Skip to main content
SpringerLink
Log in

Spinal intradural extramedullary arachnoid cysts in adults—operative therapy and clinical outcome

  • Original Article - Spine - Other
  • Published:
Acta Neurochirurgica Aims and scope Submit manuscript

Abstract

Background

Spinal arachnoid cysts (SAC) are rare mostly idiopathic intradural lesions with compression of the spinal cord and clinical signs of radiculo- and/or myelopathy. We retrospectively analyzed radiological and clinical characteristics of patients with surgical treatment of SAC including a subgroup evaluation of long-term outcome and QoL.

Method

Patients with SAC treated between 1993 and 2017 were evaluated. Craniocaudal (c.c.) and anteroposterior (a.p) cyst diameters were measured pre- and post-OP. McCormick and Odom score for myelopathy, general outcome and QoL (SF-36, EORTC-QLQ30) were recorded.

Results

A total of 72 patients (female:male = 1.9:1) were analyzed with mean FU of 44.8 ± 60 months (long-term data from 25 patients with FU 78.2 ± 63.9 months). All had surgery due to solitary cysts: 10 cervical (13.9%), 45 thoracic (62.5%), and 17 lumbosacral (23.6%), the majority (79.2%) located dorsally. Main symptoms were gait disturbance (80%), dysesthesia (64%) and paresis (80%). Patients had (hemi-)laminectomy with cyst fenestration in 48 (66.7%) and complete resection in 18 cases (25.0%). Four cases (5.5%) were treated by cystoperitoneal shunt, 2 by marsupialization (2.8%). In total, 11 revisions were necessary in 9/72 (12.5%) patients (one patient underwent 3 revisions). Two patients were reoperated for wound revision/epidural hematoma (each n = 1). Seven patients needed additional cyst wall resection after 1.5–31.0 months due to insufficient cyst shrinking and persistent clinical symptoms after first surgery; most of the cysts were multiple septated and of post-hemorrhagic origin. The mean c.c. size decreased from 5.2 ± 3.7 cm pre-OP to 2.7 ± 3.9 cm (p < 0.05); the a.p. diameter decreased from 1.0 ± 0.5 cm to 0.3 ± 0.3 cm (p < 0.0001) without significant differences between fenestration and resection. McCormick and Odom scores revealed improved symptoms, particularly of gait disturbance, sensory deficits, and general performance. Long-term FU displayed satisfying QoL performance without differences of fenestration or resection.

Conclusion

SAC mostly affect women and are predominantly located in the thoracic spine, becoming apparent with clinical myelopathy. For cysts without intracystic septae and compartments, both fenestration and resection of the cyst wall provided significant reduction of cyst size and clinical improvement.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. Agnoli AL, Schonmayr R, Laun A (1982) Intraspinal arachnoid cysts. Acta Neurochir 61:291–302

    Article  CAS  Google Scholar 

  2. Bellut D, Burkhardt JK, Mannion AF, Porchet F (2015) Assessment of outcome in patients undergoing surgery for intradural spinal tumor using the multidimensional patient-rated Core Outcome Measures Index and the modified McCormick Scale. Neurosurg Focus 39:E2. https://doi.org/10.3171/2015.5.FOCUS15163

    Article  PubMed  Google Scholar 

  3. Bitaraf MA, Zeinalizadeh M, Meybodi AT, Meybodi KT, Habibi Z (2009) Multiple extradural spinal arachnoid cysts: a case report and review of the literature. Cases J 2

  4. Cloward RB (1968) Congenital spinal extradural cysts: case report with review of literature. Ann Sug 168(5):851–864

    Article  CAS  Google Scholar 

  5. Ebner FH, Roser F, Falk M, Hermann S, Honegger J, Tatagiba M (2010) Management of intramedullary spinal cord lesions: interdependence of the longitudinal extension of the lesion and the functional outcome. Eur Spine J 19:665–669. https://doi.org/10.1007/s00586-009-1232-1

