Postoperative lumbar extradural arachnoid cyst. Report of two cases and review of the literature

Two cases of postoperative extradural arachnoid cyst in the lumbar region were reported. The symptoms such as lumbago, sciatica and paresis of foot which were perfectly cured at discharge relapsed after several months of daily business. The two patients were readmitted and reexamined by myelography and computer assisted tomography. In the two patients a cystic pooling of metrizamide having a connection with the subarachnoid space was noted in the same way. At the second operation a small dural tear and an extradural arachnoid cyst were recognized similarly. Burres and coworkers reported that an extradural arachnoid cyst would easily grow through a small dural defect in the lumbar region, because the hydrostatic pressure is higher than that of the cervical level. Our two cases might well coincident with their theory. In consequence of the experience of the two postoperative extradural arachnoid cyst, we give emphasis that even though the dural tear would be small, especially in the lumbar region, it should not be overlooked and be closed carefully with fine sutures.     

Extradural spinal arachnoid cysts associated with spina bifida occulta

Summary Introduction. Spinal extradural arachnoid cysts are an uncommon cause of neural compression in children. Even more uncommon is the association of such cysts with spina bifida occulta. Material. Two girls, 12 and 8-years-old, presented with left leg pain, deteriorating gait, clinical signs of left L5 and S1 root compression, without bladder or bowel symptoms. The first patient had left foot drop. The second patient had muscle wasting and smaller left foot with pes cavus. Radiographs showed spina bifida occulta of S1 in both. MRI revealed an extradural cyst at the S1 level, indenting the thecal sac and the L5 and S1 roots. At operation in both patients a large arachnoid cyst arising from a small dural defect in the axilla of the left S1 root was compressing and displacing it and the dural sac. It was removed and the defect was repaired. The first patient improved with complete recovery of the foot drop. An MRI at 12 months showed no cyst recurrence. The second patient made good recovery initially, but at 10 months developed recurrent symptoms. An MRI scan showed recurrence of the cyst with root compression. On repeat exploration a different dural defect was identified in a more anterior position and was repaired. Discussion. The coexistence of extradural arachnoid cyst and corresponding bifid spinal segment has not been described previously. It raises the suspicion that the dural defect giving rise to the arachnoid cyst may be due to segmental dural dysgenesis in the context of the dysrhaphic neuroectodermal malformation.     

Expansive duraplasty for the treatment of spinal extradural arachnoid cysts: case report

The authors report the case of a 25-year-old man with a thoracolumbar extradural arachnoid cyst who underwent expansive duraplasty. Symptoms, preoperative magnetic resonance imaging features, and intraoperative findings suggested the involvement of entrapment neuropathy in the manifestation of symptoms. To the authors' knowledge, this case represents the first evidence that expansive duraplasty can achieve complete resolution of the symptoms in a patient with a spinal extradural arachnoid cyst. The results indicate that duraplasty may be an alternative option in cases in which complete resection of the lesion is difficult and widening of the dural sac is necessary at surgery.     

Multiple spinal extradural meningeal cysts presenting as acute paraplegia. Case report and review of the literature

Multiple spinal extradural meningeal cysts are rare. To the authors' knowledge, there have been only four reported cases in the world literature. The authors report a case of multiple spinal extradural meningeal cysts in a 31-year-old woman presenting with acute paraplegia. Magnetic resonance imaging of the thoracolumbar spine revealed multiple extradural cystic lesions extending from T-7 to T-8 and from T-12 to L-3. Intraoperative findings demonstrated a white, fibrous, and tense cyst filled with cerebrospinal fluid-like colorless fluid. Excision of the posterior wall of the symptomatic cyst was followed by immediate neurological improvement. The examination of the pathological specimen showed a thick duralike layer of collagen and an inner membrane of arachnoid that is often not found in these lesions. The final diagnosis was based on combined imaging, intraoperative, and histopathological findings. The authors review the literature and discuss the etiological, diagnostic, and therapeutic aspects of this lesion.     

A case of syringomyelia associated with postoperative extradural cyst and adhesive arachnoiditis

We report a rare case of syringomyelia associated with postoperative adhesive arachnoiditis and an extradural cyst. A 61-year-old male was admitted to our hospital five years after surgical removal of a cervical neurinoma. He complained of progressive quadriparesis and sensory disturbance. A CT scan showed a large cyst posteriorly within the C2, 3, 4 laminectomy area. MRI revealed syringomyelia with an extradural cyst at the C2, 3, 4 level. The operative findings revealed adhesive arachnoiditis on the dorsal surface at the C2, 3, 4 level and an extradural cyst communicating with the subarachnoid space through a dural defect on the left side of the C2 level. By excision of the extradural cyst and placement of a syringo-cisternal shunt, the syringomyelia shrank and the extradural cyst disappeared. It can be speculated that the pathogenesis of syringomyelia in this case was associated with ischemic change of the spinal cord due to compression and constriction caused by the extradural cyst and adhesive arachnoiditis.     

