachnoid and epidermoid-dermoid cysts: is diffusion-weighted MRI useful?

BACKGROUND

Appropriate differentiation between epidermoid-dermoid and arachnoid cysts is important for patient management. MRI has had limitations in differentiating these two types of cysts, especially in the region of the spinal cord.

OBJECTIVE

To evaluate the role of diffusion-weighted (DW) MRI for differentiation between spinal arachnoid and epidermoid-dermoid cysts.

MATERIALS AND METHODS

Four children underwent conventional and DW MRI. Turbo spin-echo imaging was used to obtain DW images.

RESULTS

On conventional MRI, low T1-W and high T2-W signal was present in all lesions. DW imaging showed restricted diffusion in two patients with epidermoid-dermoid cysts and no water restriction in two patients with arachnoid cysts. Three of four children had extramedullary lesions and one patient had an intramedullary lesion. Three children had surgery, two with epidermoid-dermoid cysts and one with arachnoid cyst. Diagnosis was confirmed by histopathology. One child with a thoracic arachnoid cyst had stable clinical imaging findings during a follow-up of 21 months.

CONCLUSION

On conventional MRI, epidermoid-dermoid and arachnoid cysts have similar signal characteristics. Initial experience with spine DW imaging shows promise in differentiating epidermoid-dermoid cysts from arachnoid cysts. Preoperative differentiation is important because it changes management and surgical approach.

Rapid expansion of a ventral arachnoid cyst after syringo-subarachnoid shunting in the thoracic spinal cord: case report

BACKGROUND

Intradural spinal arachnoid cysts have rarely been reported in association with intramedullary cysts. These associated lesions most commonly occur in the thoracic spine.

CASE DESCRIPTION

We reported an unusual balance of cerebrospinal fluid dynamics between an initially occult arachnoid cyst and syringomyelia. The arachnoid cyst was not allowed to express itself until the syrinx was decompressed with a syringo-subarachnoid shunt.

CONCLUSION

Only one other report in the literature described a similar case; however, our case is the first to be confirmed by intraoperative ultrasound.

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.

Anterior cervical arachnoid cyst presenting with traumatic quadriplegia

INTRODUCTION

Intraduralspinal arachnoid cysts are rare. Rarer still are cysts located anteriorto the cervical spinal cord. To date,only 10 such cases have been re-ported in the English-language liter-ature.

CASE REPORT

Two cases ofanterior cervical arachnoid cysts thatpresented as traumatic quadriplegiaare reported.

Intradural spinal arachnoid cysts in adults

BACKGROUND

Idiopathic arachnoid cysts are rare lesions not associated with trauma or other inflammatory insults. To date, there have been few large series describing the presentation and management of these lesions.

METHODS

Twenty-one cases of intradural spinal arachnoid cysts were identified (1994-2001). Pediatric patients and cases with antecedent trauma were excluded. There were eight women and 13 men with an average age of 52 years. Follow-up averaged 17 months.

RESULTS

Cysts were most commonly found in the thoracic spine (81%). Fifteen cysts were dorsal to the spinal cord and six were ventral to the spinal cord. All patients underwent laminectomy with cyst fenestration and radical cyst wall resection. Based upon intraoperative ultrasonography, four cysts were also shunted to the subarachnoid space, and seven patients had an expansile duraplasty with freeze-dried dural allograft. Of the seven patients with syringomyelia, three resolved with extramedullary cyst resection alone. Four required syrinx to subarachnoid shunting. Follow-up MRI demonstrated cyst resolution in all cases. All seven intramedullary syrinxes were decreased in size and four resolved completely. Weakness (100%), hyperreflexia (91%), and incontinence (80%) were more likely to improve than neuropathic pain (44%) and numbness (33%). One patient had increased numbness postoperatively.

CONCLUSIONS

Ventral cysts are more likely to cause weakness and myelopathic signs. Preoperative symptoms of neuropathic pain and numbness are less likely to improve than weakness and myelopathy. Utilizing intraoperative ultrasound to guide aggressive surgical treatment with the adjuncts of shunting and duraplasty results in a high rate of cyst and syrinx obliteration.

