Outline Management of Painful Paraparesis Due to Non-Neoplastic - PowerPoint PPT Presentation

6/1/2013 Outline Management of Painful Paraparesis Due to Non-Neoplastic Spinal Cysts • Definition and classification • Clinical presentation • Diagnosis and imaging A rare but treatable cause of spinal pain and neuro-deficit • Recent literature • Management (UCSF Recent Experience) – Medical treatment Philip R. Weinstein MD – Indications for surgery Cynthia T. Chin MD – Surgical techniques Bruno Soares MD – Results of surgery – Risks and limitations UCSF Spinal Disorders Symposium-2013 – Future directions Department of Neurosurgery, Division of Neuroradiology UCSF Fluid filled intra-spinal mass lesions Clinical Presentation causing cord and root compression • Spinal pain • Infectious • Radicular pain • Traumatic • Neuropathic pain • Hemorrhagic • Myelopathy/spastic paraparesis • Congenital/developmental • Radiculopathy • Postoperative • Positional – Arachnoiditis/subdural fibrosis • Valsalva aggravated • Post-myelography • Progressive pain and deficit • Connective tissue disorders • Unresponsive to steroids unless inflammatory • Arachnoid cyst---idiopathic 1

6/1/2013 Diagnosis Medical Pain Management • MRI (total spine) • NSAID’s – Contrast • Oral steroids – CSF flow study • Analgesics – Diffusion – Neurogam (STIR) • Anti-spasmodics – FIESTA • Membrane stabilizers • CT myelogram • Surgical spinal pain implants • Dynamic “cine” CT myelogram – DCS • CT guided aspiration or injection therapy – ITDD • CT or MRI brain Intradural Spinal Arachnoid cysts N=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 2

6/1/2013 Additional recent references Idiopathic cystic spinal arachnoiditis Vaughan D, et al Br J. Neurosurg, 2012 26 (4): 555-7 Giant ant. arachnoid cyst with syrinx Peruzotti-Jametti L, et al Spine 2010; 35 (8) 322-4 Partial median corpectomy for C2-3 ant. arach. cyst Srinivasan US, et al Neurol India 2009 57 (6): 803-5 Spinal intradural juxtamedullary cysts Bassiouni H, et al Neurosurg 2004; 55 (6) 1352-9 Surgical treatment of spinal extradural arachnoid cysts Funao H, et al Neurosurg 2012; 71(2): 278-84 3

6/1/2013 Recent UCSF Cases Arachnoid Cyst MRI • Synovial cyst • Arachnoid cyst • Tarlov’s cyst • Meningeal cyst • Ventral cord hernia- • Inflammatory/post- dorsal “cyst” infectious cyst • Cystic Schwanoma • Postoperative cyst • Dermal sinus/tether • Post traumatic syrinx • Pseudo-meningocoel • Epidermoid tumor • Discogenic cyst • Cystic Arachnoiditis Meningeal Cyst Arachnoid Cyst myelogram T2 4

6/1/2013 NEUROCYSTICERCOSIS NEUROCYSTICERCOSIS ARACHNOIDITIS ARACHNOIDITIS T2 Gad Post-operative Nerve root herniation 5

6/1/2013 Post traumatic syrinx Post traumatic syrinx T2 T1 T2 Discal Cyst Dean Chou J Neurosurg Spine 2007 Jan 6(1):81 Post-gad T1 6

6/1/2013 Discal cyst SYNOVIAL GRE CYST Five months later Gad T2 Tarlov Cyst Axial T2 Gad Sag STIR T2 7

6/1/2013 Ventral Dural Defect cord herniation Tarlov cyst Myelogram Ventral Dural Defect cord herniation Dermal cyst myelogram 8

6/1/2013 Cystic conus schwannoma Cystic conus schwannoma Gad T2 Steady State Free Precession MRI (SSFP) FIESTA Low flip angle gradient echo; short repetition High spatial resolution Increased water-tissue resolution Enhances imaging detail of spinal meninges, nerve roots, cord and relationships to cystic structures May obviate need for CTM (CSF flow study for communication) 9

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6/1/2013 History History • 55 yo male engineer • L L5-S1 discectomy for L sciatica 1988 • Back and bilat. posterolateral leg pain to knees • Preop/postop myelogram: spinal headache 2wks • Numbness soles of both feet ascending • Pain free until 2 yrs. ago • Progressively incapacitating for any activity • Severe progressive LBP: spontaneous onset • Sitting aggravates back pain • ESI 2 yrs. ago triggered onset progressive leg • Walking or Valsalva increases leg pain pain/numb feet ever since • DVT after bedrest in Jan. • Medrol dose pak completely relieved leg • NSAID’s, Analgesics, PT: no relief symptoms for one week 2 mos. ago LS MRI –S1: T2/STIR MRI T1 + C: Cystic arachnoiditis 11

6/1/2013 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 12