SciELO - Scientific Electronic Library Online

 
vol.67 issue1Widening of intervertebral foramen by tortuous vertebral arteryOccipital condyle fracture in a patient with head trauma author indexsubject indexarticles search
Home Pagealphabetic serial listing  

Services on Demand

Article

Indicators

Related links

  • Have no similar articlesSimilars in SciELO

Share


Arquivos de Neuro-Psiquiatria

Print version ISSN 0004-282X

Arq. Neuro-Psiquiatr. vol.67 no.1 São Paulo Mar. 2009

http://dx.doi.org/10.1590/S0004-282X2009000100029 

CLINICAL/SCIENTIFIC NOTES

 

Giant cervico-thoracic extradural arachnoid cyst

 

Cisto gigante cérvico-torácico extradural da aracnóide

 

 

Andrei Fernandes JoaquimI; Elton Gomes da SilvaI; Marcos Juliano dos SantosI; Donizeti César HonoratoII

IMédico Residente, Disciplina de Neurocirurgia da Universidade Estadual de Campinas, Campinas SP, Brasil (UNICAMP)
IIProfessor Doutor, Disciplina de Neurocirurgia da Universidade Estadual de Campinas, Campinas SP, Brasil (UNICAMP)

 

 

Spinal extradural cysts, like synovial, Tarlov's, arachnoid and dermoid1, are unusual causes of epidural compressive syndromes. We discuss the clinical treatment and evolution of a rare giant cervico-thoracic extradural arachnoid cyst, that has rarely been reported in the literature2-4. Arachnoid extradural cysts are usually located in the inferior thoracic region, with a wide range of clinical presentation, varying from totally asymptomatic to a severe myelopathy. Surgical resection is usually indicated for symptomatic patients4-7.

 

CASE

A 46-year-old man was referred to our institution with a two months history of progressively reduction of muscular strength and numbness in the superior limbs, followed by leg weakness, impairing his walking abilities. He denied sphincter or sexual dysfunction. He mentioned a cervical spine trauma history 10 years before, that did not require any specific treatment. On examination, a spastic tetraparesis was noted. Muscle strength: superior limbs: 3/5; inferior limbs: 3/5. Hoffman and Babinski's signs were also detected. Bilateral forearm and hands atrophy were present, being more severe on the left side. Radiological investigation with magnetic resonance (MR) (Fig 1) showed a cervical spinal cord compression, being visualized a posterior giant epidural cyst.

 

 

An extensive laminectomy from C2 to T1 was performed (Fig 2). Then, a large extradural cervico-thoracic cyst was visualized. After microsurgical dissection, total resection was achieved without cyst rupture, closing the dural defect at C6 with unabsorbable suture, at the exit of the nerve root, on the left side. Then, an in situ arthrodesis was performed with the graft obtained from the laminectomy. At the post-operative period, a cervico-thoracic orthosis (Minerva brace) was prescribed for the next six months.

 

 

Six months after surgery, a neurological improvement was achieved. Muscular strength was returned to 5/5 in the superior limbs, with just mild dexterity impairment, and 4/5 strength in the inferior limbs were noted, returning to ambulation without assistance. Cervical X-rays showed normal cervical alignment without kyphosis (Fig 3).

 

 

DISCUSSION

The pathogenesis and etiology of the arachnoid cysts are not well established in the literature. Some authors reported a causal relation with a dural defect, primary or secondary to previous inflammation, surgery or spinal trauma3,4,8-10. The history of cervical trauma of our patient may have influenced cyst formation.

In our literature review, we found 41 cases of extradural arachnoid cysts. Most of them were located at the inferior thoracic region3,6,8,10-14, with just four cases in the cervico-thoracic level.

MR is the standard exam to diagnosis these lesions. Cyst contents have a hypointense sign on T1 and a hyperintense on T2-weighted sequence, similar to the cerebrospinal fluid sign. Absence of a mural nodule with contrast enhancement is another important radiological characteristic. Some authors suggest a myelo computerized tomography to visualize the communication between the cyst and the subarachnoid space4,9,10,15. A detailed MR evaluation is the most important step before surgery.