Spinal arachnoid cysts associated with syringomyelia: report of two cases and a review of the literature

We describe two cases of spinal arachnoid cyst associated with syringomyelia and report the clinical results after surgical treatment using excision of the cyst without a shunt operation for the syringomyelia. Case 1 is a 73-year-old woman who presented with a spastic gait and numbness of her bilateral lower extremities. Magnetic resonance imaging (MRI) showed the presence of a spinal arachnoid cyst extending from T3 to T8 and syringomyelia from T8 to T10. The cyst had compressed the spinal cord anteriorly. We excised the cyst without applying a shunt tube for the syringomyelia. Case 2 is a 68-year-old woman who presented with gait disturbance and numbness of her left lower extremity. MRI indicated that the spinal cord had been compressed anteriorly by a spinal arachnoid cyst extending from T10 to T11. Syringomyelia existed just caudal to the cyst at T11. In our surgical treatment, we excised only the cyst. In both cases, neurologic examination after the operation showed amelioration of the condition. Postoperative MRI indicated that the spinal cord had moved to the center, its original position, and the syringomyelia had decreased in size. Conclusively, spinal arachnoid cyst associated with syringomyelia can be treated by simple excision of the cyst without shunting the syrinx if the decompression effect resulting from removal of the cyst is sufficient.

Spinal intradural arachnoid cysts located anterior to the cervical spinal cord. Report of two cases and review of the literature

The authors describe two rare occurrences of radiographically, surgically, and pathologically confirmed spinal intradural arachnoid cysts (not associated with additional pathological entities) that were located anterior to the cervical spinal cord. These lesions have been reported previously in only eight patients. The patients described in this report were young adults who presented with progressive spastic tetraparesis shortly after sustaining mild cervical trauma and in whom no neurological deficit or bone fracture was demonstrated. The presence of an intradural arachnoid cyst was detected on postcontrast computerized tomography (CT) myelography and on magnetic resonance imaging; both diagnostic tools correctly characterized the cystic nature of the lesion. Plain radiography, plain tomography, and contrast-enhanced CT scans were not diagnostic. In both cases a laminectomy was performed, and the wall of the cyst was excised and fenestrated with subarachnoid space. Postoperatively, the patients made complete neurological recoveries. Based on a review of the literature, arachnoid cysts of the spinal canal may be classified as either extra- or intradural. Intradural arachnoid cysts usually arise posterior to the spinal cord in the thoracic spine region; however, these cysts very rarely develop in the cervical region. The pathogenesis of arachnoid cysts is unclear, although congenital, traumatic and inflammatory causes have been postulated. The authors believe that the formation of an arachnoid cyst cannot be explained by simply one mechanism because, in some reported cases, there has been accidental or iatrogenic trauma in association with congenital lesions. They also note that an intradural arachnoid cyst located anterior to the cervical spinal cord is an extremely rare disorder that may cause progressive myelopathy; however, the postoperative prognosis is good.

Cervical arachnoid cysts after craniocervical decompression for Chiari II malformations: report of three cases

OBJECTIVE AND IMPORTANCE

We describe three cases in which ventrally situated cervical arachnoid cysts led to spinal cord or cervicomedullary compression after repeat craniocervical decompression for Chiari II malformations.

CLINICAL PRESENTATION

All three patients underwent craniocervical decompression when their Chiari malformations became symptomatic. The first patient developed chronic vertiginous spells and headache and was treated with repeated craniocervical decompression procedures during several years. Seven months after undergoing her third decompression procedure, she developed severe dizzy spells, which were determined to be of brain stem origin. The second patient had a small, asymptomatic arachnoid cyst anterior to the brain stem discovered at age 6 years. After undergoing repeat craniocervical decompression for headaches 8 years after undergoing his first procedure, the patient developed severe neck pain and acute quadraparesis. A third patient underwent repeat craniocervical decompression at age 14 years for cranial nerve dysfunction. Postoperatively, he acutely developed paresis of extraocular movements and incoordination of the upper extremities. All three patients were found to have anteriorly situated arachnoid cysts compressing the brain stem and/or cervical spinal cord.

INTERVENTION AND TECHNIQUE

Fenestration of the arachnoid cyst or drainage with cystoperitoneal shunting adequately treated acute brain stem or cervical spinal cord compression. All three patients had achieved satisfactory relief from their acute symptoms of neural compression at their follow-up examinations.

CONCLUSION

An association between spinal arachnoid cysts and neural tube defects has previously been reported. However, the development of previously undetected spinal arachnoid cysts after craniocervical decompression was unexpected. We hypothesize that extensive craniocervical decompression may alter the cerebrospinal fluid pressure dynamics in such a way that the anterior subarachnoid space, previously compressed, may dilate. Occasionally, because of perimedullary arachnoiditis, the cerebrospinal fluid may become loculated and act as a mass. Direct fenestration or shunting may successfully treat this problem, and less extensive craniocervical decompression may avoid it.

Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature

STUDY DESIGN

This case report describes the unique occurrence of acquired intradural spinal arachnoid cyst after lumbar puncture, which was proven radiographically and surgically.

OBJECTIVES

To review and explore complications of lumbar puncture in the context of subsequent cyst development and to review the incidence, presentation, pathogenesis, and management of spinal intradural arachnoid cysts.

SUMMARY OF BACKGROUND DATA

The etiology of the spinal intradural arachnoid cyst remains obscure; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and assumed by many authors to be congenital.

METHODS

A 20-Year-old woman with back and leg pain underwent lumbar myelography that yielded normal results with no evidence of arachnoid cyst at that time. Within 5 months, clinical symptoms of cauda equina compression and an S1 radiculopathy developed. Subsequent myelography and magnetic resonance imaging revealed a lumbar spinal arachnoid cyst. There was no history of intervening trauma or arachnoiditis. The lumbar puncture was thought to be the cause of the arachnoid cyst.

RESULTS

A laminectomy was performed with complete excision of the arachnoid cyst. The patient had an unremarkable postoperative course with excellent relief of her symptoms.

CONCLUSIONS

This case provides supporting evidence for the traumatic etiology of spinal intradural arachnoid cyst. The development of an intradural spinal arachnoid cyst should be included as a possible complication of lumbar puncture.

Negative-pressure hydrocephalus

Two cases of children with closed myelodysplasia, Arnold-Chiari malformation, and shunted hydrocephalus who underwent spinal arachnoid cystopleural shunting are presented. Postoperatively, both patients developed craniovertebral symptomatology accompanied by radiologically documented ventricular dilation in spite of negative intracranial pressure and functional ventriculoperitoneal (VP) shunts. Both patients recovered after the cystopleural shunts were revised to increase the resistance to flow within the system. The authors believe that some communication between the arachnoid cyst and the subarachnoid space existed in both cases and that the negative pleural pressure was transmitted preferentially to the spinal and cerebral convexity subarachnoid spaces with relative sparing of the ventricular system. A transmantle pressure gradient was thereby established, leading to ventricular dilation. The authors further suggest that a craniospinal gradient was possibly established as well, leading to craniovertebral symptomatology in the patients. Return of flow in the VP shunts was obtained by correcting this iatrogenic transmantle pressure gradient.

Intradural extramedullary cysts of the spinal canal: clinical presentation, radiographic diagnosis, and surgical management

Fourteen patients with intradural extramedullary cysts of the spinal canal are described. Histological classification included 11 arachnoid, 2 epithelial, and 1 ependymal cyst. There were 9 thoracic, 3 cervical, and 2 lumbar cysts. The most common clinical presentation was a slowly progressive myelopathy. Twelve patients (85%) had objective neurological findings at the time of diagnosis. Radiographic diagnosis was made by a combination of myelography, computed tomographic scan with myelography, and magnetic resonance imaging. Complete surgical resection was accomplished for 8 dorsal cysts, and 6 ventral cysts were widely fenestrated into the subarachnoid space. Overall results were considered excellent or good in 9 patients, fair in 3, and poor in 2. There was one recurrence, which required a second operation. We conclude that the majority of intradural spinal cysts can be successfully managed surgically with a favorable clinical outcome.

A variant of the syndrome of spinal arachnoid cysts with multiple congenital defects

We report an apparently unique case of multiple spinal intradural arachnoid cysts in association with distichiasis, late onset lower limb lymphoedema, and previously unrecognized features of associated bilateral megaureters, Arnold Chiari malformation with hydrocephalus and syringomyelia. The literature on this unusual group of congenital malformations is reviewed.

Spinal meningeal malformations in children (without meningoceles or meningomyeloceles)

Multiple meningeal malformations are described: anterior or lateral meningoceles, extradural meningeal cysts, and intradural arachnoid cysts. All diverticulae appear to be extensions of the subarachnoid space, producing symptoms early or later. It is impossible to unify all these lesions because they cause multiple pathological conditions, depending upon the anatomical form or level, other systemic malformations, spinal abnormalities, or associated familial diseases. Surgical treatment requires complete evaluation of each anatomical aspect before procedure.

