Spinal arachnoid diverticula

Fifth Lumbar L5 Perineural Cyst with Unusual Radiculopathy: Traction Plexopathy

Perineural cysts are cystic dilations and are frequently seen in relation to the lumbosacral spine. We describe a case of a fifth lumbar (L5) perineural cyst with unusual radicular symptoms and discuss the possible role of traction plexopathy caused by the cyst. A 38-year-old male presented with a longstanding history of back pain and right side thigh pain. This pain radiated from the buttocks to the lateral and anterior aspect of the thigh. He described the pain as pins and needles/burning with no significant relief with medications or rest. Imaging of the lumbar spine revealed a cystic lesion on the right side involving the L5 nerve root in the foraminal region. He failed conservative treatment and elected to have the cyst removed even with a guarded prognosis. A wide L5 laminectomy was performed. Due to the size of the cyst which was causing traction on the exiting L5 nerve root, the L5 pedicle was excised in order to delineate the cyst and to prevent any iatrogenic injury to the root. The patient had the dramatic improvement in his radicular pain immediately after the surgery and continues to be pain-free at his latest three-year follow-up. This case highlights the unusual pain pattern distribution from a perineural cyst possibly secondary to traction effect of the tumor.

Spinal arachnoid cysts in the pediatric population: report of 31 cases and a review of the literature

OBJECT

The goal of this study was to review all cases of pediatric spinal arachnoid cysts (SACs) surgically treated at the authors' institution between 1992 and 2008 and to compare these cases to the published literature for the general population.

METHODS

The charts of all pediatric patients with SACs were reviewed for demographics, medical history, presenting symptoms, imaging findings, operative procedure(s), complications, and outcomes. Following a complete literature review, the pediatric data were compared with data from the general population and unique findings associated with pediatric patients were identified.

RESULTS

Thirty-one pediatric patients (median age 6.9 years) underwent operative intervention for SACs between 1992 and 2008 (median duration of follow-up 4.2 years). There were 17 female patients (55%) and 14 male patients (45%). Twenty-one patients (68%) presented with symptoms of radiculopathy or myelopathy. The most common presenting symptoms were pain (42%), lower-extremity weakness (39%), gait instability (32%), spasticity (19%), sensory loss (10%), and bladder dysfunction (7%). In 3 patients (10%) SACs were incidental findings. Intradural SACs were more common (18 patients, 58%) than extradural SACs (11 patients, 36%). One patient (3%) had extradural and intradural components. One patient (3%) had a purely intramedullary cyst, and 1 patient (3%) had both an intradural and intramedullary component. Of the 18 intradural SACs, 9 (50%) were located ventral to the spinal cord and 9 (50%) were dorsally situated. One dorsal intradural SAC had an intramedullary component. All extradural SACs were located dorsal to the spinal cord. Intradural SACs were primarily concentrated in the cervical and thoracic regions (67%), whereas extradural cysts were more evenly distributed between the thoracic, lumbar, and sacral regions. Of the 18 patients with intradural SACs, 13 (72%) had significant previous CNS abnormalities, compared with 3 (27%) of 11 patients with extradural SACs. There were 2 operative complications. One patient had a CSF leak treated with a lumbar drain, and the second patient had a pseudomeningocele. No patients had neurological deterioration as a result of surgical intervention. Twenty-one patients (68%) had complete remission of symptoms, 6 (19%) had improvement, 3 (10%) were stable, and 1 (3%) has worsening of symptoms with recurrence that ultimately required cystoperitoneal shunting, despite multiple failed attempts at fenestration.

CONCLUSIONS

Spinal arachnoid cysts are rare lesions in the pediatric population. Affected patients present with back pain, weakness, and/or gait instability. In children, SACs predominantly develop in the thoracic region and are more likely to occur intradurally, compared with SACs in the general population. Overall outcomes following surgical fenestration or excision of SACs are excellent, with complete remission or improvement of symptoms achieved in 87% of cases.

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.

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 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.

Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases

BACKGROUND

The widespread use of magnetic resonance imaging (MRI), now the first line investigation for back and leg pain, reveals cystic sacral lesions more often than myelography did in the past. There is agreement that symptomatic perineurial sacral cysts should be treated surgically. However, it is still debated whether the preference should be given to the curative option, consisting of excision of the cyst with duraplasty, or to drainage of the cyst to relieve symptoms. In this retrospective study the efficacy of microsurgical cyst resection with duraplasty is evaluated.

METHODS

In 15 patients presenting with pain and neurologic deficits, myelography and/or MRI detected sacral cysts. The clinical features suggested that the space-occupying lesions caused the disturbances. Microsurgical excision of the cyst along with duraplasty or plication of the cyst wall was performed in all the cases. Postoperative care included bed rest and CSF drainage for several days.

RESULTS

In 13 out of 15 patients the preoperative radicular pain disappeared after surgery. The 2 patients with motor deficits and the 6 patients with bladder dysfunction recovered completely. In all except 1 of the 10 patients complaining of sensory disturbances a significant improvement was achieved. No complications were observed.

CONCLUSION

Microsurgical excision of the cyst combined with duraplasty or plication of the cyst wall is an effective and safe treatment of symptomatic sacral cysts and, in the view of the authors, the method of choice.

Symptomatic spinal arachnoid cysts: report of two cases with review of the literature

STUDY DESIGN

Two unusual cases of intradural extramedullary noncommunicating arachnoid cysts are presented, with a review of literature.

OBJECTIVE

To assess surgical excision results in the reversal of symptoms and neurologic deficits.

SUMMARY OF BACKGROUND DATA

Most patients harboring arachnoid cysts are asymptomatic. Noncommunicating intradural extramedullary arachnoid cysts are more rare than communicating intradural extramedullary cysts. Noncommunicating intradural extramedullary arachnoid cysts are a very rare cause of spinal cord compression. Rarely, these cysts can present with bizarre symptoms, such as angina.

MATERIALS AND METHODS

The first case, a 75-year-old woman, presented with progressive paraparesis. The second case, a 40-year-old man, presented with signs and symptoms of angina, with mild spasticity in the lower limbs. In both cases, magnetic resonance imaging revealed compression of the spinal cord as the etiology of presentation. The first patient is the second oldest patient in the literature with an idiopathic spinal arachnoid cyst. The second case has an unusual presentation that has not previously been reported in the literature.

RESULTS

Both cases underwent surgical excision of the arachnoid cyst, with resolution of symptoms and reversal of neurologic deficit.

CONCLUSIONS

Our experience indicates that complete recovery from an arachnoid cyst is possible after surgical excision, even when symptoms are present for a long duration, even in the elderly.

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.

Multiple communicating intradural arachnoid cysts: usefulness of myelography and myelo-computed tomography using both lumbar and cervical punctures. Case report

We report a case of multiple communicating intradural cystic lesions. Magnetic resonance imaging did not demonstrate the lesions. Neuroradiological diagnosis of the intradural arachnoid cysts was made from myelography and myelo-computed tomography using both lumbar and cervical punctures. These procedures give us useful information about flow dynamics in the spinal subarachnoid space.

Craniospinal intradural arachnoid cyst

A patient with an uncommonly situated congenital intradural arachnoid cyst is reported. The cyst extended from the cervical spinal canal into the posterior cranial fossa and was posterolateral to the spinal cord. The patient's initial complaint was urinary hesitancy. The location of the cyst is unique and the presenting complaint rare.

