Spinal Meningeal Cysts Research Articles

Feasibility and safety of one-stage sacral laminoplasty with autologous sacral laminar reimplantation fixed by absorbable fixation clamps in direct microsurgical treatment of symptomatic sacral extradural spinal meningeal cysts

Feasibility and safety of one-stage sacral laminoplasty with autologous sacral laminar reimplantation fixed by absorbable fixation clamps in direct microsurgical treatment of symptomatic sacral extradural spinal meningeal cysts

Sacral terminal filar cyst: a distinct variant of spinal meningeal cyst and midterm clinical outcome following combination resection surgery.

Spinal meningeal cysts (SMCs) are currently classified into three types: extradural cysts without nerve root fibers (Type I), extradural cysts with nerve root fibers (Type II), and intradural cysts (Type III). However, the sacral terminal filar cyst is a distinct subtype with the filum terminale rather than nerve roots within the cyst. This study aimed to investigate the clinicoradiological characteristics and surgical outcomes of sacral terminal filar cysts. A total of 32 patients with sacral terminal filar cysts were enrolled. Clinical and radiological profiles were collected. All patients were surgically treated, and preoperative and follow-up neurological functions were evaluated. Chronic lumbosacral pain and sphincter dysfunctions were the most common symptoms. On MRI, the filum terminale could be identified within the cyst in all cases, and low-lying conus medullaris was found in 23 (71.9%) cases. The filum terminale was dissociated and cut off in all cases, and the cyst wall was completely resected in 23 (71.9%) cases. After a median follow-up period of 26.5 ± 15.5 months, the pain and sphincter dysfunctions were significantly improved (both P < 0.0001). The cyst recurrence was noted in only 1 (3.1%) case. Sacral terminal filar cysts are rare, representing a distinct variant of SMCs. Typical MRI features, including filum terminale within the cyst and low-lying conus medullaris, may suggest the diagnosis. Although the optimal surgical strategy remains unclear, we recommend a combination of resection of the cyst wall and dissociation of the filum terminale. The clinical outcomes can be favorable.

An interdural spinal cyst in the cervicothoracic spine: a review and proposal for a revised classification of spinal meningeal cysts. Illustrative case.

Spinal cysts in the interdural space are extremely rare and are not included in the standard classification of spinal meningeal cysts. A 60-year-old female presented to our hospital with a spastic gait and numbness in both palms. Magnetic resonance imaging (MRI) revealed a spinal cyst from C4 to T4 compressing the spinal cord. Computed tomography myelography revealed a fistula at C4-5 and C5-6 that connected the cyst along the right C5 and C6 root sleeves. The cyst was located within the dura mater, and communication with the arachnoid space was achieved using a shunt tube. There was partial spastic gait amelioration after the procedure, but the patient experienced a relapse 2 months postoperation. A repeat procedure was performed without a shunt tube to allow greater communication between the cyst and the subarachnoid space. After this, marked improvement in gait function was observed, and MRI showed a significant reduction in cyst volume. Interdural spinal meningeal cysts are rare. When the interdural cyst cannot be removed entirely, surgery may be appropriate for providing a shunt tube or establishing communication between the cyst and arachnoid space to maintain the circulation of cerebrospinal fluid collected in the cyst cavity.

Diagnostic Accuracy of Magnetic Resonance Imaging With 3-Dimensional T2-SPACE Techniques for Preganglionic Injury of the Brachial Plexus

An accurate diagnosis of the site and severity of a brachial plexus injury is imperative for selecting the appropriate management. Conventional magnetic resonance imaging (MRI) does not allow for the precise interpretation of preganglionic injuries (pre-GIs), especially intravertebral canal injuries. We developed 4 MRI sequences of conventional 1.5-tesla 3-dimensional T2-weighted turbo spin echo sampling perfection with the application of optimized contrasts using different flip angles evolution (T2-SPACE) images to clearly visualize each component of the brachial plexus. The purpose of this study was to introduce basic normal and pathologic findings of our current MRI approach, focusing on its diagnostic accuracy for pre-GIs. We initially examined 119 patients with brachial plexus injuries who underwent surgical exploration by MRI using 4 sequences of the 1.5-tesla 3-dimensional T2-SPACE technique. We obtained coronal, transverse, coronal oblique, and coronal cuts of T2 short time inversion recovery. The images of 595 roots were interpreted by multiple-image synchronizing techniques of the 4 views to precisely interpret the presence of spinal cord edema, numbers of anterior and posterior rootlets, sites of ganglions, meningeal cysts, and the "black line sign" (displaced ruptured dura or bundles of ruptured rootlets). We assessed the accuracy, sensitivity, and specificity of these abnormal findings with regard to diagnosing pre-GIs by comparing surgical exploration. The absence or decreased numbers of anterior and posterior rootlets and displacement of ganglions were definitive evidence of pre-GIs and the other findings, like spinal cord edema, meningeal cysts, and black line signs, were predictive signs. The synchronizing techniques of the four 1.5-tesla 3-dimensional T2-SPACE images provided high diagnostic accuracy of pre-GIs. Diagnostic II.