    Article  PubMed  Google Scholar 

  6. Endo T, Takahashi T, Jokura H, Tominaga T (2010) Surgical treatment of spinal intradural arachnoid cysts using endoscopy. J Neurosurg Spine 12

    PubMed  Google Scholar 

  7. Ersahin Y, Ylldlzhan A, Seber N (1993) Spinal extradural arachnoidcyst. Childs Nerv Syst 9

    Article  CAS  Google Scholar 

  8. Evangelou P, Meixensberger J, Bernhard M, Hirsch W, Kiess W, Merkenschlager A, Nestler U, Preuss M (2012) Operative management of idiopathic spinal intradural arachnoid cysts in children: a systematic review. Childs Nerv Syst 29

    Article  Google Scholar 

  9. Fam MD, Woodroffe RW, Helland L, Noeller J, Dahdaleh NS, Menezes AH, Hitchon PW (2018) Spinal arachnoid cysts in adults: diagnosis and management. A single-center experience. J Neurosurg Spine 29:711–719. https://doi.org/10.3171/2018.5.SPINE1820

    Article  PubMed  Google Scholar 

  10. Fortuna A, La Torre E, Ciappetta P (1977) Arachnoid diverticula: a unitary approach to spinal cysts communicating with the subarachnoid space. Acta Neurochir 39

    Article  CAS  Google Scholar 

  11. Funao H, Nakamura M, Hosogane N, Watanabe K, Tsuji T, Ishii K, Kamata M, Toyama Y, Chiba K, Matsumoto M (2012) Surgical treatment of spinal extradural arachnoid cysts in the thoracolumbar spine. J Neurol Surg 71

    Article  Google Scholar 

  12. Gao Y, Zhang H, Yang J, Fu Q, Zheng J, Shuai M, Hu Z, Tan W, Cao W, Yang X, Jin A, Zhou R, Lu H (2015) Thoracolumbar arachnoid cyst with Horner syndrome: a case report and review of the literature. Cell Biochem Biophys 71

  13. Griessenauer CJ, Bauer DF, Moore TA 2nd, Pritchard PR, Hadley MN (2014) Surgical manifestations of thoracic arachnoid pathology: series of 28 cases. J Neurosurg Spine 20:30–40. https://doi.org/10.3171/2013.9.SPINE1323

    Article  PubMed  Google Scholar 

  14. Hamamcioglu MK, Kilincer C, Hicdonmez T, Simsek O, Birgili B, Cobanoglu S (2006) Giant cervicothoracic extradural arachnoid cyst: case report. Eur Spine J 15

  15. Hamburger C, Lanksch W, Oeckler R, Bachmann C (1994) The treatment of spondylotic cervical myelopathy by ventral discectomy. Long term results on 121 patients. Neurosurg Rev 17:247–252. https://doi.org/10.1007/bf00306811

    Article  CAS  PubMed  Google Scholar 

  16. Hingwala D, Chatterjee S, Kesavadas C, Thomas B, Kapilamoorthy TR (2011) Applications of 3D CISS sequence for problem solving in neuroimaging. Indian J Radiol Imaging 21:90–97. https://doi.org/10.4103/0971-3026.82283

    Article  PubMed  PubMed Central  Google Scholar 

  17. Hironori F, Kazuhiro S, Toshiro K, Koichi M, Kenji F, Tooru I (2015) Extensive multilocular spinal extradural meningeal cyst developed 16 years after traumatic brachial plexus injury: a case report. World Neurosurgery

  18. Kadono Y, Yuguchi T, Ohnishi Y, Iwatsuki K, Yoshimine T (2015) A symptomatic spinal extradural arachnoid cyst with lumbar disc herniation. Case Rep Orthop 2015

  19. Kazan S, Ozdemir O, Akyüz M, Tuncer R (1999) Spinal intradural arachnoid cysts located anterior to the cervical spinal cord. Report of two cases and review of the literature. J Neurosurg 91

