Spinal neurenteric cysts and their relation to more common aspects of occult spinal dysraphism

Mature teratoma of conus medullaris: A case report and review of literature

In conus medullaris, mature teratomas are rare. We report a case of a 40-year-old man who presented with urinary incontinence, low back pain, and muscle weakness. Magnetic resonance imaging revealed a mass in conus medullaris (T11-L1), further confirmed as a mature teratoma by pathological examination. We identified 63 cases of conus medullaris teratoma over the past two decades by systematically analyzing the case reports. Findings demonstrated that most cases were diagnosed in the fourth decade of life, with the majority of cases (57.6%) being male. Lower back pain, radiating pain in the extremities, hypoesthesia, and urinary dysfunction are the most common clinical presentations among patients with teratoma of conus medullaris. Mature teratoma is the dominant pathologic subtype of teratomas in this region, comprising more than 95% of cases. Our case highlights the importance of considering spinal teratoma as a differential diagnosis in patients presenting with urinary incontinence and lumbar pain.

The loop-tail mouse model displays open and closed caudal neural tube defects

Neural tube defects (NTDs) are the second most common cause of congenital malformations and are often studied in animal models. Loop-tail (Lp) mice carry a mutation in the Vangl2 gene, a member of the Wnt-planar cell polarity pathway. In Vangl2+/Lp embryos, the mutation induces a failure in the completion of caudal neural tube closure, but only a small percentage of embryos develop open spina bifida. Here, we show that the majority of Vangl2+/Lp embryos developed caudal closed NTDs and presented cellular aggregates that may facilitate the sealing of these defects. The cellular aggregates expressed neural crest cell markers and, using these as a readout, we describe a systematic method to assess the severity of the neural tube dorsal fusion failure. We observed that this defect worsened in combination with other NTD mutants, Daam1 and Grhl3. Besides, we found that in Vangl2+/Lp embryos, these NTDs were resistant to maternal folic acid and inositol supplementation. Loop-tail mice provide a useful model for research on the molecular interactions involved in the development of open and closed NTDs and for the design of prevention strategies for these diseases.

Neurenteric cyst of the craniovertebral junction treated to reduce recurrence using different strategies: Two case reports and a literature review

RATIONALE

Neurenteric cysts are rare benign lesions that are usually located in the lower cervical and upper thoracic spine and extremely rare in the craniovertebral junction. It is generally challenging to completely remove the neurenteric cysts of the craniovertebral junction. We report the cases of 2 patients with neurenteric cyst in the ventral craniovertebral junction managed using different treatment strategies.

PATIENT CONCERNS

The first patient was a 64-year-old man. He man was admitted with headache, posterior neck pain, and a tingling sensation in both the forearms. The second patient was a 53-year-old woman. She was admitted with tingling sensations and numbness in both the hands and feet.

DIAGNOSES

Cervical spine magnetic resonance imaging showed 2 intradural extramedullary cystic lesions in case 1 and a C2 to C3 intradural extramedullary cystic mass in case 2.

INTERVENTIONS AND OUTCOMES

The patient of the case 1 underwent a left C1 to C2 hemi-laminectomy and the cysts were completely removed. Eleven years after the surgery, there was no recurrence. In case 2, we performed a left C2 to C3 hemi-laminectomy and removed only a part of the outer membrane to enable sufficient communication with the surrounding normal subarachnoid space. After removing the cyst wall, the patient underwent C1 to 2 trans articular screw fixation to prevent cervical instability. Ten years after surgery, there was no recurrence of the cyst or new lesions.

LESSONS

Clinicians should consider neurenteric cyst in the differential diagnosis of arachnoid cyst or epidermoid cyst. If performing a complete surgical removal is difficult, partial surgical removal, using a cysto-subarachnoid shunt and stabilization, such as screw fixation, could be an alternative treatment option to reduce the risk of mortality and morbidity.

A case of neurenteric cyst of spine mimicking an arachnoid cyst

BACKGROUND

Intradural cysts of the spine are arachnoid cysts, neuroenteric cysts, and ependymal cysts. The usual finding in case of a neurenteric cyst is a ventrally located non-contrast-enhancing lesion that is isointense on T1-weighted sequence and hyperintense on T2-weighted imaging. An arachnoid cyst is hypointense in T1-weighted image and hyperintense in T2-weighted image, mimicking cerebrospinal fluid(CSF), and the location is dorsal to the cord. But a neurenteric cyst can mimic an arachnoid cyst in appearance.

CASE

A 48-yr old autorikshaw driver presented with weakness of fingers and lower limbs. All sensations were decreased below xiphisternum(T6). The gait was spastic. Magnetic Resonance Imaging(MRI) showed an extramedullary intradural cyst at C7-T1 level. It was hypointense on T1-weighted image and hyperintense on T2-weighted image. There was no enhancement with contrast. C7/T1 Laminectomy was done. On gentle retraction of the cord, a whitish cyst was seen. Some clear fluid was aspirated and cyst was excised en toto. Myelopathy improved over two weeks. Histopathological examination showed a cyst wall composed of fibrocollagenous tissue, and lined by pseudostratified epithelium containing many goblet cells and having focal ciliation. The findings were consistent with neurenteric cyst. Follow-up MRI after five years showed no recurrence.

