Dermoid Cysts

With dermoid cysts the situation is different; they contain cells that produce some kind of gradually accumulating product. This will increase the size of the cyst with the potential of progressive pressure on the spinal cord. The history is considerably shorter compared to lipomas - 29±51 months in this series, ranging from 1 month to 10 years. Even acute presentations related to aseptic meningitis [65, 296] or abscess formation [49] have been described. The average age was 32±6 years (range 25-42 years), with pain in three patients and motor weakness in two patients as the major clinical problems (Table 3.27) [197].

The goal of treatment should be a radical excision. Unfortunately, the cyst wall may be extremely adherent to the cord substance, making it almost impossible to achieve a complete resection without damaging the cord. Sharp dissection is often required (Figs. 3.50 and 3.81). Furthermore, the cyst material maybe very irritating for the arachnoid membrane, with a significant risk of aseptic meningitis, if the subarachnoid space becomes contaminated [197]. Therefore, we consider dermoid cysts to be one of the most difficult surgical challenges among intradural spinal pathologies. If a complete resection can be performed, the outcome will be favorable [30, 179]. On the other hand, it may be wiser to leave part of the cyst wall in

Fig. 3.81. a Sagittal T1-weighted MRI scan of an intramedullary dermoid cyst at L1-L2 and a tethered cord in a 42-year-old woman with a 10-year history of pain and progressive paraparesis. The postoperative T1-weighted image (b) demonstrates the result after partial resection of the cyst and release of the tethering. No duraplasty was inserted, but despite postoperative fixation of the conus to the dura, no progressive myelopathy developed

Fig. 3.81. a Sagittal T1-weighted MRI scan of an intramedullary dermoid cyst at L1-L2 and a tethered cord in a 42-year-old woman with a 10-year history of pain and progressive paraparesis. The postoperative T1-weighted image (b) demonstrates the result after partial resection of the cyst and release of the tethering. No duraplasty was inserted, but despite postoperative fixation of the conus to the dura, no progressive myelopathy developed

place rather than to force the issue of radical excision (Figs. 3.50 and 3.81). After incomplete resections, recurrence rates appear to be low [197]. We have resected one dermoid cyst completely, performed subtotal resections in the other three instances, and a decompression in one patient. No recurrences were observed for these patients (Table 3.27). Again, two patients were affected by a dysesthesia syndrome, of which one progressed to a myelopathy associated with cord retethering.

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