Imaging of intraspinal cystic lesions: A review.

Several distinct conditions present as cystic or pseudocystic lesions within the spinal canal. Some of the most common spinal cystic lesions include spinal meningeal cysts, juxtafacet cysts, dermoid/epidermoid cysts, nerve sheath tumors, and syringohydromyelia. Clinical presentation is usually nonspecific and imaging characteristics are frequently overlapping, which may pose a challenging presurgical diagnosis. We provide a pictorial review of cystic intraspinal lesions and discuss the main imaging features that can aid the neuroradiologist in the differential diagnosis. First, we propose a categorization of the lesions according to their location as extradural, intradural extramedullary, and intramedullary. This is a crucial initial step in the diagnostic workup and surgical planning. Second, for each of these locations, we organize the lesions according to their etiology: congenital and developmental disorders, degenerative disorders, traumatic or postsurgical collections, infectious conditions, neoplastic lesions, and other miscellaneous disorders. Finally, we summarize the clinical highlights and MR features that provide important insights for the differential diagnosis. MR is the technique of choice in presurgical evaluation and postsurgery follow-up. It provides accurate lesion localization and characterization and, most of the times, it will allow a confident differential diagnosis. High-resolution three-dimensional T2-weighted sequences and diffusion-weighted imaging can provide important hints in specific cases. Signal correlation with T1-weighted and fat-saturated sequences allows to differentiate true cystic lesions from hemorrhage or fat tissue.

Arachnoidal Diverticula of Sacral Extradural Meningeal Cyst: A Novel Definition and Case Series

Sacral cysts are classically divided into Tarlov cysts and meningeal diverticula. However, the pathogenesis of sacral cysts remains unclear. This study aimed to clarify a novel type of sacral extradural spinal meningeal cyst with a specific arachnoidal structure. Nine patients with prophylactic diverticula were included in the study. All patients underwent MRIpreoperative reconstruction and traditional neck transfixation. All patients presented with more than one symptom. The major symptom was lower extremity pain, followed by lower extremity numbness (77.8%, 7/9), lower extremity weakness (55.6%, 5/9), bowel/bladder and sexual dysfunction (55.6%, 5/9), and tenesmus (22.2%, 2/9). After long-term follow-up, the outcome was classified as improved in 9 patients (100%). The clinical findings of this study illustrate a special subtype and may help explain the mechanism of sacral cyst formation.

Location Distribution of Fistulas and Surgical Strategies for Spinal Extradural Meningeal Cysts: A Retrospective Analysis of 30 Cases at a Single Center.

ObjectiveThis study aimed to illustrate the features of fistula location distribution, surgical strategies, and outcomes in spinal epidural meningeal cysts (SEMCs). MethodsThe authors searched and reviewed the medical records for cases of SEMCs. Imaging features, operative reports, and media were reviewed to accurately describe the surgical techniques employed. We recorded the level and laterality of the fistula according to the operative report and the media. Consistency analysis was performed on the dominant laterality of the cyst on preoperative axial magnetic resonance imaging and laterality of the fistula in the operative media or report. When cyst and fistula lateralities were the same, they were considered consistent. Finally, the Japanese Orthopedic Association (JOA) score was used to obtain patient-reported results at each follow-up. ResultsThirty patients with SEMCs were identified. Fistula repair was performed in all patients. Two patients experienced cyst recurrence after surgery and were repaired during the second surgery. Based on imaging findings, SEMCs mostly occurred in the thoracolumbar junction. Most of the fistulas (87.88%) were at the T12 or L1 levels. In patients with multiple adjacent SEMCs, the fistula may be at one end of the cyst rather than in the middle level of the cyst. A fistula laterality of 72.72% was consistent with cyst laterality. The JOA improvement rate was 61.84%±26.63%. ConclusionMost fistulas were always located at the T12–L1 level as well as the middle level of the cyst, which is always consistent with cyst laterality. In patients with multiple adjacent SEMCs, the fistula may be at one end of the cyst. Cleft closure is key to healing SEMCs.