CONCLUSION

To our knowledge, the peculiarities of the case are that the radiological features mimicked arachnoid cyst in having the intensity of CSF. But the ventral location was suggestive of a neurenteric cyst. Total excision could be done through the posterior approach after decompressing the cyst by aspiration.

Supratentorial Intraparenchymal Neurenteric Cyst Treated by Neuroendoscopic Fenestration: A Case Report and Review of Literature

Neurenteric cysts (NCs) are rare benign congenital neoplasms in the central nervous system that originate from endodermal elements. NCs are more commonly located in the spine than in the brain. Although almost all intracranial NCs are found in the posterior fossa, some have reported supratentorial NCs. The complete excision of the cyst wall is suggested as a curative treatment; however, endoscopic treatment is less discussed. We present a supratentorial intraparenchymal NC in the frontal lobe treated by neuroendoscopic fenestration and review the literature regarding supratentorial NCs. A 43-year-old woman presenting with right hemiparesis and gait disturbance who was found to have a huge cystic lesion with calcification in her left frontal lobe underwent endoscopic fenestration to the ipsilateral lateral ventricle and biopsy. The histopathological diagnosis was consistent with NC. Postoperatively, her right hemiparesis and gait disturbance disappeared. Postoperative MRI showed shrinkage of the cyst. She was discharged without neurological deficits and no recurrence was seen 1 year after surgery. To the best of our knowledge, there have been no reports of a supratentorial intraparenchymal NC treated by neuroendoscopic fenestration. Minimally invasive treatments, such as neuroendoscopic cyst fenestration, can be considered depending on the location of the cyst.

Gastrointestinal duplication cysts: what a radiologist needs to know

Gastrointestinal tract duplication cysts are rare congenital malformations which can be diagnosed as early as the prenatal period but are frequently found in infancy or incidentally in adulthood. They can be seen throughout the alimentary tract with the most common involving the distal ileum and second most common the esophagus. Many duplication cysts are asymptomatic and thus discovered as an incidental imaging finding, though they can also be symptomatic with an array of clinical presentations dependent largely on their location. The vast majority of duplication cysts are benign; however, there are rare instances of malignant transformation reported. The aim of this review is to show how multimodality imaging can help in the diagnosis of duplication cysts at various anatomical locations. Duplication cyst can become symptomatic and in rare cases undergo malignant transformation; therefore, they are typically managed with surgical excision, particularly if found prenatally or during infancy. Given the diversity of anatomic locations, multiple differential diagnoses, and the need for surgical intervention, it is valuable to comprehend the role of multimodality imaging role in diagnosing duplication cysts.

Antenatally diagnosed intraspinal-posterior mediastinal neurenteric cyst - what is the optimal management?

Neurenteric cyst is a rare congenital anomaly that belongs to the spinal dysraphism spectrum. It is classically a disease of late childhood, with some rare reports of intrauterine and adult presentation. The increase in incidental antenatal diagnosis raises new management questions. We present a case of an asymptomatic combined intraspinal-posterior mediastinal neurenteric cyst. The cyst was diagnosed on antenatal ultrasound and was initially treated with image-guided aspiration in early infancy. However, the cyst recurred and the patient developed recurrent episodes of bacterial meningitis. Two-stage surgical resection was performed, although the infection prohibited complete excision. We caution against image guided aspiration of neurenteric cysts, and suggest a management algorithm based on the available literature.

Congenital Spinal Cysts: An Update and Review of the Literature

Congenital spinal cysts are rare and encompass a wide variety of diseases including arachnoid, enterogenous, teratomatous, neurenteric, foregut, bronchogenic, epithelial, ependymal, dermoid, and epidermoid cysts. Here, we elucidate the epidemiology, pathology, pathogenesis, and diagnostic findings of the most common congenital spinal cysts, followed by a discussion of their presentation and treatment options. Differentiating the cause of each lesion is crucial for targeted clinical and surgical management for the patient. Our review describes how arachnoid cysts can be observed, fenestrated, percutaneously drained, or shunted; however, the primary goal for neurenteric, dermoid, and epidermoid cysts is removal. Further, we discuss how patient presentation is dependent on the rate of growth and location of compression on the spinal cord and nerve roots. However, although many of these lesions are discovered incidentally on imaging, the spectrum of possible symptoms include pain, weakness, ataxia, bladder incontinence, and progressive or acute neurologic deficits. We present and review the histology and imaging of a variety of cysts and discuss how although the goal of treatment is resection, the risks of surgery must be considered against the benefits of complete resection in each case.

Conus Medullaris Teratoma: Case Report and Literature Review

Teratomas are benign germ cell tumors that usually found out of their anatomical origin. Teratomas usually are found in sacrococcygeal area, gonads, mediastinum, cervicofacial region and intracranial fossa. Spinal teratomas are rare. In this study we describe a case of conus medullaris teratoma which was diagnosed based on imaging studies. The patient underwent surgery. We did bilateral laminectomy. The mass lesion had an obvious and rigid attachment to the conus medullaris. The wall of the lesion was resected as much as possible, but total resection of the lesion's wall could not be done due to changes in neural monitoring. Previous related studies are reviewed.