Surgical treatment is always indicated when there is spinal cord compression or when the lesion is located in the anterior portion of the cord, due to ischemic risk of the compression in this region. Total resection with dural defect closure is the main goal to avoid late relapse3,4,5,7,16. Extensive cervical laminectomies can be followed by fusion and instrumentation to avoid progressive deformities, like post-operative kyphosis2,6,17. We usually perform laminectomy or non expandable laminotomy for intra or extradural lesions and closing radiological follow-up to detect patients with signs of progressive spine deformity.

Good clinical results can be achieved with surgical treatment even in giant cysts with severe myelopathy.

 

REFERENCES

1. Wilkins RH. Intraspinal cysts. In: Wilkins RH, Rengachary SS (eds.) Neurosurgery. New York: McGraw-Hill 1996:3509-3519.         [ Links ]

2. Freidberg SR, Fellows T, Thomas CB, Mancall AC. Experience with symptomatic spinal epidural cysts. Neurosurgery 1994;34:989-993.         [ Links ]

3. Krings T, Lukas R, Reul J, et al. Diagnostic and therapeutic management of spinal arachnoid cysts. Acta Neurochir (Wien) 2001;143:227-235.         [ Links ]

4. Liu JK, Cole CD, Kan P, Schmidt MH. Spinal extradural arachnoid cysts: clinical, radiological, and surgical features. Neurosurg Focus 2007;22:1-5.         [ Links ]

5. Kikuta KI, Hojo M, Gomi M, Hashimoto N, Nozaki K. Expansive duraplasty for the treatment of spinal extradural arachnoid cysts: case report. J Neurosurg Spine 2006;4:251-255.         [ Links ]

6. Hamamcioglu MK, Kilincer C, Hicdonmez T, Simsek O, Birgili B, Cobanoglu S. Giant cervicothoracic extradural arachnoid cyst: case report. Eur Spine J 2006;15:595-598.         [ Links ]

7. Suryanigtyas W, Arifin M. Multiple spinal extradural arachnoid cysts occurring in a child: case report. J Neurosurg 2007;106:158-161.         [ Links ]

8. Rabb CH, McComb JG, Raffel C, Kennedy JG. Spinal arachnoid cysts in the pediatric age group: an association with neural tube defects. J Neurosurg 1992;77:369-372.         [ Links ]

9. Chang IC, Chou MC, Bell WR, Lin ZI. Spinal cord compression caused by extradural arachnoid cysts: clinical examples and review. Pediatr Neurosurg 2004;40:70-74.         [ Links ]

10. Miyamoto M, Kim K, Matsumoto R, Isobe M, Isu T. Utility of preoperative magnetic resonance imaging mielography for identifying dural defects in patients with spinal extradural arachnoid cysts: case report. Neurosurgery 2006;59:941.         [ Links ]

11. Hatashita S, Kondo A, Shimizu T, Korosu A, Ueno H. Spinal extradural arachnoid cyst: case report. Neurol Med Chir 2001;41:318-321.         [ Links ]

12. Safriel YI, Sanchez G, Jhaveri HS. Giant anterior cervicothoracic arachnoid cyst. Spine 2002;27:366-368.         [ Links ]

13. Miravet E, Sinisterra S, Birchansky S, et al. Cervicothoracic extradural arachnoid cyst: possible association with obstetric brachial plexus palsy. J Child Neurol 2002;17:770-772.         [ Links ]

14. Choi JY, Kim SH, Lee WS, Sung KH. Spinal extradural arachnoid cyst. Acta Neurochir (Wien) 2006;148:579-585.         [ Links ]

15. Prevo RL, Hageman G, Bruyn RP, Broere G, van de Stadt J. Extended extradural spinal arachnoid cyst: an unusual cause of progressive spastic paraparesis. Clin Neurol Neurosurg 1999;101:260-263.         [ Links ]

16. Campos WK, Linhares MN, Brodbeck IM, Ruhland I. Anterior cervical arachnoid cyst with spinal cord compression. Arq Neuropsiquiatr 2008;66:272-273.         [ Links ]

17. Raimondi AJ, Gutierrez FA, Di Rocco C. Laminotomy and total reconstruction of the posterior spinal arch for spinal canal surgery in childhood. J Neurosurg 1976;45:555-560.         [ Links ]

 

 

Received 11 August 2008, received in final form 6 November 2008. Accepted 15 December 2008.

 

 

Dr. Andrei Fernandes Joaquim – Rua Pedro Vieira da Silva 144 / F 11 - 13080-570 Campinas SP - Brasil. E-mail: andjoaquim@yahoo.com