A Single Vertebral Surgical Approach for Spinal Extradural Meningeal Cysts Spanning Multiple Vertebral Segments by Auxiliary Neuroendoscope

Spinal extradural meningeal cysts (SEMCs) are rare lesions, especially those spanning multiple vertebral segments, and the surgical strategy has remained controversial. In the present study, we have described the outcomes of 4 patients with SEMCs treated with dural defect repair alone assisted by neuroendoscopy. From January 2018 to January 2020, 4 patients with SEMCs spanning multiple vertebral segments had undergone single-vertebral laminectomy or hemilaminectomy. The SEMCs in all 4 patients had spanned multiple vertebral segments, from T11 to L2. Using magnetic resonance imaging, the location of the dural defect was predicted correctly for 3 patients. Single-vertebral laminectomy was used in 2 patients and single-vertebral hemilaminectomy in 2 patients. Intraoperatively, the entire cyst, including the upper pole, lower pole, and middle segment of the cyst, was explored using neuroendoscopy. In each patient, only 1 dural defect was found, which had been located in the middle segment of the cyst (T12-L1). All cyst dural defects had been sutured under a microscope. In all cases, the cyst wall was not removed. Postoperatively, the symptoms for all the patients had improved significantly, andsubsequent magnetic resonance imaging studies showed obvious cyst regression. During the follow-up period of 15-44 months, no recurrence was observed. For SEMCs spanning multiple vertebral segments, dural defect repair without cyst wall resection through single-vertebral hemilaminectomy or laminectomy can be effective. Intraoperative neuroendoscopy can assist, not only in finding the dural defect, but also in avoiding the omission of multiple dural defects as much as possible.

Multiple lumbar spinal inter-dural cysts

Abstract Introduction: Cysts of the spinal canal may be located in the extradural or intradural space. Distinct from these cysts, inter-dural spinal cysts form between the two layers of the spinal dura and contain fluid, including cerebrospinal fluid (CSF) and blood. Inter-dural spinal cysts are extremely rare. We recently encountered a patient presenting with a multiple lumbar spinal inter-dural cysts. Patient concerns: A 58-year-old woman presented with an acute onset of back pain radiating to her left leg. She had no history of surgery or trauma and no other medical illness. Her pain was not relieved by considerable attempts to control it through medication or physical therapy Diagnosis: The magnetic resonance imaging indicated multiple cystic lesions ventral and dorsal to the thecal sac at L2/3 which were compressing the roots of the cauda equina. The contents of the ventral lesion were relatively high signal on T2-weighted images and low-signal on T1-weighted images, suggesting a CSF. Additional magnetic resonsnce myelography was highly suggestive of multiple isolated cysts located in the inter-dural space, with a thin wall separated from the CSF. Interventions: The patient underwent total laminectomy of the 2nd to 3rd lumbar vertebral to expose the cyst. After midline dural incision, inner dural leaflet was found and we could have confirmed the exact position of the cyst was interdural space, and the inner dura was excised. We then retracted the rootlets to find another ventral cyst. A small incision was made in the inner dura overlying the ventral cyst and yellowish fluid was drained. Complete cyst fenestration and excision of the inner dural leaflet was performed. Outcomes: A histopathology report confirmed the cyst to be dura. The patient had complete resolution of symptoms and was asymptomatic 3 years after surgery. Conclusions: Inter-dural cysts occur very rarely. We report the first case of multiple lumbar spinal inter-dural cysts. Acknowledging inter-dural spinal cysts as a type of spinal meningeal cyst is imperative, as this will allow surgeons to avoid unnecessary dural breaches and associated complications.

Surgical Treatment of Ten Adults with Spinal Extradural Meningeal Cysts in the Thoracolumbar Spine.