Congenital Spinal Lipomatous Malformations. Part 1. Spinal Lipomas, Lipomyeloceles, and Lipomyelomeningoceles

Background: Lumbosacral spinal lipomas and lipomyeloceles are usually identified in early childhood. Terminology, histopathology, and diagnosis for these malformations can be confusing. Materials and Methods: This is a PubMed review with comparison of embryology, gross, and histopathology, and reporting requisites for these and related closed spinal malformations. Results: The spinal lipoma group (congenital spinal lipomatous malformations) includes subcutaneous, transdural, intradural, and noncontiguous malformations stretching through the entire lower spinal region. This lipomyelocele trajectory overlaps the embryonic tail's caudal eminence. Histopathologically, the lipomyelocele spectrum is a heterogeneous, stereotypical set of findings encountered from dermis to spinal cord. Diagnosis requires detailed correlation of images, intraoperative inspection, and histopathology. Conclusions: Appropriate terminology and clinicopathologic correlation to arrive at a diagnosis is a critical activity shared by pathologist and clinician. Prognostic and management differences depend on specific diagnoses. Familial and genetic influences play little if any role in patient management in closed spinal malformations.

CERVICAL NEURENTERIC CYST: A CASE REPORT

ABSTRACT Objective Neurenteric cysts account for 0.7–1.3% of all spinal cord tumors. These rare lesions are composed of heterotopic endodermal tissue. Methods A 26-year-old woman with a 13-month history of severe cervicalgia and brachial paresthesia. Clinically she had mildbilateral brachial paresis (4/5), generalized hyperreflexia and a left Babinski Sign. Past medical history was significant for a cervical fistula closure when she was 1yearold. The superior somatosensory evoked potentials revealed medullary axonal damage with a left predominance. A cervical magnetic resonance imaging of the neck was performed showing a dorsal homogeneous cystic intradural extramedullary lesion with high signal intensity on T2. Computed tomography revealed a Klippel-Feil syndrome. Results A posterior laminectomy and surgical excision were performed without complications. Post-operative follow-up showed a complete recovery of arm strength. The histopathological report confirmed the preoperative diagnosis of neurenteric cyst. Most neurenteric cysts are located in the spine, mainly in a ventral position. A total of 95% of neurenteric cysts are found in the intradural/intramedullary compartment. Symptomatic neurenteric cysts typically appear in the second and third decades of life and are 1.5 to 3 times more common in men. In 50% of the cases, other vertebral malformations have also been reported. In this case, a congenital dorsal enteric cyst and a Klippel-Feil syndrome were observed. Conclusions The intraspinal neurenteric cysts are rare lesions that must be included in the differential diagnosis of a dorsal, intradural cystic structure. The diagnosis may be overlooked, especially in cases of chronic neck pain without neurological deficit. Level of evidence V; Expert Opinion.

Comprehensive Review of Spinal Neurenteric Cysts with a Focus on Histopathological Findings

Among the occult spinal dysraphisms, neurenteric cysts (NECs) are rare and are thought to arise due to a failure of the separation of the primitive endoderm and ectoderm. Patients experience various neurological symptoms depending on the location of the lesion. As the epithelial morphology of NECs share similarities with other intracranial and intraspinal cystic growths, the definitive diagnosis of NEC can be made after a histochemical analysis with endodermal markers. Complete resection is associated with the lowest disease recurrence rate.

Pathophysiology and Grading of the Ventral Displacement of Dorsal Spinal Cord Spectrum

Study Design

A retrospective study of the ventral displacement of dorsal spinal cord (VDDSC) spectrum pathophysiology and grading.

Purpose

This study aimed at examining the pathophysiology of VDDSC between D3 and D7, using magnetic resonance imaging (MRI) correlation and severity grading.

Overview of Literature

The pathologies that lead to VDDSC were previously discussed in various articles. We attempted to group these pathological conditions under a single spectrum, and grade them according to their severity.

Methods

We reviewed the MRI images of the dorsal spines of 1,350 patients over a period of 4 years (February 2013–February 2017); all MRI images were analyzed by two experienced radiologists.

Results

Of the 1,350 patients, 28 exhibited VDDSC between D3 and D7. Additional findings included ventral transdural herniation of the spinal cord (n=10), anterior spinal cord adhesion (n=7), arachnoid web (n=6), and arachnoid cyst (n=5).

Conclusions

We grouped the pathologies that lead to VDDSC at the thoracic level into a single spectrum of varying severity and graded VDDSC, from mild to severe.

Thoracolumbar spinal neurenteric cyst with tethered cord syndrome and extreme cervical lordosis in a child: A case report and literature review

RATIONALE

Neurenteric cysts, are rare benign tumors of the central nervous system that are mostly located in the spinal cord and predominantly seen in male children although adult form of the disorder also occurs. The etiology and treatment of this disorder is still a matter of debate. Our case further throws more light on the pathogenesis and treatment of this disorder.

