Extradural arachnoid cyst with bony erosion: a rare case report

Case Reports


doi: 10.21037/jss-20-590.

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Case Reports

John J Bowman et al.


J Spine Surg.


2020 Dec.

Abstract

The authors present the case of an otherwise healthy 38-year-old female with an atypical extradural arachnoid cyst with multi-level involvement in the lumbar spine leading to left quadriceps weakness and dysesthesia. Upon presentation, a lumbar spine MRI with contrast and plain radiographs revealed extensive L4 bony erosion. An MR angiogram and cervical spine MRI with contrast were then obtained in order to rule out any aortic root or cervical spine pathology. With no other apparent clinically relevant pathology revealed by these additional tests, an L3-5 posterior decompression and fusion procedure was performed. Her preoperative symptoms were successfully resolved following the procedure, with no resultant surgical complications. The cyst is atypical not only due to its size and location, but also due of the significant bony erosion of the left L4 pedicle and vertebral body. To the authors’ knowledge, this is the first reported case of an extradural arachnoid cyst in the lumbar spine with bony erosion of the pedicle and vertebral body. In cases such as this, a CT myelogram may be useful in planning the operative approach through visualization of the exact communication between cyst and dura. This approach may also aid in diagnosing and identifying atypical cyst presentations such as the one presented here.


Keywords:

Arachnoid; case report; cyst; lumbar vertebrae.

Conflict of interest statement

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jss-20-590). The authors have no conflicts of interest to declare.

Figures


Figure 1


Figure 1

Preoperative sagittal midline (A) and axial L4 (B) MRI images reveal large cystic lesion with thecal sac compression and near complete erosion of the left L4 pedicle. Preoperative lateral (C) and anteroposterior (D) radiograph reveal healthy appearing spinal anatomy excepting the atrophic left L4 pedicle. Preoperative sagittal midline cervical MRI (E) shows the cerebellar tonsils to extent ~1 cm below the foramen magnum. Preoperative MR angiogram (F) reveals healthy appearing aortic root.


Figure 2


Figure 2

The patient’s complete course of treatment, including dates of additional testing and clinic visits. Initial symptoms: 5 years of left leg weakness (grade 4/5 quadriceps) with accompanying dysesthesias markedly worsening over the immediately preceding 6 months. Initial consult: lumbar MRI and plain radiographs reviewed with patient upon presentation to clinic revealing an intraspinal fluid collection and L4 pedicle and vertebral body erosion. Additional imaging: MR angiogram and cervical MRI performed revealing no clinically significant abnormalities. Operation: 3-hour and 1-minute L3-5 posterior decompression and fusion procedure performed with no surgical complications. Postoperative visit: patient demonstrated complete resolution of symptoms at the 2-month postoperative visit with no further follow-up needed. No adverse events were noted during this period.


Figure 3


Figure 3

(A) Exposed cyst (A1) and healthy dura (A2). (B) Distal cyst tie-off. (C) Cyst removal: adhesions between cyst and healthy dura. (D) Deflated cyst (D1) and healthy dura (D2). (E) Dural defect with nerve root protrusion. (F) Dural defect repair.


Figure 4


Figure 4

Standing anteroposterior (A) and lateral (B) radiographs.

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