ObjectiveTo retrospectively analyze the clinical characteristics and surgical experience of 10 adults with spinal extradural meningeal cysts (SEMCs) in the thoracolumbar spine which may further provide evidence for surgical decision-making. MethodsTen adults with SEMCs in the thoracolumbar spine were surgically treated and enrolled in this study. Clinical manifestations, imaging data, intraoperative findings and postoperative outcome were recorded. ResultsClinical manifestations of SEMCs included motor and sensory dysfunction of the lower limbs and urination and defecation disturbance. The cysts presented as intraspinal occupying lesions dorsal to the spine, ranging from the T8 to L3 level. Defects of eight cases were found on preoperative magnetic resonance imaging (MRI). Selective hemilaminectomy or laminectomy were used to reveal the defect within the cyst, which was further sutured with microscopic technique. The final outcome was excellent or good in seven cases and fair in three cases. No recurrence was observed during follow-up. ConclusionSEMCs are rare intraspinal cystic lesions. Radiography and MRI are clinically practical methods to assess defects within SEMCs. Selective hemilaminectomy or laminectomy may reduce surgical trauma. Detection and microscopic suturing of the defects are the key steps to adequately decompress the nervous tissue and prevent postoperative recurrence.

Frequency of Nerve Root Sleeve Cysts in Autosomal Dominant Polycystic Kidney Disease.

There is sporadic data about the occurrence of spinal meningeal cysts in patients with autosomal dominant polycystic kidney disease (ADPKD). We suggest that there is a relationship with the frequency and size of spinal meningeal cysts and headache, intracranial aneurysms, and cerebrospinal fluid leakage in patients with ADPKD. To investigate the relationship with spinal meningeal cyst, cerebrospinal fluid leakage, and headache in patients with ADPKD. Cross-sectional study. We enrolled 50 patients with ADPKD and 37 healthy volunteers. This cross-sectional study included patients with ADPKD and matched healthy volunteers. Magnetic resonance imaging myelography was performed using the 3D-T2 HASTE technique in an MRI scanner. We questioned our subjects regarding presence of headache and evaluated headache severity using a visual analog scale. The relationship between the number and size of spinal meningeal cysts with headache, intracranial aneurysms, and liver cysts was also investigated. Spinal meningeal cysts were more numerous and larger in patients than in controls (14.8±11.6 vs. 6.4±4.6 cysts respectively, p<0.001, 68.3±49.3 vs. 25.4±20.1 mm, p<0.001, respectively). Spinal cyst number and size were similar in APDKD patients with or without intracranial aneurysms. Headache score was correlated with the size and number of spinal meningeal cysts. This was valid only in patients with ADPKD. Abnormality involving the vessel wall in ADPKD may explain the increased number of spinal meningeal cysts in ADPKD. Moreover, leakage of cerebrospinal fluid secondary to spinal meningeal cyst may be responsible for recurrent severe headache by causing spontaneous intracranial hypotension in these patients.

MRI Findings of Non-Degenerative Pathoanatomical Changes in Low Back Pain

Non-degenerative pathoanatomical changes are far less common than degenerative changes but benefi ts most from imaging assessment. This study aimed to evaluate the non-degenerative pathoanatomical changes in patients undergoing MRI for low back pain.The study was a retrospective study conducted for the duration of 3 years in a multimodality-imaging center. All patients undergoing MRI of lumbosacral spine with complains of low back pain with or without radiculopathy were assessed for morphological changes and other abnormal fi ndings. After excluding patients with degenerative changes, non-degenerative pathologies were evaluated. Data was entered in predesigned proforma and analysis was done with SPSS 21.0.There were 183 patients who met the inclusion criteria and were included in the study. The mean age of the patients was 51.23 ±16.86 years. Compression fracture of the vertebra was the most common non-degenerative changes accounting for 34% cases followed by spinal meningeal cysts (26%) and infection (14%). Fractures were more common in upper lumbar level as compared to lower lumbar levels. Meningeal cysts were noted to involve the sacral spinal canal more frequently followed by lower lumbar levels. Infective lesions were equally distributed throughout the lumbar spine. Hemangioma was common lesion involving 16% of cases. Lumbosacral transitional vertebra was seen in 7(3.8%) patients.The common non-degenerative pathoanatomical changes associated with low back pain were traumatic lesion, infection, neoplastic lesion and lumbosacral transitional vertebra.Nepal Journal of Neuroscience 12:59-62, 2015

Are Tarlov Cysts Being Identified and Reported on Lumbar Spine MRI Scan in Patients with Sciatica