PATIENT CONCERNS

A 4-year-old boy presented with 5-month history of cervical lordosis and bilateral lower extremity pain that progressed to his abdomen and upper body. The pain was general, recurrent, non-persistent and progressive in nature with no paralysis. The pain was aggravated by trunk stretching and relieved when he assumed opisthotonos position so he preferred sleeping in this position at night.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed a cystic lesion at the thoracolumbar spine with tethering of spinal cord and cervical lordosis.

INTERVENTIONS

He was operated on successfully and the cervical lordosis and pain resolved.

OUTCOMES

The child recovered well with no tumor recurrence and massive improvement of his life.

LESSONS

The gold standard treatment for this disorder is surgery although the precise surgical approach is still a matter of debate. We are of the view that surgical approach should be individualized and aim at total excision of the cyst.

Management of an unusual, recurrent neurenteric cyst in an infant: case report and review of the literature

PURPOSE

Neurenteric cysts are rare congenital remnants formed by a failure of separation between endoderm and ectoderm in utero.

METHODS

We describe a case of a 7-month-old male with a large cervical neurenteric cyst presenting with intermittent neck stiffness and irritability.

RESULTS

This cyst was resected, recurred, and required repeat surgery. The patient's postoperative course included aseptic meningitis and hydrocephalus requiring ventriculoperitoneal shunt and later management of tethered cord, necessitating detethering.

CONCLUSION

Unique features of this case include the presence of intermittent pain symptoms, which may be attributable to cyst filling and emptying. Hydrocephalus is an uncommon finding that may be secondary to aseptic meningitis from cyst rupture. Tethered cord is also an unusual entity that can accompany this diagnosis, warranting additional imaging work-up and monitoring.

Spinal neurenteric cyst in a dog

CASE DESCRIPTION An 11-year-old English Cocker Spaniel was evaluated because of chronic progressive ataxia of the hind limbs. CLINICAL FINDINGS The dog had no history of previous illness, and findings of physical examination and laboratory tests were unremarkable. Neurologic examination revealed that the dog was ambulatory with severe ataxia of the hind limbs. Proprioception was decreased in the right and left hind limbs (right affected more than left), and spinal reflexes were bilaterally unremarkable. Moderate signs of pain were detected during palpation of the lumbar portion of the vertebral column. Findings suggested a lesion within the thoracolumbar or lumbar segments of the spinal cord. Magnetic resonance imaging revealed extradural spinal cord compression attributable to an extradural space-occupying lesion originating from or infiltrating the L4 lamina on the right side. TREATMENT AND OUTCOME Hemilaminectomy was performed to remove the extradural lesion. Histologic findings for tissue samples collected during the procedure were consistent with a neurenteric cyst. The late onset and progression of clinical signs of this rare congenital malformation were suspected to have been the result of enlargement of the neurenteric cyst through continuous production of mucus by goblet cells. The dog responded favorably to surgical decompression and was clinically normal 1 year after surgery. It was euthanized 2 years after surgery for an unrelated reason (end-stage heart disease), and no neurologic deficits were evident before that point. CLINICAL RELEVANCE Congenital neurenteric cysts should be considered as a differential diagnosis for neoplastic disease in dogs in which results of diagnostic imaging indicate the presence of an extradural mass affecting vertebral structures.

Intramedullary and Extramedullary Cervical Neurenteric Cyst Requiring Fixation and Fusion

BACKGROUND

Spinal neurenteric cysts are rare in the literature, described by sporadic case reports and small case series. In the vast majority of cases, these lesions are intradural extramedullary. We report the novel case of a cervical neurenteric cyst that was simultaneously intramedullary and extramedullary.

CASE DESCRIPTION

A 47-year-old man underwent C2 through C7 laminectomies for microsurgical resection of a large cystic intradural mass, with C1 through T1 instrumentation and fusion. Gross total resection was obtained. Fusion was necessary after removal of the posterior elements because the vertebrae were thinned extensively and remodeled around the tumor, a treatment paradigm that has not been described adequately for neurenteric cysts previously.

CONCLUSIONS

A novel case of cervical intramedullary and extramedullary neurenteric cyst is presented with clinical, radiographic, and histologic details. Given the potential for bony remodeling around these developmental tumors, the possibility exists for instability after certain neurenteric cysts are resected. Thus, the present case adds fixation and fusion to the potential treatment paradigm for select spinal neurenteric cysts.

Spinal neurenteric cysts: Associated developmental anomalies and rationale of surgical approaches

BACKGROUND

Neurenteric cysts (NC) occur due to failure of separation of neurectoderm from endoderm at the 3rd week of embryogenesis. This study focuses on key clinico-radiological features of NCs, with emphasis on surgical nuances involved in resecting anteriorly placed NC, especially at the foramen magnum (FM).

METHOD

Sixteen consecutive patients having a spinal NC were included. Their clinico-radiological status, surgical nuances and follow-up status were noted.