Intradural arachnoid cysts of the spinal canal associated with intramedullary cysts

Five patients had intradural arachnoid cysts of the thoracic spinal canal associated with syringomyelia or posttraumatic intramedullary spinal cord cysts. Three cases were diagnosed 6 to 18 years after spinal surgery and two 14 to 17 years after spinal cord trauma. In each case, delayed progression of symptoms led to the identification of the lesions. The diagnosis was assisted by the use of myelography and delayed computerized tomography scanning in two cases and by magnetic resonance imaging in all five. In each case, the arachnoid cyst appeared to compress the spinal cord or nerve roots; in three cases, the syrinx cavities appeared to exert a significant mass effect. In the two trauma-related cases, the intramedullary cysts were small and may have represented areas of cystic myelomalacia. In four cases, intraoperative real-time ultrasonography helped to localize the arachnoid and intramedullary cavities. All five patients were treated by fenestration of the arachnoid cyst; additional peritoneal shunting of the cyst was performed in one case and of the intramedullary cavity in three. In one patient, the two lesions appeared to have a balancing effect; after drainage of the arachnoid cyst, the syrinx cavity expanded and had to be treated separately. The neurological deficits were reduced in four patients and stabilized in one. Intradural arachnoid cysts and intramedullary cysts may occur together as a late complication of spinal surgery or spinal cord trauma, and either or both lesions may cause delayed neurological deterioration.

Updated assessment and current classification of spinal meningeal cysts

The classification of spinal meningeal cysts (MC's) in the literature is indistinct, confusing, and in certain categories histologically misleading. Based on a series of 22 cases, the authors propose a classification comprising three categories: spinal extradural MC's without spinal nerve root fibers (Type I); spinal extradural MC's with spinal nerve root fibers (Type II); and spinal intradural MC's (Type III). Although water-soluble myelography may disclose a filling defect for all three categories, computerized tomographic myelography (CTM) is essential to reveal communication between the cyst and the subarachnoid space. Communication demonstrated by CTM allows accurate diagnosis of a spinal MC and rules out other mass lesions. Magnetic resonance imaging appears useful as an initial study to identify an intraspinal cystic mass. Final characterization is based on operative inspection and histological examination for all three categories.

Long-term results of surgically treated congenital intradural spinal arachnoid cysts

The authors report long-term results in 17 patients with surgically treated congenital intradural spinal arachnoid cysts. Comparison between the immediate and long-term results demonstrates that surgical removal of the cyst allowed a significant neurological improvement in all cases, but clinical worsening of various degrees was observed later. The authors attempt to explain the results in terms of mechanical and vascular factors.

Percutaneous insertion of the spinal end of a cysto-peritoneal shunt as definitive treatment to relieve cord compression from a spinal arachnoid cyst

A case of myelopathy with both intradural and extradural spinal arachnoid cysts is reported treated by cysto-peritoneal shunt, the spinal end of which was inserted percutaneously under fluoroscopic control. The site of drainage was determined by findings at computed myelography. The case illustrates the value of the latter in demonstrating the pathological bio-mechanics producing myelopathy in this condition.

Spinal intradural arachnoid cysts

Based on the study of 8 cases of spinal intradural arachnoid cysts, the authors underline that the diagnosis is sometimes difficult because of the limitations of the paraclinical examination. They discuss aetiopathological problems.

Intraspinal arachnoid cysts

Eight cases of intraspinal arachnoid cysts are described. The clinical, radiological, intraoperative and histological findings are presented and compared with similar reports in the literature. Opinions in the literature concerning the origin of arachnoid cysts are discussed, and compared with our own case reports. A traumatic or inflammatory origin of the arachnoid cysts is denied if accompanying histological changes are lacking. In such cases the arachnoid cysts are to be viewed as congenital malformations.

Spinal intradural arachnoid cyst

A case of spinal intradural arachnoid cyst is presented, and the literature dealing with this rare lesion is surveyed. The etiological and pathological features are discussed; emphasis is placed on the importance of correct interpretation of clinical and radiological findings that may be diagnostically misleading.

Familial intradural arachnoid cysts. Report of two cases

✓ Two cases of intradural arachnoid cysts are reported in one family. The propositus was a 27-year-old woman with right inframammillary radicular pain and subjective weakness of the lower extremities. Her 57-year-old father was admitted with a progressive, painless paraparesis of 6 years' duration. Intradural arachnoid cysts, at T8–9 and T5–6, respectively, were found in both patients at the time of exploration.