Introduction Following advances in surgical technique sacral Tarlov Cysts (TCs) are now a treatable cause of back pain and sciatica.1,2 However many surgeons and radiologists still view them as an incidental finding. This audit was performed to raise awareness of TCs within the hospital and further afield, assess the extent to which TCs are present in patients with sciatica and assess if they are being identified and reported by the radiologist and surgeon in every case. Material and Methods Following a literature review a list of all spinal MRI scans requested by the three consultant spinal surgeons working at the hospital between 1/1/2013 – 31/12/2014 was compiled by the radiology department. All patients with complaints of radicular pain or altered sensation in one or both lower limbs in their initial clinic letter then had their MRI scan reviewed using the hospital PACS system for the presence of TCs. The radiologist's report and follow-up clinic letter were then reviewed in patients with a TC present on their scan to see if it was reported by the radiologist and surgeon. Any patient who's scan or clinic letters were not were removed from the audit. Results In total 1499 patients underwent lumbar-sacral MRI scan under the care of the spinal surgeons. Of these, 1070 fitted the inclusion criteria. 6 MRI scans were not accessible, in total 1064 MRI scans were reviewed for the presence of TCs. 158 scans showed sacral TCs present, an incidence of 14.85%. Of the 158 only 33 (21%) had TCs in the radiologists' report. 4 were reported as possibly symptomatic and the rest as an incidental finding. Only the 4 potentially symptomatic TC patients were notified of the presence of the cysts during their clinic appointment following the MRI scan. No other patients notified of the presence of TCs on their MRI. Therefore of the 158 patients with sacral TCs present only 4 (2.5%) were made aware of the lesion. Only one case of symptomatic cyst was identified as the patient's symptoms decreased following excision of the cyst. Conclusion Several things were apparent from the literature review; the exact anatomical area supplied by each of the lumbar-sacral dermatomes is not known and as such pathology compressing the S2 nerve root can cause symptoms suggestive of an S! or even L5 radiculopathy,3 TCs can be progressive in nature,4 microsurgical treatment gives the best relief of symptoms and can give complete relief of symptoms,5,6 early intervention gives the best prognosis.1 From the audit it was apparent that in almost 80% of cases TCs were not being reported, this could potentially lead to patients continuing with symptoms, or developing them as the cyst progresses. A delay in diagnosis and therefore treatment of a symptomatic TC could lead to a poorer prognosis. It seems that for many Tarlov Cysts are still viewed as an asymptomatic incidental finding, until this opinion is changed it will continue to be under reported and patients will continue to suffer a potentially treatable spinal pathology. References Sun JJ, Wang ZY, Teo M, et al. Comparative outcomes of the two types of sacral extradural spinal meningeal cysts using different operation methods: a prospective clinical study. PLoS ONE 2013;8(12):e83964 Lucantoni C, Than KD, Wang AC, et al. Tarlov cysts: a controversial lesion of the sacral spine. Neurosurg Focus 2011;31(6):E14 Turek S. Orthopaedics: Principles and Their Application. 3rd ed. Philadelphia: JB Lippincott; 1977 Freidenstein J, Aldrete JA, Ness T. Minimally invasive interventional therapy for Tarlov cysts causing symptoms of interstitial cystitis. Pain Physician 2012;15(2):141–146 Caspar W, Papavero L, Nabhan A, Loew C, Ahlhelm F. Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases. Surg Neurol 2003;59(2):101–105, discussion 105–106 Neulen A, Kantelhardt SR, Pilgram-Pastor SM, Metz I, Rohde V, Giese A. Microsurgical fenestration of perineural cysts to the thecal sac at the level of the distal dural sleeve. Acta Neurochir (Wien) 2011;153(7):1427–1434, discussion 1434