  20. Kikuta K-I, Hojo M, Gomi M, Hashimoto N, Nozaki K (2006) Expansive duraplasty for the treatment of spinal extradural arachnoid cysts. J Neurosurg Spine 4

    PubMed  Google Scholar 

  21. Klekamp J (2017) A new classification for pathologies of spinal meninges-part 2: primary and secondary intradural arachnoid cysts. Neurosurgery 81:217–229. https://doi.org/10.1093/neuros/nyx050

    Article  PubMed  Google Scholar 

  22. Klekamp J (2017) A new classification for pathologies of spinal meninges, part 1: dural cysts, dissections, and ectasias. Neurosurgery 81:29–44. https://doi.org/10.1093/neuros/nyx049

    Article  PubMed  Google Scholar 

  23. Kong W, Cho K, Hong S (2013) Spinal extradural arachnoid cyst: a case report. Korean J Spine 10

    Article  Google Scholar 

  24. Kumar S, Desai A, Bhatia L, Garg A (2015) Multiple spinal arachnoid cysts in a child. Pediatr Neurol 1

  25. Kusin DJ, Ahn UM, Ahn NU (2015) The effect of smoking on spinal cord healing following surgical treatment of cervical myelopathy. Spine 40:1391–1396. https://doi.org/10.1097/brs.0000000000001014

    Article  PubMed  Google Scholar 

  26. Lee SH, Shim HK, Eun SS (2014) Twist technique for removal of spinal extradural arachnoid cyst: technical note. Eur Spine J 23

  27. Li AE, Wilkinson MD, McGrillen KM, Stoodley MA, Magnussen JS (2015) Clinical applications of cine balanced steady-state free precession MRI for the evaluation of the subarachnoid spaces. Clin Neuroradiol

  28. Liu Y, Ban D, Kan S, Cao T, Feng S (2017) The impact of diabetes mellitus on patients undergoing cervical spondylotic myelopathy: a meta-analysis. Eur Neurol 77:105–112. https://doi.org/10.1159/000453547

    Article  PubMed  Google Scholar 

  29. Mahoney FI, Barthel DW (1965) Functional evaluation: the Barthel Index: a simple index of independence useful in scoring improvement in the rehabilitation of the chronically ill. Maryland State Med J 14:61–65

    CAS  Google Scholar 

  30. Mao H-Q, Yang H-L, Geng D-C, Bao Z-H, Tang T-S (2011) Spinal extradural arachnoid cyst following percutaneous vertebroplasty. Eur Spine J 20

  31. Mohindra S, Gupta R, Bal A (2010) Intra-dural spinal arachnoid cysts: a short series of 10 patients. Br J Neurosurg 24:679–683. https://doi.org/10.3109/02688697.2010.504052

    Article  PubMed  Google Scholar 

  32. Nabors MW, Pait TG, Byrd EB, Karim NO, Davis DO, Kobrine AI, Rizolli HV (1988) Updated assessment and current classification of spinal meningeal cysts. J Neurosurg 68

  33. Nakashima H, Imagama S, Yagi H, Kato F, Kanemura T, Sato K, Kawakami N, Kamiya M, Yoshihara H, Ito K, Matsuyama Y, Nishida Y, Ishiguro N (2017) Clinical and radiographical differences between thoracic idiopathic spinal cord herniation and spinal arachnoid cyst. Spine 42:E963–E968. https://doi.org/10.1097/brs.0000000000002013

    Article  PubMed  Google Scholar 

  34. Nath PC, Mishra SS, Deo RC, Satapathy MC (2015) Intra-dural spinal arachnoid cyst; a long term post laminectomy complication: a case report and review of literatures. World Neurosurgery

  35. Nepomuceno E, Pacola LM, Dessotte CAM, Furuya RK, Defino HLA, Herrero CFPDS, RAS D (2016) Health-related quality of life and expectations of spinal stenosis patients towards the surgical treatment. Texto Contexto Enfermagem:25. https://doi.org/10.1590/0104-07072016001080015

