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Table of Contents    
LETTERS TO EDITOR
Year : 2018  |  Volume : 66  |  Issue : 6  |  Page : 1837-1839

An unusual postoperative complication in a thoracic spinal extradural arachnoid cyst


1 Department of Neurosurgery, Zulekha Hospital, Sharjah, United Arab Emirates; Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India
2 Department of Neurosurgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, Karnataka, India

Date of Web Publication28-Nov-2018

Correspondence Address:
Dr. Ravi Dadlani
Department of Neurosurgery, Zulekha Hospital, Sharjah

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.246241

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How to cite this article:
Dadlani R, Rao AS. An unusual postoperative complication in a thoracic spinal extradural arachnoid cyst. Neurol India 2018;66:1837-9

How to cite this URL:
Dadlani R, Rao AS. An unusual postoperative complication in a thoracic spinal extradural arachnoid cyst. Neurol India [serial online] 2018 [cited 2018 Dec 14];66:1837-9. Available from: http://www.neurologyindia.com/text.asp?2018/66/6/1837/246241




Sir,

Spinal cysts have been classified by Nabor et al., into four different types.[1] Spinal extradural arachnoid cyst (SEAC) corresponds to the Type IA cyst (extradural cyst without nerve root involvement).[1],[2] Most SEACs occur in the second decade and are commonest in the thoracic region.[2] These are rare causes of spinal cord compression.[2] We report an unusual complication of surgery necessitating a re-exploration.

A 42-year old man presented with gradually progressive paraparesis (grade 3) since 2 years. He also had hypoesthesia below the D4 dermatome. Babinski sign was positive with absent abdominal and cremasteric reflex. Magnetic resonance imaging (MRI) of the thoracic spine revealed a dorsal, extradural cyst [Figure 1]. He underwent a D3–D5 laminectomy. The cyst wall was very thin and it ruptured during the laminectomy. The contents were a clear fluid. A deliberate and careful attempt was made to identify the intradural communication but none could be found. No active cerebrospinal fluid (CSF) leak was noted anywhere. The wound was closed over a drain. On postoperative day 1, his paraparesis was a grade better and he was able to stand unaided. By the third postoperative day, his motor power was grade 4+ and he was walking with a little support. On this day the drain was removed. Over the next 12 h (overnight), his motor power worsened to grade 2. An MRI of the spine revealed a collection of extradural fluid, which was similar in intensity to the CSF [Figure 2]. He underwent a re-explorative surgery, and active CSF leak from the dura anterolaterally on the left was identified. It was sealed with sutures over a muscle patch and tissue glue. He recovered completely and had no neurological deficits at 3 months follow-up, and the MRI study [Figure 3] revealed no compression.
Figure 1: (a) Sagittal and (b) axial MRI images of the spinal extradural arachnoid cyst extending from D3 to D5 with significant cord compression. Septations within the cyst are clearly defined in the axial images

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Figure 2: (a-c) Postoperative MRI of the thoracic spine outlining the operative changes and significant dorsal compression by the extradural collection of fluid

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Figure 3: (a and b) Follow-up MRI after 3 months of re-exploration demonstrates the absence of any pressure or mass effect on the spinal cord

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Type 1A cysts were initially thought to be associated with a pedicle extending intradurally.[2] Recent reports have demonstrated that a Type 1A cyst can occur without an intradural communication, and hence, may not necessitate a dural repair.[2] In the present case, what initially appeared to be a Type 1A cyst without communication was later found to have a communication. Cine MRI and Intraoperative Doppler ultrasound have both been demonstrated as invaluable tools to identify the intradural extension of a SEAC.[3],[4]

This case illustrates an unusual complication of SEAC surgery and leads credence to the communicating channel hypothesis. It reinforces the need for a vigilant exploration during surgery to identify, isolate, and seal the dural rent.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Kumar A, Sakia R, Singh K, Sharma V. Spinal arachnoid cyst. J Clin Neurosci 2011;18:1189-92.  Back to cited text no. 1
    
2.
Liu JK, Cole CD, Sherr GT, Kestle JR, Walker ML. Noncommunicating spinal extradural arachnoid cyst causing spinal cord compression in a child. J Neurosurg 2005;103(3 Suppl):266-9.  Back to cited text no. 2
    
3.
Hughes G, Ugokwe K, Benzel EC. A review of spinal arachnoid cysts. Cleve Clin J Med 2008;75:311-5.  Back to cited text no. 3
    
4.
Kanetaka M, Sugita S, Chikuda H, Takeshita K, Ono T, Oshima Y, et al. Use of Doppler ultrasonography to detect an elusive communication of a spinal extradural arachnoid cyst. J Clin Neurosci 2011;18:863-4.  Back to cited text no. 4
    


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