Thoracic paraspinal lesion: question

Spinal meningeal cysts are rare lesions and comprise approximately 1–3% of spinal tumors [1–4]. Nabors et al. published a classification for spinal meningeal cysts classifying them into three categories [1]. Type I cysts are extradural meningeal cysts without spinal nerve root fibers. These lesions are further divided into type IA, or extradural meningeal/arachnoid cysts as in this patient, and type IB, or occult sacral meningoceles. Type II extradural meningeal cysts include nerve root fibers and are also known as Tarlov’s perineural cysts or spinal nerve root diverticuli. Spinal intradural meningeal/arachnoid cysts are classified as type III. Tarlov cysts remain one of the most common of these lesions and are often visualized on spinal imaging performed for various indications. Type I cysts have been attributed to arachnoid herniation through a congenital dural defect or congenital diverticula of the dura [1]. Familial tendencies for spinal meningeal cysts and association with other congenital anomalies are known [3]. Continued secretion of cerebrospinal fluid by the arachnoid in a cyst or a ball-valve effect trapping cerebrospinal fluid within the cyst after entry through its pedicle may explain extradural cyst enlargement [2]. Approximately 65% of spinal cysts occur in the thoracic spine [4]. Cysts are most commonly located dorsally and can be associated with ventral compression and thinning of the spinal cord [1]. In each of the 22 cases described in the original article by Nabors et al., patients were symptomatic with pain or neurological deficits [3]. In the present era, however, most of these lesions are actually asymptomatic and are now discovered incidentally on MRI [1]. When present, symptoms vary by level of the cyst;

Persistent Genital Arousal Disorder Caused by Spinal Meningeal Cysts in the Sacrum: Successful Neurosurgical Treatment.

To evaluate whether treatment of spinal meningeal cysts that compress sacral spinal nerve roots is associated with relief of persistent genital arousal disorder. In this case series we encountered a group of patients with persistent genital arousal disorder among a larger cohort undergoing a prospective outcomes study on the surgical treatment of symptomatic spinal meningeal cysts. Epidemiologic data were collected and the type, number, and location of the meningeal cysts in each patient were determined on magnetic resonance imaging. Postoperatively patients were asked to self-report whether their persistent genital arousal disorder was eliminated, significantly better, the same, or worse. In a cohort of 1,045 patients with symptomatic spinal meningeal cysts, we identified 11 with persistent genital arousal disorder; all were female and all had meningeal cysts in the sacral spinal canal causing sacral nerve root compression. In addition to persistent genital arousal disorder, all patients had other symptoms typical of sacral nerve root compression such as perineal, bladder, and bowel symptoms. Although multiple types of meningeal cysts were encountered, Tarlov cysts were the most common (8/11). Postoperatively, seven (64%) patients reported elimination of their persistent genital arousal disorder, three (27%) noted significant improvement, one (9%) said they were unchanged, and none experienced worsening with an average follow-up of 23 months ranging from 2 months to 6 years. Although Tarlov cysts were more numerous, the presence of persistent genital arousal disorder and the surgical outcomes appeared unrelated to the type of spinal meningeal cyst treated. Our case series suggests that sacral nerve root compression caused by spinal meningeal cysts can cause persistent genital arousal disorder. The presence of nerve root compression appears to be more important than the particular type of meningeal cyst involved. Microsurgical cyst treatment cured or significantly reduced persistent genital arousal disorder symptoms in 91% of the patients. III.

Neck transfixion for sacral extradural spinal meningeal cysts without spinal nerve root fibers.

This prospective study analyzes clinical characteristics and outcomes of sacral extradural spinal meningeal cysts (SESMC) without spinal nerve root fibers (SNRF) undergoing neck transfixion. Using the relationship between the cysts and SNRF, SESMCs were divided into two types: cysts with SNRF known as Tarlov cysts and cysts without. If the SESMCs were identified as those without SNRFs, the neck of the cyst was transfixed, ligated and the remaining cyst wall removed distal to the clip. The improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological functions of the patients. Twenty-seven patients were included in this study. The average age was 42.7±11.93years. The mean preoperative IJOA score was 17.5±2.47, and postoperative IJOA score was 19.1±1.41. The difference between preoperative and postoperative IJOA scores was statistically significant (t=-3.75, P=0.001), with a significant improvement in neurological function after surgery. Among the improvements in neurological function, the most significant was bowel/bladder function (z=-2.33, P=0.02). Most patients experienced significant improvement in their neurological function after surgery. The most significant area of neurological improvement was bowel/bladder dysfunction, however, preoperative stool or urine incontinence did not recover completely.

Spinal cerebrospinal fluid leak as the cause of chronic subdural hematomas in nongeriatric patients.

