Pediatric intraspinal arachnoid cyst: successful endoscopic fenestration. Illustrative case

Victoria Jane Horak Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois
Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois; and

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Med Jimson D. Jimenez Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois; and

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Melissa A. LoPresti Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois

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Jeffrey S. Raskin Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children’s Hospital, Chicago, Illinois

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BACKGROUND

Intradural spinal arachnoid cysts (SACs) are a rare cause of spinal cord compression. Treatment is centered on decompression of the spinal cord via laminectomy or laminoplasty followed by resection or fenestration of the cyst. Although laminectomy or laminoplasty access may be needed to achieve the desired result, either procedure can be associated with more extensive surgical dissections and long-term spinal stability concerns, including postsurgical kyphosis.

OBSERVATIONS

The authors present a case of a cervical intradural SAC in a 4-month-old girl presenting with symptomatic compression. The patient was treated by laminotomy and endoscopic fenestration of the SAC with resolution of symptoms and no disease progression 10 months postoperatively, when the patient was 14 months old.

LESSONS

Microsurgical endoscopic fenestration of an intradural SAC can provide a less invasive means of treatment while avoiding the risks associated with more invasive approaches.

ABBREVIATIONS

CSF = cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; NG = nasogastric; SAC = spinal arachnoid cyst

BACKGROUND

Intradural spinal arachnoid cysts (SACs) are a rare cause of spinal cord compression. Treatment is centered on decompression of the spinal cord via laminectomy or laminoplasty followed by resection or fenestration of the cyst. Although laminectomy or laminoplasty access may be needed to achieve the desired result, either procedure can be associated with more extensive surgical dissections and long-term spinal stability concerns, including postsurgical kyphosis.

OBSERVATIONS

The authors present a case of a cervical intradural SAC in a 4-month-old girl presenting with symptomatic compression. The patient was treated by laminotomy and endoscopic fenestration of the SAC with resolution of symptoms and no disease progression 10 months postoperatively, when the patient was 14 months old.

LESSONS

Microsurgical endoscopic fenestration of an intradural SAC can provide a less invasive means of treatment while avoiding the risks associated with more invasive approaches.

ABBREVIATIONS

CSF = cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; NG = nasogastric; SAC = spinal arachnoid cyst

Intradural spinal arachnoid cysts (SACs) are benign lesions of the spinal cord and an uncommon etiology of spinal cord compression. Most SACs are painless and asymptomatic, but they can also present with myelopathies, neuropathic pain, lower-extremity weakness, and gait instability.1,2 They arise idiopathically but are also seen as consequences of arachnoid adhesions in surgery, trauma, or hemorrhage.3–6 SACs are most often present in the cervical and thoracic spine.2 Diagnosis is centered on imaging evaluation with magnetic resonance imaging (MRI) and computed tomography (CT) myelography.7

Treatment centers on surgical decompression of the spinal cord via resection or fenestration of the cyst and can lead to complete recovery or partial relief of pain and weakness.8 Preoperative symptoms of neuropathic pain and weakness are more likely to be improved than sensory losses after surgical removal of the intradural SAC and the closure of dural defects.2,8,9 Traditionally, multilevel laminoplasty or laminectomy exposes the SACs in their entirety craniocaudally for resection employing a multilevel exposure and carrying the risks of spinal cord injury, destabilization, and postsurgical kyphotic deformities needing fixation.8–11 Cystoperitoneal or cystosubarachnoid shunts have been used to treat SACs.2,9 More recently, endoscopic techniques have been considered to minimize surgical risks and reduce the extent of adhesions.12,13

We present a case of a 4-month-old female with a cervical SAC from the lower brainstem to C6 and the presenting symptoms of lower brainstem and cord compression. We describe treatment with a C7 laminotomy and a C4–5 laminectomy for endoscopic SAC fenestration. In this case, we highlight the efficacy of a less invasive technique.

