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Management of Painful Paraparesis Due to Non-Neoplastic Spinal Cysts

A rare but treatable cause of spinal pain and neuro-deficit

Philip R. Weinstein MDCynthia T. Chin MDBruno Soares MD

UCSF Spinal Disorders Symposium-2013

Department of Neurosurgery, Division of NeuroradiologyUCSF

Outline• Definition and classification• Clinical presentation• Diagnosis and imaging• Recent literature• Management (UCSF Recent Experience)

– Medical treatment– Indications for surgery– Surgical techniques– Results of surgery– Risks and limitations– Future directions

Fluid filled intra-spinal mass lesions causing cord and root compression

• Infectious• Traumatic• Hemorrhagic• Congenital/developmental• Postoperative

– Arachnoiditis/subdural fibrosis• Post-myelography• Connective tissue disorders• Arachnoid cyst---idiopathic

Clinical Presentation• Spinal pain• Radicular pain• Neuropathic pain• Myelopathy/spastic paraparesis• Radiculopathy• Positional• Valsalva aggravated• Progressive pain and deficit• Unresponsive to steroids unless inflammatory

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Diagnosis• MRI (total spine)

– Contrast– CSF flow study– Diffusion– Neurogam (STIR)– FIESTA

• CT myelogram• Dynamic “cine” CT myelogram• CT guided aspiration or injection therapy• CT or MRI brain

Medical Pain Management• NSAID’s• Oral steroids• Analgesics• Anti-spasmodics• Membrane stabilizers• Surgical spinal pain implants

– DCS– ITDD

Intradural Spinal Arachnoid cystsN=24 USC

• Age 56 Av. M =13; F=8• Thoracic 81% Dorsal=15 Ventral=6• Laminectomy for cyst fenestration/partial resection/ ultrasound

guidance• Cysto-SAS shunt 4; Duraplasty 7• Syringo-SAS shunt 4/7; • Postop MRI all cysts resolved and syrinx decreased (7) or resolved

(4)• Improved: weakness 100%; hyper-reflexia 91%; incontinence 80%;

neuropathic pain 44%; numbness 33%; numbness increased 1 pt.

Wang MY, Levi AC, Green BA Surg Neurol 2003 60(1);49-55

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Additional recent referencesIdiopathic cystic spinal arachnoiditis

Vaughan D, et al Br J. Neurosurg, 2012 26 (4): 555-7Giant ant. arachnoid cyst with syrinx

Peruzotti-Jametti L, et al Spine 2010; 35 (8) 322-4Partial median corpectomy for C2-3 ant. arach. cystSrinivasan US, et al Neurol India 2009 57 (6): 803-5

Spinal intradural juxtamedullary cystsBassiouni H, et al Neurosurg 2004; 55 (6) 1352-9

Surgical treatment of spinal extradural arachnoid cystsFunao H, et al Neurosurg 2012; 71(2): 278-84

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Recent UCSF Cases• Arachnoid cyst• Meningeal cyst• Inflammatory/post-

infectious cyst• Postoperative cyst• Post traumatic syrinx• Discogenic cyst

• Synovial cyst• Tarlov’s cyst• Ventral cord hernia-

dorsal “cyst”• Cystic Schwanoma• Dermal sinus/tether• Pseudo-meningocoel• Epidermoid tumor• Cystic Arachnoiditis

Arachnoid CystMRI

Arachnoid Cyst myelogram

Meningeal Cyst

T2

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T2

NEUROCYSTICERCOSIS

ARACHNOIDITISNEUROCYSTICERCOSIS

ARACHNOIDITIS

Gad

Post-operativeNerve root herniation

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Post traumatic syrinx

T1 T2

Post traumatic syrinx

T2

Discal Cyst

Dean Chou J Neurosurg Spine 2007 Jan 6(1):81Post-gad T1

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Five months later

Discal cyst

T2

Gad

GRESYNOVIALCYST

T2 Gad Sag STIR

Axial T2

Tarlov Cyst

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Myelogram

Tarlov cystVentral Dural Defect cord herniation

Ventral Dural Defect cord herniation

myelogram

Dermal cyst

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Cystic conus schwannoma

T2

Cystic conus schwannoma

Gad

Steady State Free Precession MRI (SSFP) FIESTA

Low flip angle gradient echo; short repetition

High spatial resolutionIncreased water-tissue resolutionEnhances imaging detail of spinal meninges, nerve roots, cord and relationships to cystic structures

May obviate need for CTM(CSF flow study for communication)

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History• 55 yo male engineer• Back and bilat. posterolateral leg pain to knees• Numbness soles of both feet ascending• Progressively incapacitating for any activity• Sitting aggravates back pain• Walking or Valsalva increases leg pain• DVT after bedrest in Jan.• NSAID’s, Analgesics, PT: no relief

History• L L5-S1 discectomy for L sciatica 1988• Preop/postop myelogram: spinal headache 2wks• Pain free until 2 yrs. ago• Severe progressive LBP: spontaneous onset• ESI 2 yrs. ago triggered onset progressive leg

pain/numb feet ever since• Medrol dose pak completely relieved leg

symptoms for one week 2 mos. ago

LS MRI –S1: T2/STIR MRI T1 + C: Cystic arachnoiditis

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Summary• Non-neoplastic intradural cysts can cause spinal

pain, myelopathy, and/or radiculopathy• Diagnosis is verified with Contrast MRI, CSF flow

MRI, Diffusion MRI and CT MYELOGRAM• Microsurgical fenestration with ultrasound

guidance and duraplasty or shunting obliterates cysts, relieves deficits and reduces pain

• Future studies needed to evaluate FIESTA imaging and percutaneous CT or MRI guided aspiration for non-communicating cysts