Spinal arachnoid cysts in the pediatric age group: an association with neural tube defects

Between 1979 and 1991, spinal arachnoid cysts were found in 11 patients aged 19 months to 18 years (mean age 5 1/2 years). Of the 11 patients, six had a myelomeningocele and one diastematomyelia. The presenting symptoms included radicular pain (one patient), progressive weakness (three), increasing scoliosis (one), worsening spasticity (three), and recurrent urinary tract infections and progressive constipation (one). Two patients showed no symptoms from the spinal arachnoid cyst. The distribution of lesions was as follows: cervicomedullary (one patient), cervical (one), cervicothoracic (two), thoracic (four), lumbar (two), and sacral (one). Four of the 11 arachnoid cysts (all intradural) were located anterior to the spinal cord, three of which were in children with a myelomeningocele. Only two of the cysts were extradural; both were found in the lumbosacral region, and one was associated with diastematomyelia. Eight patients were treated with fenestration and/or resection of the cyst wall. Three patients with anterior cysts were treated with shunts, a cyst-to-pleural space shunt in two and a cyst-to-subarachnoid space shunt in one. All of the patients either improved or exhibited an arrest in the progression of their symptoms. Spinal arachnoid cysts are a treatable cause of progressive neurological deficits and, in this series, were frequently found in patients with neural tube defects.

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.

Spinal cord compression due to intradural extramedullary aspergilloma and cyst: a case report

A case of thoracic spinal cord compression caused by intradural extramedullary cyst associated with aspergilloma is presented. The specific diagnosis was extremely difficult and required specialized tissue studies. Clinical suspicion of fungal infection, surgical intervention for spinal cord decompression, and tissue biopsy and relentless diagnostic laboratory studies are particular features of this case.

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.

Brainstem subarachnoid respiratory epithelial cysts: report of two cases and review of the literature

Two cystic lesions that were lined by pseudostratified ciliated columnar epithelium containing goblet cells are described. Both lesions were found in the subarachnoid space between the vertebrobasilar arterial system and the brainstem. One cyst was an incidental finding in a patient who died of orbital phycomycosis. The cyst was filled with clear mucinous material. The second cyst presented as a mass adjacent to the brainstem in a woman who had progressive brainstem dysfunction. This lesion showed transition from pseudostratified ciliated columnar epithelium with goblet cells to papillary stratified squamous epithelium, histologic features essentially identical to those of squamous papillomas of the nasal cavity. This lesion was filled with squamous debris. The proposed origin of these lesions is discussed.

Association of posttraumatic spinal arachnoid cyst and syringomyelia

A patient developed a painful progressive paraparesis following trauma. Metrizamide myelography revealed an arachnoid cyst. A delayed metrizamide computed tomography scan of the area confirmed the cyst and demonstrated a syrinx at that level that was not appreciated on the myelogram. The association of these two lesions after trauma are perhaps more common than appreciated and the importance of a computed tomography scan of the abnormal area on myelography is emphasized.

Post traumatic spinal arachnoid cysts

Based on the study of 10 cases of post traumatic spinal arachnoid cysts (SAC), acute and chronic clinical variants are individualized. A physiopathological hypothesis is advanced to explain their mechanism of formation. Acute SACs should be operated upon immediately although the differential diagnosis with spinal epidural haematomas is difficult. Even more difficult is the diagnosis of the chronic SAC. Rare though it may be, the Neurosurgeon must be aware of the possibility of its occurrence, especially when treating rather vague and stubborn cases.

Spinal arachnoid cyst with unusual presentation. Case report

A case is reported of spastic paraparesis due to a thoracic spinal arachnoid cyst. Symptoms occurred about 10 years after craniospinal injury. The histological examination revealed hemosiderin-containing macrophages trapped in the cyst wall. This finding and its possible pathogenetic implications are discussed, and the pertinent literature is reviewed.

Intradural spinal cysts

18 cases of benign intradural spinal cyst (9 arachnoidal, 2 neuroepithelial, 7 endodermal) are reported and compared with 94 cases (67 arachnoidal, 7 neuroepithelial, 20 endodermal) obtained from the literature. Arachnoidal intradural cysts (AIC) have no sex preference, occur at around the fourth-fifth decades of life and have characteristic intermittent root symptoms. They prefer the thoracic level and the posterior position. (Myelography images the cystic cavity (diverticular form). Surgical removal is usually easy. Neuroepithelial intradural cysts (NIC) are rare, have a 2:1 predilection for females and occur after the fourth decade. They have a serious clinical course similar to intramedullary or extramedullary tumours. They prefer the conus-cauda and the anterolateral positions. They often give rise to manometric block and to albuminocytological dissociation. There may be substantial adhesions to the cord and roots and the intramedullary variety presents no clear plane of cleavage. Endodermal intradural cysts (EIC) have a 2:1 predilection for males and prefer the second and third decades. They may have an intermittent or serious course with signs of root and cord impairment. They prefer the cervical segment (in the anterior position) and the conus-cauda (in the posterior position). As a rule they present manometric block and albuminocytological dissociation. Their frequent tough adhesions to the roots and cord demand special care during their removal.