Illustrative Case

History and Examination

A 4-month-old female had been born at full term via an uncomplicated vaginal delivery. Within the first week of life, her mother noticed abnormal breathing, which led to a referral to pulmonology and otolaryngology. The patient was diagnosed with laryngomalacia after two failed swallow studies and was treated with laryngoscopy and supraglottoplasty. Subsequently, the patient experienced failure to thrive from severe oropharyngeal dysphagia and aspiration requiring nasogastric (NG) tube feeds, mild to moderate hypotonia of her arms, and gross motor delays.

Her physical examination was significant for drooling, restricted motion of the neck with significant head lag, 4−/5 strength in her bilateral upper and lower extremities with 3+ reflexes, and clonus in the bilateral lower extremities. Weakness was most pronounced in the bilateral C5 myotomes. In addition, because of concern for signs of upper motor neuron dysfunction, MRI of the brain and cervical spine was performed, revealing ventral cerebrospinal fluid (CSF) collection causing dorsal displacement and compression of the cervical spinal cord from the occipitocervical junction to C6, most consistent with an arachnoid cyst (Fig. 1).

FIG. 1.
FIG. 1.

Preoperative sagittal (left) and axial (right) T2-weighted MRI showed a cystic cervical spinal canal lesion 4 cm in size extending from C0 to C6. The spinal cord measured 3.6 mm in its narrowest dimension when measured on sagittal T1-weighted imaging, and its caliber normalized at the cervicothoracic junction. The localizer for the axial image is indicated by the line in the left panel.

Because of signs and symptoms of spinal cord compression and compressive pathology on imaging, surgery was recommended to decompress the cervical spine and fenestrate the arachnoid cyst. Approaches considered included multilevel cervical laminectomy, laminoplasty with intradural microsurgical cyst fenestration, or focal cervical laminectomy with endoscopic cyst fenestration. Because of the ventral location of the arachnoid cyst, microsurgical cyst fenestration from a posterior approach was less favorable. Furthermore, given the risk of postsurgical kyphosis and destabilization with multilevel laminectomies, a less invasive approach with focal laminectomies and endoscopic cyst fenestration was favored.

Operation

The child was positioned prone on gel rolls while she was under general endotracheal anesthesia. First, the midline incision was made over C4–7. Then, a bilateral paraspinal muscle takedown was performed, and self-retaining retractors were placed to maintain the operative corridor.

Laminectomies were performed at C4–5 to allow a window for ultrasound to help assess decompression of the cyst. Next, a laminotomy was performed at C7 to allow entry of the flexible neuroendoscope (Storz). The patient’s dura was opened with an 11-blade scalpel and a Woodson periosteal elevator, and then dural leaflets were tented with braided sutures. Under microscopy, the spinal cord and the arachnoid cyst located right lateral were identified. The cyst was fenestrated with a microdissector, and clear spinal fluid egressed. The flexible neuroendoscope, measuring 2.90 mm in diameter, was placed into the fenestration in the cyst and advanced rostrally until the rostral end of the cyst was identified and fenestrated with a Bugbee electrocautery device. The cranial nerves and bilateral vertebral arteries were appreciated. Then, moving caudally with the endoscope, the inferior edge of the cyst was identified and fenestrated, which resulted in the visualization of a dark cavity and free-flowing CSF. The site was then irrigated with a vancomycin-containing solution. One bleeding vessel was identified, and hemostasis was achieved with a hemostatic and pressure. The dura was then closed with a running 5-0 Gore-Tex suture (W.L. Gore & Associates Inc.), hemostatics, and fibrin glue, and the surgical wound was closed in the typical layered fashion.

Postoperative Course

The patient did well after surgery, recovered on the neurosurgical floor, and was discharged home in stable condition on postoperative day 2. Postoperative MRI confirmed adequate decompression compared with prior imaging (Fig. 2). At 6 months old, the patient continued to have a hoarse cough but had greatly improved drooling and reduction of hypotonia in her neck, leading to resolution of the patient’s persistent head lag. The patient could not fully roll over from front to back and required assistance rotating her hips and legs to reach a completely supine position. Her core control was noted to be poor, preventing her from maintaining a sturdy standing position, but she could bear weight well on her legs. Her reflexes improved to normal (2+) in the bilateral upper and lower extremities with resolution of the previously seen bilateral lower-extremity clonus.

