Iatrogenic intradural epidermoid cyst after lumbar puncture

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This 7-year-old boy presented with a 7-month history of back pain with radiation into the lower extremities. He had no gait changes or bladder dysfunction. His medical history was notable for premature birth. Three lumbar puncture attempts for sepsis evaluation were made when he was a neonate. Reportedly, a stylet was not used in the procedure and cerebrospinal fluid was difficult to obtain.

Motor, sensory, and reflex examinations revealed normal findings. He had positive straight leg raise tests bilaterally at 30°. Flexion and extension of the lumbar spine was limited due to pain. Magnetic resonance (MR) images of the lumbar

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Address reprint requests to: Daniel Refai, M.D., Department of Neurosurgery, Washington University, 660 South Euclid Avenue, St. Louis, Missouri 63110. email: refaid@nsurg.wustl.edu.

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    Sagittal T2-weighted (left) and contrast-enhanced T1-weighted (right) MR images of the lumbar spine demonstrating imaging characteristics of an intradural extramedullary epidermoid cyst involving the cauda equina.

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    Intraoperative photograph showing the epidermoid cyst.

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    Photomicrograph of the epidermoid cyst. Abundant flakes of enucleated squamae, comprising the cyst contents, arise from a thin, keratinizing, stratified squamous epithelium that is supported by collagenous connective tissue of variable thickness. Focally, the connective tissue is mineralized (not shown). Absent from the lesion are adnexal structures (such as hair follicles, apocrine glands, and sebaceous glands) required for a diagnosis of dermoid cyst. H & E, original magnification × 200.



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