Spinal extradural arachnoid cyst

Background contextSpinal extradural arachnoid cysts are uncommon expanding lesions. Idiopathic arachnoid cysts are not associated with trauma or other inflammatory insults. If they enlarge, they usually present with progressive signs and symptoms of neural compression.PurposeTotal removal of the cyst and repair of the dural defect is the primary treatment for large thoracolumbar spinal extradural arachnoid cysts causing neurogenic claudication. Laminoplasty may prevent spinal deformities in long segmental involvement.Study designA clinical case was performed.Patient sampleWe report a case of 25-year-old man with 1-year history of progressive back pain radiating to both legs. His diagnosis was dorsal intraspinal extradural cystic lesion longing from the level of T11 to L2 on magnetic resonance imaging.Outcome MeasuresThe patient's pain levels were noted as he reported. Physiologic outcome was assessed on pre- and postoperative motor and sensory examination.MethodsThe patient underwent a T11–L2 laminotomy and radical cyst wall resection was performed. A small communication with the subarachnoid space was seen at the level of T12. It was sealed with tissue fibrinogen after repair with primary suture. Titanium miniplates were used for laminoplasty.ResultsFollow-up magnetic resonance imaging demonstrated cyst resolution, and neurologic examination revealed no sensory and motor deficit.ConclusionExtradural arachnoid cysts are primarily treated with total removal of the cyst wall and closure of the dural defect. Surgical treatment is curative for this rare lesion.     

Extradural arachnoid cysts: a study of seven cases

Analysis of the management of 7 cases of extradural arachnoid cyst is presented. A brief review of the literature on the subject is presented. Seven cases of extradural arachnoid cysts were treated surgically between the years 1996 to 2002. These patients were analysed retrospectively. The average follow-up period was 32 months. Three patients were males and four were females and their ages ranged from 12 to 35 years. The patients presented with predominant complaint of progressive motor deficits. There were two cysts in the dorsal region, four in the dorsolumbar region and one in the cervicodorsal region. The extradural arachnoid cyst was located posterior to the dural tube and in the midline in six cases and all these cysts had bilateral multiple intervertebral foraminal extensions. In the case with a cervicodorsal cyst, the cyst was anterolateral to the dural tube and there was no foraminal extension. The surgery comprised of wide exposure of the cyst and radical marsupialization or resection of the cyst wall. There was no recurrence of the cyst during the period of follow-up. Radical resection of the walls leads to a lasting cure from extradural arachnoid cyst. The site of communication of the cyst contents with subarachnoid CSF could not be identified during the surgery in the series.     

Usefulness of constructive interference in steady state (CISS) imaging for the diagnosis and treatment of a large extradural spinal arachnoid cyst.

We present a rare case of a symptomatic large extradural arachnoid cyst extending from the lower thoracic to sacral region in a 12-year-old boy, who presented with the signs and symptoms of spinal cord compression over 4 years. Since the pedicle of the cyst could not be delineated using conventional magnetic resonance imaging (MRI), cine-mode MRI, and computed tomography scan, partial resection of the cyst was initially performed, which significantly improved motor function. After the first operation, a single pedicle was clearly demonstrated by 3D constructive interference in steady state (CISS) MRI. Thus, additional surgery aimed at closing the dural defect was performed to prevent future enlargement of the cyst. The operative findings were consistent with those of 3D CISS imaging. Clinical and radiological features of this lesion are discussed, focusing on the usefulness of 3D CISS MRI for preoperative evaluation, and especially for delineating the pedicle in cases of large extradural spinal arachnoid cysts.     

Spinal extradural arachnoid cyst--case report.

A 48-year-old male presented with progressive leg weakness. Magnetic resonance imaging and computed tomography myelography showed an extradural arachnoid cyst extending from the T-12 to L-2 levels in the thoracolumbar region. The cyst was confirmed at surgery and completely removed. This surgical intervention achieved improvement in the neurological symptoms.     

Management of complex giant spinal arachnoid cysts presenting with myelopathy

A giant spinal arachnoid cyst is an unusual cause of progressive epidural compressive syndrome. The authors describe 4 cases of a "complex" subtype of this lesion and discuss aspects of surgical management. The patients presented with progressive spastic paraparesis and were found to harbor extensive spinal extradural arachnoid cysts with multiple septations and significant paraspinal extensions. Extensive laminotomy and excision of the cyst along with its extensions were performed in all cases. Compared with previously indexed cases of surgically managed extensive spinal extradural arachnoid cysts, the cases reported here are unique because of their complex nature. Curative treatment consists of radical excision inclusive of the paraspinal extensions as well as closure of a dural defect, if found. A laminotomy or laminoplasty should be performed to avoid postoperative instability related to the extensive exposure. Extended follow-up and instrumentation may be required in select cases.     