RESULTS

The duration of spasticity/paraparesis/quadriparesis ranged from 15 days to 48 months. Twelve patients had an intradural extramedullary (IDEM; nine anterior and three anterolateral) cyst and four had an intramedullary (IM) cyst. Six of them had an anteriorly placed FM lesion (five IDEM and one IM). Amongst ten subaxial NCs, four were anterior, two antero-lateral and one postero-lateral; three were IM. Three patients had the characteristic stigmata of occult spinal dysraphism: two, a large mesenteric cyst, and one, a posterior mediastinal cyst. Excision was total in 13 patients. Subtotal excision of tumour capsule was performed for two recurrent cysts and an IM cyst. A far lateral approach was adopted for anteriorly placed FM lesions and posterior laminectomy for subaxial lesions. Histopathology revealed eight type A cysts, four type B cysts and four type C cysts. At follow-up (range, 8 months to 12 years; median, 60 ± 45.84 months), complete neurological recovery occurred in seven patients; six patients had persistent spasticity but only minor disability; two patients had difficulty in walking; and one patient with an anteriorly placed thoracic recurrent NC had sustained neurological deterioration.

CONCLUSIONS

Surgical difficulties in addressing NCs are related to their anterior or IM location, presence of adhesions and inability to dissect the tumour capsule from the spinal cord due to fibrous or lipomatous connections. The associated developmental anomalies must be specifically sought and addressed.

Clinical presentation and surgical outcomes of intramedullary neurenteric cysts

OBJECT

Intramedullary neurenteric cysts (NECs) are exceedingly rare lesions and have been previously reported in case reports. The aim of this study was to determine the clinical manifestations, radiological features, and long-term prognosis of patients with such lesions.

METHODS

The authors retrospectively reviewed the records of 13 patients with an intramedullary NEC. Each patient underwent MRI, laminotomy, and microsurgery. The accurate diagnosis was based on imaging and pathology findings. Each patient's follow-up status was determined through individual office visits and a structured telephone interview.

RESULTS

The series included 7 male and 6 female patients. Progressive or intermittent motor deficit was the main symptom associated with or without pain or sensory disturbance. Five cysts were located in the cervical cord, 1 in the cervicothoracic cord, 3 in the thoracic cord, and 4 in the conus medullaris. Concurrent malformations included scoliosis (3 cases), fusion of rib (1 case), enlarged spinal canal (1 case), tethered spinal cord (1 case), and ectocardia (1 case). Gross-total resection of the cyst was achieved in 8 cases, and subtotal resection (STR) was achieved in 5 cases. All patients were followed up, with a mean duration of 66.5 months. Cyst recurrence was observed in 4 cases after STR. In 2 cases the patients underwent reoperation; the other 2 patients remained clinically stable and did not undergo reoperation. At the last evaluation, neurological function was improved in 11 patients and remained stable in 2 patients.

CONCLUSIONS

Intramedullary NECs should be considered in the differential diagnosis of a middle-aged patient with intermittent neurological symptoms and concurrent malformations. Early surgery is advocated to prevent permanent neurological deficits. When gross-total resection cannot be achieved, maximally safe removal under the protection of intraoperative neuromonitoring is advised. Because of the high risk of cyst recurrence, routine follow-up MRI is needed. If a residual cyst shows obvious regrowth and results in neurological deficits, timely reoperation with a goal of STR should be performed.

Spinal neurenteric cyst in a dog

A 2-year-old female crossbreed dog was presented with progressive ataxia and paraparesis. A T3-L3 spinal lesion was determined by neurological examination. Magnetic resonance imaging (MRI) revealed an ovoid-shaped, well-circumscribed mass affecting the spinal cord at the level of the T9 vertebra. A left hemilaminectomy and a durotomy at the level of T9 allowed discovery of an ovoid deformation of the meninges with a cystic appearance.

En bloc removal was performed and appeared to be complete. Pathological analysis showed a voluminous cystic lesion lined by a heterogeneous epithelium. Three types of epithelium were present: a pseudostratified columnar epithelium, a stratified squamous epithelium and a transitional epithelium. Mucus production, the morphology of some cells with microvilli at the apical pole and immunohistochemical assays were highly in favor of an endodermal origin of the cyst. The age of the dog, anamnesis, MRI study and histological findings were consistent with an intradural neurenteric cyst as described in humans. Total surgical removal led to a progressive clinical improvement with no recurrence at 18 months. We report an unusual intradural extramedullary cyst, called a neurenteric cyst, in a 2-year-old female crossbreed dog. This type of cyst is well-known in humans but has never been described in dogs. We propose that neurenteric cysts should be included in the differential diagnoses for tumor-like or cystic intradural lesions in the young dog. Prognosis for this type of cyst seems to be good, as total surgical removal led to a progressive clinical improvement with no recurrence at 18 months.

Spinal Neurenteric Cyst in Association with Klippel-Feil Syndrome: Case Report and Literature Review

BACKGROUND

Spinal neurenteric cysts, also known as endodermal or enterogenous cysts, are rare epithelium-lined structures of presumed endodermal origin. Congenital vertebral anomalies are frequently seen in patients with neurenteric cysts, most typically anterior spina bifida, butterfly vertebrae, and hemivertebrae. However, few series of intraspinal neurenteric cysts accompanied by Klippel-Feil syndrome have been reported previously.