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.

Posttraumatic pseudomeningomyelocele (enlarging fracture?) in a vertebral body. Case report

An unusual case is reported in which a posttraumatic peudomeningomyelocele developed over many years inside the body of a fractured lumbar vertebra, eroding the pedicle and causing progressive neurological deficit. The wall of the sac was mostly formed by the scalloped bar bone, and partly by a membrane resembling the dura. The terminal part of the conus medullaris and some nerve roots of the cauda equina formed the contents and parts of the wall of the outpouching of the subarachnoid space into the vertebral body. A comparison is drawn between this lesion and formation of an "enlarging fracture" of the skull. The surgical technique used for obliteration of this pseudomeningomyelocele is described.

Arachnoidal diverticula and cystlike dilatations of the nerve-root sheaths in lumbar myelography

Diverticulum-like widening of one or several nerve-root sheaths was found in 24 of 136 patients examined by lumbar myelography. No clinical significance of the diverticula was demonstrated. The roots most commonly affected were the S 1 and S 2 roots, carrying approximately 60 per cent of the diverticula. A system of classification according to morphology and to size compared with the root involved is proposed. A relationship between magasac and arachnoidal diverticula is confirmed.

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.

Arachnoid diverticula: a unitary approach to spinal cysts communicating with the subarachnoid space

The authors report six cases of so-called spinal subdural arachnoid cysts, emphasizing the clinical and myelographic findings which, if not properly evaluated, may be misleading diagnostically. The literature of so-called perineural cysts and of extradural arachnoid cysts is likewise reviewed. Their clinical, roentgenological, and pathological features are examined. A common pathogenesis for all these lesions is proposed. It implies disruption and secondary proliferation of the arachnoid membrane. Hence, the term arachnoid diverticulum is advanced to include all lesions communicating with the subarachnoid space. Their varying relations with the subarachnoid space depend on the sites of the primary abnormalities and on hydrodynamic factors. Numerous observations of associated arachnoid diverticula, either perineural, subdural, or extradural, further favour a common pathogenesis.

Recurrent intraspinal arachnoid cyst treated with a shunt procedure

A case of a recurrent arachnoid cyst in the thoracic region in a 13-year-old boy is reported. At the first operation, complete removal of the cyst proved impossible. At a second operation four years later, it was still impossible to remove the cyst so we performed a shunt procedure with drainage through a Hakim valve to the right atrium. This procedure was successful, resulting in complete disappearance of symptoms. In the presence of recurrent intraspinal cysts the authors recommend this treatment, as it is an easy operation which does not cause undue discomfort to the patient.

Septum posticum cysts: an uncommon cause of chronic back pain

The authors describe two patients with posterior thoracic pain associated with cysts of the septum posticum. One patient's pain was relieved by surgical removal of the cysts; the second patient's symptoms temporarily resolved after myelography. Posterior thoracic pain can be ascribed to myelographically proven arachnoid cysts when the pain is persistent, positionally exacerbated and associated with radicular sensory changes. Excision of the cysts may provide pain relief for some patients.

Spinal arachnoid cysts. Report of six cases

✓ Six cases of symptomatic spinal arachnoid cysts are presented. All lesions but one were intradural. Although these cysts are frequently indistinguishable clinically from spinal cord tumors, their correct early diagnosis by myelography and treatment by excision or marsupialization gives gratifying results. The authors emphasize that precise diagnosis and definitive treatment are sometimes delayed because of intermittent symptoms.