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Acquired cauda equina epidermoid cyst.
Epidermoid cysts are uncommon (0.5-1% of all spinal tumours). Intraspinal epidermoid cysts can be congenital or acquired. Acquired tumours account for approximately 40% of intraspinal epidermoids and are considered a late complication of lumbar puncture (LP).[1] Epidermal elements are implanted into the spinal canal and slowly grow, resulting in an extramedullary intradural mass that usually adheres to the nerve roots and pia-arachnoid. A 24 year old male patient developed low back pain, with radiation to posterior aspect of both lower limbs. There were no sphincter disturbances or weakness of limbs. 5 years earlier he had suffered from numbness of his right leg, for which a myelography was performed at another hospital, which was reported to be normal. Motor system examination revealed weakness of left extensor hallucis longus. He had 50% decrease in pain and touch sensations in the distribution of right L4, L5 and S1 and left L4, L5 dermatomes. Deep tendon reflexes were normal with plantars flexor. Straight leg raising test was 40O on the right and 20O on the left. He had bilateral paraspinal muscle spasms. Magnetic resonance imaging (MRI) of lumbosacral spine revealed a well defined intradural lesion at L2-L3 level which was isointese on TI and hyperintense on T2W images. Contrast MRI scan revealed faint peripheral enhancement of the lesion [Figure 1]. A L2-L3 laminectomy and total excision of cauda equina cystic lesion was done. Histopathology examination confirmed the diagnosis of epidermoid cyst. Post operative period was uneventful. His neurological deficit gradually improved. Intraspinal epidermoid sequestration cysts are rare.[2] In this location, they are usually associated with congenital abnormalities indicating a dysraphic disorder.[3] Absence of congenital defects of the spinal column in our patient and the history of LP for myelogram support the hypothesis of iatrogenic implantation. Choremis et a1[4] encountered 6 cases of epidermoid implantation cysts in children aged 7-12 years, who had multiple spinal punctures without stilets for treatment of tuberculous meningitis. In 1962, Manno[5] reviewed the literature on intraspinal epidermoid and reported an additional case of an adult who had spinal anaesthesia 23 years before the discovery of an intradural inclusion cyst at L4. Pear[6] reported 3 cases of iatrogenic epidermoid cyst of the spinal canal following lumbar puncture or discography, one of these cases has been previously reported by Boyd.[7] Visciani et a1[8] reported a case following subarachnoid injection of methotrexate. As would be expected, however, the iatrogenic sequestration cysts have almost uniformly occured in the region of the cauda equina, excepting only one case reported at TI0 level.[1] Usuallly, these are intradural lesions with rare extradural occurence. Discovery of the cysts has been from 2" to 23 years following the apparent time of implantation.6 In our case it was 5 years following myelography.
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