CASE DESCRIPTION

Our purpose is to present the clinical, radiological, and histological results of a 29-year-old patient with a spinal neurenteric cyst associated with Klippel-Feil syndrome and to review previous reported cases of neurenteric cysts associated with Klippel-Feil syndrome. In our patient, cervical radiography demonstrated C5-T1 vertebral fusion and magnetic resonance imaging revealed a large intradural cystic mass. The cystic lesion was removed successfully, and it was histopathologically diagnosed as a neurenteric cyst.

CONCLUSION

Neurenteric cysts should always be considered in the differential diagnosis of an intraspinal cystic mass seen in the setting of vertebral anomalies.

Two-stage approach in the management of thoracic neuroenteric cyst with spinal extension: thoracoscopic excision following dorsal laminectomy

BACKGROUND

Neuroenteric cysts (NC) are rare pathologies and localized generally in posterior mediastinum or abdomen where they may extend to spinal canal through a vertebral defect. Isolated spinal lesions require dorsal/ventral laminectomy and thoracic ones thoracotomy or thoracoscopy. Posterolateral approach via thoracotomy is generally performed for lesions with both thoracic and spinal components. Minimal invasive excision of a thoracic NC with spinal extension in an infant is presented herein.

CASE REPORT

A term female newborn with an antenatal (26th week) diagnosis of congenital diaphragmatic hernia (CDH) was admitted. On physical examination, she was normal except mild dyspnea and CDH were excluded on radiogram. Left parenchymal opacity necessitated thorax tomography that revealed lobulated cystic lesion (6 × 3.5 × 4.5 cm) in posterior mediastinum. MRI showed intraspinal extension of the lesion through a hemivertebrae (6th). Two-stage procedure was planned for suspected neuroenteric cyst. First, intraspinal component was excised with dorsal laminectomy and the connection was closed. Then, the thoracic component was excised thoracoscopically. Histopathological evaluation confirmed the diagnosis. Total parenteral nutrition and high dose somatostatin analog was needed due to transient left chylothorax on postoperative course. She was well and symptom-free in postoperative period.

CONCLUSION

Neuroenteric cysts may lead to misdiagnoses in antenatal period. MRI is critical to show spinal and vertebral pathologies in suspected cases. Thoracoscopy may safely be performed for thoracic lesions with spinal extension in two-stage approach following closure of the connection and excision of the spinal component.

Neurosurgical management of neurenteric cysts in children

OBJECT

Neurenteric cysts (NCs) are endothelium-lined structures of presumed endodermal origin. There have been few pediatric series of intracranial NCs reported previously. The authors present their experience in the management of these lesions.

METHODS

A retrospective chart review of all cases of NCs identified between 1977 and 2007 was carried out. Demographics, details of clinical presentation, surgical therapy, and outcome data were extracted.

RESULTS

Eleven cases were identified, involving 6 girls and 5 boys. The patients' average age was 4.6 years (range 1 day-14 years). Limb weakness was the most common presenting symptom. The location of the cysts was cervical in 2 cases, cervicothoracic in 4 cases, and thoracic in 3 cases. One cyst was anterior to the pons with extension to the left cerebellopontine angle and 1 cyst was at the craniocervical junction. Five patients had an apparently complete initial excision, with 1 recurrence. Four patients were initially treated with incomplete excision and/or cyst drainage, usually into an Ommaya reservoir. A neonate with a large cervicothoracic cyst died of multiple congenital anomalies without any intervention. All other patients were alive at last follow-up. One patient with a radiologically identified presumed cyst, which remained stable, was simply followed up. Several patients required multiple procedures and 1 patient developed hydrocephalus after aseptic meningitis and was treated with CSF shunting.

CONCLUSIONS

Neurenteric cysts are rare in the pediatric population. Total resection, if possible, provides the best long-term outcome. Incomplete excision may lead to multiple procedures, including cyst drainage, but can lead to long-term stability.

Spinal cord malformations

Malformations of the spinal cord are one of the most frequent malformations. They should be clearly divided into two completely different families of malformations: open dysraphisms and occult dysraphisms. Open dysraphism mostly consists in myelomeningocele (MMC). Its incidence is 1/1000 live births with a wide variation. Folic acid supplementation has been shown to reduce its risk. In most cases, the diagnosis is done prenatally by serum screening and ultrasound and may lead to termination of pregnancy. In case of decision to continue pregnancy, surgical treatment must be achieved during the first days of life, and in 50 to 90% of cases, a ventricular shunt must be installed. The follow-up of these children must be continued throughout life looking for late complications (Chiari II and syringomyelia, vertebral problems, neuropathic bladder, tethered cord). Occult dysraphisms are a heterogeneous group of malformations. Lipomas (filum and conus) are the most frequent and their treatment remains controversial. Diastematomyelia, neurenteric cysts, dermal sinus, and more complex forms (Currarino syndrome) belong to this group. Most of them can and must be diagnosed prenatally or at birth by careful examination of the lower back for the cutaneous stigmata of the disease to decrease the risk of neurological, urological, or orthopedic permanent handicap.