Twist technique for removal of spinal extradural arachnoid cyst: technical note

Study design

We document a spinal extradual arachnoid cyst treated by twist technique. The cyst is tightly adherent to the neural tissue or the dura, and the communication stalk is little or short.

Objective

To demonstrate the effectiveness of twist technique of closure of the communication stalk for the removal of spinal extradural arachnoid cyst.

Summary of background data

The standard treatment for a spinal extradural arachnoid cyst is complete excision of the cyst, followed by obliteration of the communication stalk and repair of the dural defect. To our knowledge, twist technique of the communication stalk for removal of spinal extradural arachnoid cyst has not been reported.

Methods

A 44-year-old woman presented with a 10-year history of pain and dysesthesia, initially in the posterior neck region and extending gradually to the distal portion of the right upper extremity. Pain and dysesthesia were exaggerated when she was lying down and relieved when standing or walking. She was diagnosed with an extradural arachnid cyst ranging from spinal regions T1 to T3 using MRI. Computerized tomography myelography revealed a mass located posterior to the spinal cord. Pooling of contrast medium was observed in the lesion indicating communication with the subarachnoid space. Laminectomy of the T1–T3 region was performed, preserving the spinous processes and the facet joints. A short communication stalk was found at the proximal root sleeve of right T3. This stalk was closed using twist technique.

Results

The patient experienced marked reduction of pain and dysesthesia after surgery, and the headache and blurred vision completely disappeared. Five days after the operation, she was discharged home in good condition. Postoperative 1 year later, the patient had completely recovered and resumed her normal life.

Conclusions

Twist technique can be seen safe and effective as another surgical option for spinal extradural arachnoid cysts containing a short stalk and dense fibrous adhesion with the dura mater.     

Primary spinal extradural hydatid cyst in a child: case report and review of the literature

Spinal hydatid cyst is a rare but serious condition. An 8-year-old boy presented with back pain, progressive weakness and numbness in both legs. Magnetic resonance imaging (MRI) of the lumbar region showed a cystic lesion with regular contour located in extradural space. There was cerebrospinal fluid- (CSF-) like signal intensity on T1- and T2-weighted images. The lesion had excessively compressed the dural sac and caudal roots, and expanded to the L3 and L4 neural foramina. The case was explored with L2, L3, L4 laminectomy and the hydatid cyst was removed totally. The clinical presentation, diagnosis and surgical treatment of this rare case of spinal hydatid disease is discussed, and all available cases of primary extradural hydatid cyst reported in the literature are presented.     

Intrasacral extradural arachnoid cysts

Three patients presented with rare intrasacral extradural arachnoid cysts manifesting as sensory deficiencies and pain in the lower extremities. Magnetic resonance imaging with various sequences identified the cysts. Two patients underwent surgery via laminectomy of the sacrum for cyst exploration and disconnection of the cyst with the dural theca. Postoperative outcome was favorable in these two patients. Intrasacral extradural arachnoid cyst should be considered in the differential diagnosis of low back pain.     

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.     

Spinal extradural meningeal cysts that contain nerve fibers: case report

We describe a case of extradural meningeal cysts of the lumbar spine that contain nerve fibers. These lesions are anatomically distinct from both perineurial and meningeal cysts. Drainage and suturing of the cyst walls to the dorsal dura mater was effective in relieving the clinical symptoms.     

Giant cervicothoracic extradural arachnoid cyst: case report

The pathogenesis, etiology, and treatment of the spinal arachnoid cyst have not been well established because of its rarity. A 57-year-old male was presented with spastic quadriparesis predominantly on the left side. His radiological examination showed widening of the cervical spinal canal and left neural foramina due to a cerebrospinal fluid - filled extradural cyst that extended from C2 to T2 level. The cyst was located left anterolaterally, compressing the spinal cord. Through a C4–T2 laminotomy, the cyst was excised totally and the dural defect was repaired. Several features of the reported case, such as cyst size, location, and clinical features make it extremely unusual. The case is discussed in light of the relevant literature.

