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|LETTER TO EDITOR
|Year : 2012 | Volume
| Issue : 5 | Page : 540-542
Giant thoracolumbar extradural arachnoid cyst: An uncommon cause of spine compression
Souvagya Panigrahi, Sudhansu S Mishra, Manmath K Dhir, Deepak K Parida
Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha, India
|Date of Web Publication||3-Nov-2012|
Department of Neurosurgery, S.C.B. Medical College and Hospital, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Panigrahi S, Mishra SS, Dhir MK, Parida DK. Giant thoracolumbar extradural arachnoid cyst: An uncommon cause of spine compression. Neurol India 2012;60:540-2
Spinal archnoid cysts (AC) are relatively rare spinal lesions and symptomatic extradural ACs are even less common.  They represent expanding diverticula of the subarachnoid space herniating through a dural defect into the extradural space. The pathogenesis of this entity is still unclear. Cystic lesion, often small are mostly reported in the dorsal spine,  rarely they can be giant.  The largest reported cystic lesion in spine is extradural AC in cervicodorsal region in a child.  We describe a patient with spinal cord compression caused by a giant spinal extradural AC.
A 15-year-old boy presented with 6-month history of progressive ascending bilateral numbness, weakness in the lower limbs and urinary incontinence. Neurological examination revealed spastic paraparesis with sensory disturbance below L1 level. Deep tendon reflexes were brisk with ankle clonus and bilateral extensor plantar response. Plain radiographs of the thoracolumbar spine showed increased interpedicular distance with widening of spinal canal [Figure 1]. Magnetic resonance imaging (MRI) of the thoracolumbar spine revealed a sharply defined extradural long segment T1 hypointense, T2 isointense lesion of 138 Χ 31 Χ 18 mm in size compressing the spinal cord posteriorly from T8 to L1 with bilateral bulge into the neural foramina [Figure 2] and [Figure 3]. At surgery, posterior decompression of a colourless fluid-filled thin walled extradural cyst was done through T10 - T11 laminotomy with careful excision of the dorsal wall. The remaining cyst wall was marsupialized that was followed by obliteration of the communicating pedicle and watertight repair of the dural defect. Histological examination confirmed the diagnosis of AC [Figure 4]. At 6 month follow- up, he has complete neurological recovery with good urinary control.
|Figure 1: Anteroposterior and lateral radiograph of the dorsolumbar spine showing increased interpedicular distance, widening of spinal canal and neural foramina|
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|Figure 2: Sagittal T1-weighted hypointense (a) and T2-weighted isointense (b) magnetic resonance images showing a sharply-defined tumour extending from T8-L1 compressing the distal spinal cord|
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|Figure 3: Axial T1-weighted image showing a hypointense lesion compressing the thecal sac and extending into the bilateral neural foramina|
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|Figure 4: Photomicrograph of the cyst wall demonstrating a thin arachnoid layer lined by discrete nests of meningothelial cells|
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Spinal extradural ACs are rare cause of spinal cord compression with reported incidence of 12% in thoracolumbar region. , They are thought to arise from congenital defects in the dura mater, and they almost always communicate with the intrathecal subarachnoid space through a small defect in the dura. , They could occur either dorsal or ventral to the cord, with the former being more common.  A few have been reported to extend into or through the neural foramen.  The clinical picture varying from paresis, sensory disturbances, autonomic dysfunction and gait impairment and depends on the level of cord compression.  Most frequently, patients complain of spinal pain, radicular and/or myelopathic symptoms. MRI is currently considered the diagnostic procedure of choice for detecting the intraspinal extradural ACs.  It is useful to assess the size, nature, and extent of the cystic lesion as well as the mass effect on the cord and associated signs of meningeal inflammation.
There is general agreement that the successful treatment of a spinal AC requires complete excision from the posterior aspect of the thecal sac, followed by obliteration of the communicating pedicle and watertight dural repair to eradicate the ball-valve mechanism.  In our patient, due to the presence of long segment AC, we preferred to do single level laminar fenestration and marsupialization of the cyst by resecting the dorsal wall of the cyst followed by closure of the dural defect.
Although quite rare, the diagnosis of AC should be included in the differential diagnosis of intraspinal extradural cystic lesions, causing spinal cord compression. For long segment involvements, hemilaminectomy or laminotomy with dural repair is preferable to laminectomy in order to prevent postoperative deformity.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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