Tethered cord syndrome secondary to the unusual constellation of a split cord malformation, lumbar myelomeningocele, and coexisting neurenteric cyst

We describe a seminal case report of a child with a tethered cord syndrome secondary to the unusual constellation of a split cord malformation, lumbar myelomeningocele, and coexisting neurenteric cyst. A 17-year-old adolescent girl with a several-month history of myelopathy and urinary incontinence was examined whose spinal MRI scan demonstrated a type II split cord malformation with a large bone spur and an intradural neurenteric cyst in addition to lumbar myelomeningocele. Untethering of the spinal cord was achieved via a lumbar laminectomy. Pathological examination confirmed the intradural cyst to be a neurenteric cyst. Postoperatively there was stabilization of the neurological symptoms. Prophylactic surgery with total resection of the neurenteric cyst when feasible and spinal cord un-tethering appears to be associated with excellent outcomes.

Intramedullary neurenteric cyst associated with a tethered spinal cord: Case report and literature review

Background:

Neurenteric cysts are benign tumors of the central nervous system (CNS) that represent 0.3% to 0.5% of all spinal cord tumors. They are usually extramedullary and found in the lower cervical and thoracic spine. Only 12.2% of neurenteric cysts are documented to be intramedullary.

Case Description:

The authors report a case of a 35-year-old female that presented with progressive weakness and loss of coordination in her legs. Magnetic resonance imaging (MRI) showed an intramedullary cystic lesion in the thoracolumbar region and a low-lying conus medullaris suggesting tethered cord. The patient was taken to the operating room for detethering of her spinal cord and resection of the lesion. Pathologic examination of the tissue confirmed the diagnosis of a neurenteric cyst.

Conclusion:

A search of the literature since the advent of MRI showed 29 published cases of intramedullary neurentic cysts. Of the 24 published cases with a follow-up MRI, the average recurrence rate was 25% with a mean follow up of 51 months.

An occult spinal neurenteric cyst associated with congenital hemivertebrae. A case report

We describe a case of an occult spinal neurenteric cyst associated with congenital hemivertebrae. Different intraspinal anomalies, such as neurenteric cysts (representing 0.3 to 0.5 % of all spinal tumors) have been reported in association with congenital hemivertebrae. Indeed, although CT is the best examination to study vertebral anomalies, MRI should be performed in order to exclude a more complex dysraphic condition.

Tethered cord syndrome in adults

OBJECT

The treatment of tethered cord syndromes in adults is discussed regarding the natural history and surgical indications. The author analyzes data obtained in patients who were diagnosed with a tethered cord in adulthood and either underwent surgical or conservative therapy between 1991 and 2009.

METHODS

Since 1991, data obtained in 2515 patients with spinal cord pathologies were entered into the spinal cord database, and prospective follow-up was performed through outpatient visits and questionnaires. Of the 2515 patients, 85 adults with a tethered cord syndrome formed the basis of this study. The tethering effect was caused either by a split cord malformation, a thick filum terminale, a conus medullaris lipoma with extradural extension, or various combinations of these mechanisms. The mean age of the patients was 46 ± 13 years (range 23-74 years) and the mean follow-up duration was 61 ± 62 months. Two groups were distinguished based on the absence (Group A, 43 patients) or presence (Group B, 42 patients) of an associated lipoma or dysraphic cyst (that is, dermoid, epidermoid, or neurenteric cyst). Surgery was recommended for patients with symptoms only. Short-term results were determined within 3 months of surgery, whereas long-term outcomes (clinical recurrences) were evaluated using Kaplan-Meier statistics.

RESULTS

For all patients, pain was the most common major complaint. Severe neurological deficits were rare. In Group A, 20 of 43 patients underwent surgery, whereas in Group B 23 of 42 patients underwent surgery. Among individuals who did not undergo surgery, 17 patients refused surgery and 25 patients underwent recommended conservative treatment. Short-term postoperative results indicated a significant improvement of pain and a stabilization of neurological symptoms. Long-term results showed a good prognosis in patients in whom first-time (that is, nonrevision) surgery achieved successful untethering, with a 10-year rate of neurological stabilization in 89% of Group A and a 10-year rate of neurological stabilization in 81% of Group B patients. The benefit of secondary operations in Group B was limited, with eventual clinical deterioration occurring in all patients within 10 years. For patients treated conservatively, follow-up information could be obtained in 33 of 42 patients. Twenty-eight patients remained in stable clinical condition. Only 5 of the conservatively treated patients experienced clinical deterioration over time; in 4 of these individuals with deterioration, surgery had been recommended but was refused by the patient. The clinical recurrence rate in all conservatively treated patients was 21% after 10 years. With a recommendation for surgery this figure rose to 47% within 5 years.

CONCLUSIONS

Surgery in adult patients with a tethered cord syndrome should be reserved for those with symptoms. In surgically treated patients, pain relief can often be achieved, and long-term neurological stabilization tends to persist more often than it does in conservatively treated patients. A conservative approach is warranted, however, in adult patients without neurological deficits. Revision surgery in patients with complex dysraphic lesions should be performed in exceptional cases only.