     

Leptomeningeal cyst development after endoscopic craniosynostosis repair: case report

OBJECTIVE AND IMPORTANCE: Endoscopically assisted (minimally invasive) craniosynostosis repair has been suggested as an alternative to traditional open craniosynostosis repair. Advocates of this approach assert advantages, including decreased blood loss, operative time, and hospital stay, while providing esthetic results and safety comparable with traditional open craniosynostosis repair. The difficulties inherent in endoscopic visualization may result in complications, however, that could temper enthusiasm for this procedure. The authors report a child in whom a leptomeningeal cyst developed after performance of endoscopic craniosynostosis repair, presumably from an iatrogenic dural laceration. CLINICAL PRESENTATION: A 5-month-old girl with sagittal synostosis underwent endoscopically assisted craniosynostosis repair. By report, the procedure was uneventful and the initial results were acceptable. The authors performed a chart review of their own experience with both endoscopically assisted craniosynostosis repair and traditional open repair. INTERVENTION: Five months after surgery, a pulsating forehead mass developed. Neuroimaging confirmed the diagnosis of a leptomeningeal cyst. The child was referred to our pediatric neurosurgery practice for operative repair. At the time of surgery, a dural defect lying directly under a previous osteotomy site was identified. After uneventful repair and follow-up of more than 1 year, the child is well and is without the development of a clinical seizure disorder or recurrence of her leptomeningeal cyst. CONCLUSION: Unrecognized dural injury combined with an overlying osteotomy in an infant can result in the development of a leptomeningeal cyst. Care must be taken at the time of endoscopic extradural surgery to recognize any inadvertent dural tears and to perform a direct repair at the time of the initial occurrence. Facility with and use of an appropriate endoscope is essential to the safe performance of minimally invasive craniosynostosis surgery.     

Spinal extradural meningeal cyst with spinal stenosis

STUDY DESIGN: Case report. OBJECTIVE: To present a rare pathology causing a common disease. SETTING: Spine unit of the orthopaedic surgery department of a university hospital in Berlin/Germany. CASE REPORT: A 39-year-old female with an intraspinal extradural arachnoid cyst of the lumbar spine presented with intermittent radiating lumbar pain. The magnetic resonance imaging (MRI) showed a dorsal spinal extradural arachnoid cyst at L3/4. After wide laminotomy L3, operative cyst resection and stabilisation at L3/4 by posterior lumbar interbody fusion (PLIF), major symptom relief occurred. CONCLUSION: Spinal extradural arachnoid cysts are a rare entity causing low back pain and intermittent radicular syndromes. They can be caused by arachnoid herniation through dural weak spots which are hereditary or occur after trauma. A ball-valve mechanism promotes growth. The main diagnostic tool for spinal extradural cysts is the MRI scan. Additionally, myelography is helpful to demonstrate fluid communication. Complete surgical removal of the cyst should be attempted to reduce risk of recurrence. If extensive decompression is needed for the surgical approach causing segmental instability, interbody fusion is recommended. The outcome depends on age, duration and degree of neurological damage.     

Huge thoracolumbar extradural arachnoid cyst excised by recapping T-saw laminoplasty

Background context

Spinal extradural arachnoid cysts are rare expanding lesions in the spinal canal. Total removal of the cyst and repair of the dural defect is the primary treatment for symptomatic spinal extradural arachnoid cysts.

Purpose

To report the usefulness of recapping T-saw laminoplasty in treating huge extradural arachnoid cyst.

Study design

Case report.

Methods

We report the case of a 43-year-old man who presented with a 2-year history of progressive muscle weakness and numbness of the lower extremities. Magnetic resonance imaging (MRI) showed a huge extradural arachnoid cyst at the T12–L3 level extending into bilateral neural foramina and severe posterior compression of the spinal cord and cauda equina.

Results

The patient underwent total resection of the cyst and closure of the communication. En bloc recapping T-saw laminoplasty of T12–L2 including the T12–L1 and L1–L2 facet joints was performed to obtain extensive exposure and preserve posterior stability. Postoperatively, the patient achieved complete recovery of neurologic functions. Follow-up MRI demonstrated no recurrence of the cyst. Bone union after laminoplasty was obtained within 6 months.

Conclusion

Total resection of the cyst and closure of the communication is curative for this rare lesion. Recapping T-saw laminoplasty provides extensive exposure for removal of a large cyst while allowing complete preservation of the posterior spinal elements.     

Pseudomeningocele presenting with cauda equina syndrome: is a 'ball-valve' theory the answer?

Pseudomeningocele is an uncommon complication of spinal surgery. The condition is most often asymptomatic and self-limiting. A proportion of patients may present with lower back pain, dural fistulas, radiculopathy or myelopathy. Cauda equina syndrome due to a pseudomeningocele has been reported due to herniation of the Cauda equina roots through the dural defect. We report a case of large pseudomeningocele causing an impending Cauda equina syndrome by acting as an extradural mass lesion.