  36. Odom GL, Finney W, Woodhall B (1958) Cervical disk lesions. J Am Med Assoc 166:23–28. https://doi.org/10.1001/jama.1958.02990010025006

    Article  CAS  PubMed  Google Scholar 

  37. Osenbach RK, Godersky JC, Traynelis VC, Schelper RD (1992) Intradural extramedullary cysts of the spinal canal: clinical presentation, radiographic diagnosis, and surgical management. Neurosurgery 30:35–42

    Article  CAS  Google Scholar 

  38. Ospina Moreno C, Vela Marin AC, Castan Senar A, Montejo Ganan I, Cozar Bartos M, Marin Cardenas MA (2016) Radiological diagnosis of spinal arachnoid cysts: a pictorial essay. J Med Imaging Radiat Oncol 60:632–638. https://doi.org/10.1111/1754-9485.12470

    Article  PubMed  Google Scholar 

  39. Papavlasopoulos F, Stranjalis G, Kouyialis AT, Korfias S, Sakas D (2007) Arachnoiditis ossificans with progressive syringomyelia and spinal arachnoid cyst. J Clin Neurosci 14:572–576. https://doi.org/10.1016/j.jocn.2006.02.024

    Article  CAS  PubMed  Google Scholar 

  40. Parmar H, Park P, Brahma B, Gandhi D (2008) Imaging of idiopathic spinal cord herniation. Radiographics 28:511–518. https://doi.org/10.1148/rg.282075030

    Article  PubMed  Google Scholar 

  41. Perret G, Green D, Keller J (1962) Diagnosis and treatment of intradural arachnoid cysts of the thoracic spine. Radiology 79:425–429. https://doi.org/10.1148/79.3.425

    Article  CAS  PubMed  Google Scholar 

  42. Peruzzotti-Jametti L, Ferrari S, Politi LS, Snider S, Mammi S, Comi G, Comola M (2010) Giant anterior arachnoid cyst associated with syringomyelia: implications for treatment and follow-up. Spine (Phila Pa 1976) 35:E322–E324. https://doi.org/10.1097/BRS.0b013e3181c8a40a

    Article  Google Scholar 

  43. Petridis AK, Doukas A, Barth H, Mehdorn HM (2010) Spinal cord compression caused by idiopathic intradural arachnoid cysts of the spine: review of the literature and illustrated case. Eur Spine J 19(Suppl 2):S124–S129. https://doi.org/10.1007/s00586-009-1156-9

    Article  PubMed  Google Scholar 

  44. Qi J, Yang J, Wang G (2014) A novel five-category multimodal T1-weighted and T2-weighted magnetic resonance imaging-based stratification system for the selection of spinal arachnoid cyst treatment: a 15-year experience of 81 cases. Neuropsychiatr Dis Treat 10:499–506. https://doi.org/10.2147/NDT.S52517

    Article  PubMed  PubMed Central  Google Scholar 

  45. Qi W, Zhao L, Fang J, Chang X, Xu Y (2015) Clinical characteristics and treatment strategies for idiopathic spinal extradural arachnoid cysts: a single-center experience. Acta Neurochir 157

    Article  Google Scholar 

  46. Rexed BA, Wennstrom KG (1957) Arachnoidal proliferation and cystic formation in the spinal nerve-root pouches of man

  47. Skoog A (1915) Spinal cord compression from leptomeningeal cysts. With a report of two cases. JAMA 65

  48. Spiegelmann R, Rappaport ZH, Sahar A (1984) Spinal arachnoid cyst with unusual presentation. J Neurosurg 60

    Article  CAS  Google Scholar 

  49. Spiller WG (1903) A case of intradural arachnoid cyst with operation and recovery. Trans Coll Physicians Philadelphia 25:1–18

    Google Scholar 

  50. Srinivasan VM, Fridley JS, Thomas JG, Omeis I (2016) Nuances in localization and surgical treatment of syringomyelia associated with fenestrated and webbed Intradural spinal arachnoid cyst: a retrospective analysis. World Neurosurg 87:176–186. https://doi.org/10.1016/j.wneu.2015.11.004