FIG. 2.
FIG. 2.

Postoperative day 1 sagittal (left) and axial (right) T2-weighted MRI of the patient’s cervical spine identified laminectomies at C4–6 with persistent but improved narrowing of the spinal cord within the cervical spine, now measuring 4.7 mm at its narrowest when measured on sagittal T1-weighted imaging. The localizer for the axial image is indicated by the line in the left panel.

At 10 months old, the patient was noted to be meeting her gross motor milestones, walking, talking, and eating appropriately for her age. The NG tube was removed. At 14 months old, her physical examination findings also lacked gross abnormalities, and the patient maintained adequate core strength for stabilization. Imaging showed a stable appearance of the patient’s ventral cervical cyst and decreased spinal cord compression compared with admission (Fig. 3).

FIG. 3.
FIG. 3.

Ten-month postoperative sagittal (left) and axial (right) T2-weighted MRI of the patient’s cervical spine showed postsurgical changes of a C4–6 laminectomy and a gradual decrease in the size of the ventral thecal sac. The size of the sac was measured as 3.4 × 0.9 × 1.8 cm, spanning from C2 to C5, with stable flattening of the cervical spinal cord seen in the previous imaging. The localizer for the axial image is indicated by the line in the left panel.

Patient Informed Consent

The necessary patient informed consent was obtained in this study.

Discussion

Given the rarity of SACs in the pediatric population, they are not well covered in the literature, and there are currently no specified surgical guidelines or gold-standard operative procedures.8 Although a classification system exists for spinal cysts, surgical approaches are not well delineated, partly because of the location and size of the SAC.14 A recent paper attempted to stratify SACs through a multimodal MRI-based approach by expanding to a five-category system, which is diagnostically helpful but lacks a treatment-based delineation based on the classification of the SAC.15 Guidance from MRI contrast and CT myelography can reveal cyst localization, cord compression involvement, and septations that facilitate a bespoke, patient-specific surgical plan. However, because of the involvement of delicate central nervous system structures, many clinical manifestations, such as neuropathic pain, hyperesthesia, generalized weakness, and gait ataxia, exist as hurdles for a generalized treatment approach.16

Observations

In our case, MRI was enough to demonstrate a cystic cervical spinal canal lesion 4 cm in size from the C0–6 vertebrae and causing mass effect leading to multiple neurological deficits. The goal of the posterior approach laminectomy and SAC fenestration surgery was cord decompression while minimizing the future risk of postsurgical kyphosis. Viswanathan et al.17 have shown that treatments involving SAC fenestration allow cord decompression and improvement of myelopathic symptoms in a sample of 14 patients. Instead of multilevel laminectomies spanning the entirety of the cyst, in this case from C0–6, a smaller multilevel laminectomy acted as an access point for endoscopic access to the cyst. Microsurgical endoscopy, which fenestrates the cyst on its most rostral and caudal aspects, allows a less invasive approach, and passing the endoscope into the subarachnoid space confirms the absence of other adhesions; this has been demonstrated in the literature, and complete fenestration even in the multilevel arachnoid cyst is achievable.13,18,19 In older populations, adding laminoplasty may reduce postoperative kyphosis as proposed by other studies.20

Limitations

As was noted, Fig. 3 shows that the patient’s cyst and spinal cord compression, although reduced, are ever present. The remaining reduced cyst poses the threat of a symptomatic recurrence and the potential for more permanent neurological sequelae, because the cyst could refill after fenestration. Because this case study followed the patient for a limited time and not the patient’s entire lifespan, we cannot conclude from this case that microsurgical endoscopic fenestration is a definitive treatment in this patient or in patients like her. Yet, this less invasive approach has been used successfully in a pediatric patient with tetrasomy 18p who presented with an SAC, and the patient showed improvement, but not full recovery, from the related neurological impairments.21

In addition, because this case report considers a single patient, we do not know if this is broadly applicable to the target patient population. A multicenter study of pediatric patients with symptomatic SACs would provide a more complete picture of successful treatment options, including the use of endoscopic fenestration and any nuance that must be considered in treatment.