The etiology of chronic subdural hematoma (CSDH) in nongeriatric patients (≤ 60 years old) often remains unclear. The primary objective of this study was to identify spinal CSF leaks in young patients, after formulating the hypothesis that spinal CSF leaks are causally related to CSDH. All consecutive patients 60 years of age or younger who underwent operations for CSDH between September 2009 and April 2011 at Bern University Hospital were included in this prospective cohort study. The patient workup included an extended search for a spinal CSF leak using a systematic algorithm: MRI of the spinal axis with or without intrathecal contrast application, myelography/fluoroscopy, and postmyelography CT. Spinal pathologies were classified according to direct proof of CSF outflow from the intrathecal to the extrathecal space, presence of extrathecal fluid accumulation, presence of spinal meningeal cysts, or no pathological findings. The primary outcome was proof of a CSF leak. Twenty-seven patients, with a mean age of 49.6 ± 9.2 years, underwent operations for CSDH. Hematomas were unilateral in 20 patients and bilateral in 7 patients. In 7 (25.9%) of 27 patients, spinal CSF leakage was proven, in 9 patients (33.3%) spinal meningeal cysts in the cervicothoracic region were found, and 3 patients (11.1%) had spinal cysts in the sacral region. The remaining 8 patients (29.6%) showed no pathological findings. The direct proof of spinal CSF leakage in 25.9% of patients suggests that spinal CSF leaks may be a frequent cause of nongeriatric CSDH.

Dural Dissection Cyst: a More Accurate Term for Extradural Meningeal Cyst

Spinal extradural meningeal cyst (EMC) aetiology remains unclear. Based on our in-depth analysis of EMC clinical characters, we propose the alternative term 'dural dissection cyst' (DDC), which is more consistent with its aetiology and pathological manifestations. We examined the clinical, imaging and operative findings of four patients with spinal EMC (type I A) and analysed the aetiology and treatment of the cyst. Spinal DDC was observed between T10 and L3 in our series. Patients presented with low back pain, lower extremity numbness and weakness, and segmental muscle atrophy. Small clefts were found on the inner wall of all cysts. Microscopic suture of the cleft successfully improved patient's symptoms and neurological deficits. Spinal EMC (type I A) is characterized by dural dissection, so the term DDC can best reflect its aetiology. Because it is a dissection cyst, the most reasonable treatment is to suture the fistula.

Comparative Outcomes of the Two Types of Sacral Extradural Spinal Meningeal Cysts Using Different Operation Methods: A Prospective Clinical Study

This prospective study compares different clinical characteristics and outcomes of patients with two types of sacral extradural spinal meningeal cysts (SESMC) undergoing different means of surgical excision. Using the relationship between the cysts and spinal nerve roots fibers (SNRF) as seen under microscope, SESMCs were divided into two types: cysts with SNRF known as Tarlov cysts and cysts without. The surgical methods were tailored to the different types of SESMCs. The improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological function of the patients. Preoperative IJOA scores were 18.5±1.73, and postoperative IJOA scores were 19.6±0.78. The difference between preoperative and postoperative IJOA scores was statistically significant (t = -4.52, p = 0.0001), with a significant improvement in neurological function after surgery. Among the improvements in neurological functions, the most significant was sensation (z=-2.74, p=0.006), followed by bowel/bladder function (z=-2.50, p=0.01). There was a statistically significant association between the types of SESMC and the number (F=12.57, p=0.001) and maximum diameter (F=8.08, p=0.006) of the cysts. SESMC with SNRF are often multiple and small, while cysts without SNRF tend to be solitary and large. We advocate early surgical intervention for symptomatic SESMCs in view of significant clinical improvement postoperatively.

Reconstruction of nerve root sheaths for sacral extradural spinal meningeal cysts with spinal nerve root fibers

This study analyzed the clinical characteristics and outcomes of sacral extradural spinal meningeal cysts with spinal nerve root fibers treated by reconstruction of the nerve root sheaths. The relationships between the cysts and spinal nerve root fibers were examined microscopically, the cysts were partially excised, and the defects were oversewn to reconstruct the nerve root sheaths. The Improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological function. Thirty-eight patients were included in this study, with a mean age of 41.4 ± 15.57 years. The mean IJOA score was 18.8 ± 1.32 preoperatively and 19.6 ± 0.65 postoperatively, which was a significant difference (t=-3.77, P=0.001). These results indicate a significant improvement in neurological function after surgery. The most significant improvement in neurological function was sensation (z=-2.86, P=0.004), followed by bowel/bladder function (z=-2.31, P=0.02).