management of painful paraparesisdue to outline non ... · pdf file• post-myelography...
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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