Lessons

With our use of an endoscopic minimal access surgical technique, our patient experienced cyst decompression and gradual neurological improvement. Her head lag was resolved at 6 months, and by 14 months old, her NG tube was removed, and she had a normal swallow, voice, and neurological examination. This microsurgical approach is a potentially viable option for treating other children with SACs; using a small operating corridor as opposed to complete exposure of the cyst decreases disruption to the osteoligamentous complex, reduces unnecessary intraoperative spinal cord exposure, and may reduce the risk of postoperative kyphosis. Future studies may include a scoping review and should include long-term follow-up of these patients.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Raskin. Acquisition of data: Raskin, Horak. Analysis and interpretation of data: all authors. Drafting the article: all authors. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Raskin. Administrative/technical/material support: Raskin, Horak. Study supervision: Raskin.

References

  • 1

    Takahata M, Watanabe T, Endo T, Ogawa Y, Miura S, Iwasaki N. Pulsating spinal arachnoid cyst as a hidden aggravating factor for thoracic spondylotic myelopathy: a report of 3 cases. JBJS Case Connect. 2022;12(2):e22.00027.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bond AE, Zada G, Bowen I, McComb JG, Krieger MD. Spinal arachnoid cysts in the pediatric population: report of 31 cases and a review of the literature. J Neurosurg Pediatr. 2012;9(4):432441.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Andrews BT, Weinstein PR, Rosenblum ML, Barbaro NM. Intradural arachnoid cysts of the spinal canal associated with intramedullary cysts. J Neurosurg. 1988;68(4):544549.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Basaran R, Kaksi M, Efendioglu M, Onoz M, Balkuv E, Kaner T. Spinal arachnoid cyst associated with arachnoiditis following subarachnoid haemorrhage in adult patients: a case report and literature review. Br J Neurosurg. 2015;29(2):285289.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Kumar K, Malik S, Schulte PA. Symptomatic spinal arachnoid cysts: report of two cases with review of the literature. Spine (Phila Pa 1976). 2003;28(2):E25E29.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Hubbard ME, Hunt MA, Jones KE, Polly DW. Thoracic spinal cord impingement by an arachnoid web at the level of a hemivertebra: case report. J Neurosurg Spine. 2017;27(6):638642.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Silbergleit R, Brunberg JA, Patel SC, Mehta BA, Aravapalli SR. Imaging of spinal intradural arachnoid cysts: MRI, myelography and CT. Neuroradiology. 1998;40(10):664668.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Eroglu U, Bozkurt M, Kahilogullari G, et al. Surgical management of spinal arachnoid cysts in adults. World Neurosurg. 2019;122:e1146e1152.

  • 9

    Garg K, Borkar SA, Kale SS, Sharma BS. Spinal arachnoid cysts - our experience and review of literature. Br J Neurosurg. 2017;31(2):172178.

  • 10

    Bitaraf MA, Zeinalizadeh M, Meybodi AT, Meybodi KT, Habibi Z. Multiple extradural spinal arachnoid cysts: a case report and review of the literature. Cases J. 2009;2:7531.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Ordaz JD, Huh A, Desai V, Raskin JS. Iatrogenic spinal deformity following spinal intradural arachnoid cyst fenestration despite minimal access with laminoplasty and endoscopy in a pediatric patient. Cureus. 2022;14(2):e22053.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Ben Ali H, Hamilton P, Zygmunt S, Yakoub KM. Spinal arachnoid web—a review article. J Spine Surg. 2018;4(2):446450.