    Article  PubMed  Google Scholar 

  51. Stern Y, Spiegelmann R, Sadeh M (1991) Spinal intradural arachnoid cysts. Neurochirurgia (Stuttg) 34

  52. Sun C, Meng X, Xie S, Yu Y, Yang H, Wu B (2011) Unilateral hemilaminectomy for patients with intradural extramedullary tumors. Biomed Biotechnol 12

  53. T KM (1996) The interpretation of scores from the EORTC quality of life questionnaire QLQ-C30. Qual Life Res 5

  54. Tarlov IM (1970) Spinal perineurial and meningeal cysts. J Neurol Neurosurg Psychiatry 33

  55. Tauro A, Jovanovik J, Driver CJ, Rusbridge C (2018) Clinical application of 3D-CISS MRI sequences for diagnosis and surgical planning of spinal arachnoid diverticula and adhesions in dogs. Vet Comp Orthop Traumatol 31:83–94. https://doi.org/10.3415/VCOT-16-12-0169

    Article  PubMed  Google Scholar 

  56. Tucer B, Yılmaz MB, Ekıcı MA, Menku A, Koc K (2014) Spinal arachnoid cysts associated with syringomyelia: a review of the literature and report of a case. Turk Neurosurg 24

  57. Viswanathan VK, Manoharan SR, Do H, Minnema A, Shaddy SM, Elder JB, Farhadi HF (2017) Clinical and radiologic outcomes after fenestration and partial wall excision of idiopathic intradural spinal arachnoid cysts presenting with myelopathy. World Neurosurg 105:213–222. https://doi.org/10.1016/j.wneu.2017.05.136

    Article  PubMed  Google Scholar 

  58. Zhang D, Papavassiliou E (2017) Spinal Intradural arachnoid webs causing spinal cord compression with inconclusive preoperative imaging: a report of 3 cases and a review of the literature. World Neurosurg 99:251–258. https://doi.org/10.1016/j.wneu.2016.12.015

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Neurosurgery, University Hospital LMU, 81377, Munich, Germany

    Michael Schmutzer, Joerg-Christian Tonn & Stefan Zausinger

Authors
  1. Michael Schmutzer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Joerg-Christian Tonn
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Stefan Zausinger
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Michael Schmutzer.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.

Additional information

Comments

Schmutzer et al. present a large series of spinal intradural extramedullary arachnoid cysts. A few aspects are interesting and should be pointed out. First, CISS-3D MRI sequences are valuable in defining a cyst as monocompartimental and, if so, fenestration seems to be as good as cyst wall resection. Second, among the various myelopathic symptoms, only gait ataxia appears to benefit substantially from the surgical treatment. For other symptoms surgery is less beneficial and patients should also be informed on the possibility of relapse over time. Third, post-hemorrhagic cysts are rare but more prone to require revision surgery.

Francesco Sala

Verona, Italy

The authors report on 72 patients who had spinal intradural extramedullary arachnoid cysts. These cysts were treated with either fenestration or resection of the cyst. In a few cases, a cystoperitoneal shunt was utilized, and two patients had marsupialization. Good follow-up was provided with good neurological recovery. A good review of the literature is also provided. The authors found that comparing the two surgical techniques, the results were similar. It is still unclear to this reviewer when fenestration should be done vs. complete resection of the cyst wall. I congratulate the authors on an excellent follow-up when reporting on this relatively rare entity.

Volker K. H. Sonntag

Phoenix, Arizona

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Spine - Other

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Schmutzer, M., Tonn, JC. & Zausinger, S. Spinal intradural extramedullary arachnoid cysts in adults—operative therapy and clinical outcome. Acta Neurochir 162, 691–702 (2020). https://doi.org/10.1007/s00701-019-04156-0

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00701-019-04156-0

Keywords

Search

Navigation