Isolated spinal neurenteric cyst presenting as intramedullary calcified cystic mass on imaging studies: case report and review of literature

Intramedullary neurenteric cysts (NEC) without associated malformations are extremely rare and, to our knowledge, have never been reported in association with calcification. We report a unique imaging presentation as a partially calcified mass of an isolated intramedullary neuroenteric cyst of the lower thoracic spinal cord with pathologic correlation. The literature for isolated forms of intramedullary NEC since the advent of magnetic resonance imaging is also reviewed.

Congenital Anomalies of the Spine

The complexity of the congenital anomalies of the spine can make the neuroradiologic diagnosis challenging. Knowledge of spinal embryology greatly helps in the understanding and classification of these anomalies. We use the classification devised by Tortori-Donati and Rossi and find it helpful from clinical and imaging standpoints. We believe that most patients who have known or suspected congenital spinal anomalies benefit from MR imaging.

Spinal Neurenteric Cysts in the Magnetic Resonance Imaging Era

OBJECTIVE:

Neurenteric cysts are derived from displaced entodermal tissue. They are infrequently found in the ventral spinal canal with varying degrees of success in their removal. Experience with 10 such individuals is critically analyzed to aid in the diagnosis and management.

METHODS:

Ten patients, ages 4 through 55 years, with neurenteric cysts were encountered in the last 20 years. This series included three females and seven males; seven children and three adults. The follow-up periods ranged from 3 to 18 years. Three cysts were located at the ventral cervicomedullary junction, five in the midventral cervical spine, and one thoracic and one lumbosacral. The symptoms reflected the location.

RESULTS:

Six of the 10 patients had associated bony abnormalities such as bifid clivus, hemivertebrae, segmentation failures at the site of the lesion, and blocked vertebra. The patient with the thoracic spinal lesion (age, 55 yr) had symptoms from early childhood. A diplomyelia at the site of the lesion was seen in one individual and tethered spinal cord in the same adult and in a young child. Two patients had undergone laminectomy for aspiration and partial resection before referral to our institution at the time of recurrence. Cervicomedullary junction lesions were approached via the far lateral transcondylar approach; two of the cervical intramedullary lesions were resected via a ventral corpectomy with radical resection and interbody fusion. The goal in each case was complete resection to avoid recurrences.

CONCLUSION:

Spinal neurenteric cysts are ventrally located, usually intradural and extramedullary, but may insinuate into the spinal cord. They are isointense on T1 images and hyperintense on T2-weighted images on magnetic resonance imaging without true enhancement. These lesions may be associated with block and hemivertebrae with a predisposition to the craniocervical region. Partial resections have led to recurrence and arachnoiditis.

Neurenteric cyst: Case report and a review of the potential dysembryology

We report a 13-year-old female who presented to an outside emergency room following blunt trauma to the head. As part of her evaluation, an unenhanced CT of the face and radiographs of the cervical spine were performed. She was referred to our clinic with "abnormal" imaging. Radiographs revealed dysmorphic cervical spine and ventral clefting of the vertebral bodies from C7-T2. A subsequent MRI was obtained that demonstrated a large spinal cord mass. MRI demonstrated an unenhanced intramedullary mass of the cervicothoracic spinal cord measuring approximately 1.5 cm in greatest axial diameter. Surgical exploration of her intraspinal mass revealed a neurenteric cyst. Spinal neurenteric cysts are categorized in the spectra of occult spinal dysraphism and most likely arise from incomplete separation of the developing notochord and foregut in the embryo. We discuss potential etiologies for the formation of such cysts. The clinician should consider neurenteric cysts in their differential diagnosis of patients with spinal dysraphism and/or intraspinal masses.

Intramedullary neurenteric cyst with a false mural nodule: case report

OBJECTIVE AND IMPORTANCE

Spinal neurenteric cysts are rare congenital lesions that may occur either alone or in the context of a complex malformative disorder including typical vertebral and cutaneous abnormalities. The interest of the case of a spinal neurenteric cyst described here lies in its rare intramedullary location and in the false mural nodule image on the preoperative magnetic resonance imaging scan. A further distinctive feature is the association with a cleft spinal cord.

CLINICAL PRESENTATION

A 28-year-old woman presented with a 2-year history of progressive paraparesis and urinary retention. A magnetic resonance imaging study disclosed a T8-T9 intramedullary cystic lesion with a mural nodulelike formation on the posterior face.

INTERVENTION

A posterior midline myelotomy exposed a cystic lesion that had translucent walls and contained a milky fluid. No mural nodules were found. Once the cyst had been emptied, a collateral finding was a cleft that was clearly observed in the anterior spinal cord. The histological diagnosis was a neurenteric cyst. Retrospectively, the nodular lesion found on the preoperative scan was attributed to mucinous clots deposited at the bottom of the cyst.

CONCLUSION

This case report demonstrates that neurenteric cysts can vary widely in radiological appearance, depending on the contents of the cyst. These differences become especially important if the associated stigmata are lacking and the preoperative diagnosis rests on magnetic resonance imaging scan appearance alone.