  • 13

    Endo T, Takahashi T, Jokura H, Tominaga T. Surgical treatment of spinal intradural arachnoid cysts using endoscopy. J Neurosurg Spine. 2010;12(6):641646.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Nabors MW, Pait TG, Byrd EB, et al. Updated assessment and current classification of spinal meningeal cysts. J Neurosurg. 1988;68(3):366377.

  • 15

    Qi J, Yang J, Wang G. A novel five-category multimodal T1-weighted and T2-weighted magnetic resonance imaging-based stratification system for the selection of spinal arachnoid cyst treatment: a 15-year experience of 81 cases. Neuropsychiatr Dis Treat. 2014;10:499506.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Dyck P. Myelopathy due to spinal arachnoid cyst. A case report. Spine (Phila Pa 1976). 1986;11(1):8082.

  • 17

    Viswanathan VK, Manoharan SR, Do H, et al. Clinical and radiologic outcomes after fenestration and partial wall excision of idiopathic intradural spinal arachnoid cysts presenting with myelopathy. World Neurosurg. 2017;105(4):21322.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Papadimitriou K, Cossu G, Maduri R, et al. Endoscopic treatment of spinal arachnoid cysts. Heliyon. 2021;7(4):e06736.

  • 19

    Ebot J, Domingo R, Ruiz Garcia H, Chen S. Intradural thoracic arachnoid cyst fenestration for spinal cord compression: a case illustration and video demonstration. Cureus. 2020;12(1):e6572.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Tokmak M, Ozek E, Iplikcioglu AC. Spinal extradural arachnoid cysts: a series of 10 cases. J Neurol Surg A Cent Eur Neurosurg. 2015;76(5):348352.

  • 21

    Imperato A, Cinalli MA, Iammarrone FS, Ruggiero C, Cinalli G. Minimally invasive endoscopic fenestration of a spinal arachnoid cyst in a child with tetrasomy 18p: illustrative case. J Neurosurg Case Lessons. 2022;3(21):CASE21682.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • Collapse
  • Expand
  • FIG. 1.

    Preoperative sagittal (left) and axial (right) T2-weighted MRI showed a cystic cervical spinal canal lesion 4 cm in size extending from C0 to C6. The spinal cord measured 3.6 mm in its narrowest dimension when measured on sagittal T1-weighted imaging, and its caliber normalized at the cervicothoracic junction. The localizer for the axial image is indicated by the line in the left panel.

  • FIG. 2.

    Postoperative day 1 sagittal (left) and axial (right) T2-weighted MRI of the patient’s cervical spine identified laminectomies at C4–6 with persistent but improved narrowing of the spinal cord within the cervical spine, now measuring 4.7 mm at its narrowest when measured on sagittal T1-weighted imaging. The localizer for the axial image is indicated by the line in the left panel.

  • FIG. 3.

    Ten-month postoperative sagittal (left) and axial (right) T2-weighted MRI of the patient’s cervical spine showed postsurgical changes of a C4–6 laminectomy and a gradual decrease in the size of the ventral thecal sac. The size of the sac was measured as 3.4 × 0.9 × 1.8 cm, spanning from C2 to C5, with stable flattening of the cervical spinal cord seen in the previous imaging. The localizer for the axial image is indicated by the line in the left panel.

  • 1

    Takahata M, Watanabe T, Endo T, Ogawa Y, Miura S, Iwasaki N. Pulsating spinal arachnoid cyst as a hidden aggravating factor for thoracic spondylotic myelopathy: a report of 3 cases. JBJS Case Connect. 2022;12(2):e22.00027.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Bond AE, Zada G, Bowen I, McComb JG, Krieger MD. Spinal arachnoid cysts in the pediatric population: report of 31 cases and a review of the literature. J Neurosurg Pediatr. 2012;9(4):432441.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Andrews BT, Weinstein PR, Rosenblum ML, Barbaro NM. Intradural arachnoid cysts of the spinal canal associated with intramedullary cysts. J Neurosurg. 1988;68(4):544549.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Basaran R, Kaksi M, Efendioglu M, Onoz M, Balkuv E, Kaner T. Spinal arachnoid cyst associated with arachnoiditis following subarachnoid haemorrhage in adult patients: a case report and literature review. Br J Neurosurg. 2015;29(2):285289.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Kumar K, Malik S, Schulte PA. Symptomatic spinal arachnoid cysts: report of two cases with review of the literature. Spine (Phila Pa 1976). 2003;28(2):E25E29.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Hubbard ME, Hunt MA, Jones KE, Polly DW. Thoracic spinal cord impingement by an arachnoid web at the level of a hemivertebra: case report. J Neurosurg Spine. 2017;27(6):638642.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Silbergleit R, Brunberg JA, Patel SC, Mehta BA, Aravapalli SR. Imaging of spinal intradural arachnoid cysts: MRI, myelography and CT. Neuroradiology. 1998;40(10):664668.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Eroglu U, Bozkurt M, Kahilogullari G, et al. Surgical management of spinal arachnoid cysts in adults. World Neurosurg. 2019;122:e1146e1152.

  • 9

    Garg K, Borkar SA, Kale SS, Sharma BS. Spinal arachnoid cysts - our experience and review of literature. Br J Neurosurg. 2017;31(2):172178.

  • 10

    Bitaraf MA, Zeinalizadeh M, Meybodi AT, Meybodi KT, Habibi Z. Multiple extradural spinal arachnoid cysts: a case report and review of the literature. Cases J. 2009;2:7531.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Ordaz JD, Huh A, Desai V, Raskin JS. Iatrogenic spinal deformity following spinal intradural arachnoid cyst fenestration despite minimal access with laminoplasty and endoscopy in a pediatric patient. Cureus. 2022;14(2):e22053.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Ben Ali H, Hamilton P, Zygmunt S, Yakoub KM. Spinal arachnoid web—a review article. J Spine Surg. 2018;4(2):446450.

  • 13

    Endo T, Takahashi T, Jokura H, Tominaga T. Surgical treatment of spinal intradural arachnoid cysts using endoscopy. J Neurosurg Spine. 2010;12(6):641646.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Nabors MW, Pait TG, Byrd EB, et al. Updated assessment and current classification of spinal meningeal cysts. J Neurosurg. 1988;68(3):366377.

  • 15

    Qi J, Yang J, Wang G. A novel five-category multimodal T1-weighted and T2-weighted magnetic resonance imaging-based stratification system for the selection of spinal arachnoid cyst treatment: a 15-year experience of 81 cases. Neuropsychiatr Dis Treat. 2014;10:499506.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Dyck P. Myelopathy due to spinal arachnoid cyst. A case report. Spine (Phila Pa 1976). 1986;11(1):8082.

  • 17

    Viswanathan VK, Manoharan SR, Do H, et al. Clinical and radiologic outcomes after fenestration and partial wall excision of idiopathic intradural spinal arachnoid cysts presenting with myelopathy. World Neurosurg. 2017;105(4):21322.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Papadimitriou K, Cossu G, Maduri R, et al. Endoscopic treatment of spinal arachnoid cysts. Heliyon. 2021;7(4):e06736.

  • 19

    Ebot J, Domingo R, Ruiz Garcia H, Chen S. Intradural thoracic arachnoid cyst fenestration for spinal cord compression: a case illustration and video demonstration. Cureus. 2020;12(1):e6572.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Tokmak M, Ozek E, Iplikcioglu AC. Spinal extradural arachnoid cysts: a series of 10 cases. J Neurol Surg A Cent Eur Neurosurg. 2015;76(5):348352.

  • 21

    Imperato A, Cinalli MA, Iammarrone FS, Ruggiero C, Cinalli G. Minimally invasive endoscopic fenestration of a spinal arachnoid cyst in a child with tetrasomy 18p: illustrative case. J Neurosurg Case Lessons. 2022;3(21):CASE21682.

    • PubMed
    • Search Google Scholar
    • Export Citation

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