Reason for Consultation:

Intradural extramedullary cystic mass consistent with arachnoid cyst C7-T5.
This is a 38-year-old female who sent her medical records to Johns Hopkins Hospital for a second opinion.

The patient apparently had been in her usual state of health until about 5/9. At that time, the patient reportedly developed difficulty moving her right arm as well as numbness in the right upper extremity. Furthermore, she complained of pain in the area of the lower neck as well as shoulders.

These were initially treated with acupuncture and moxa cautery in an Oriental Medicine Clinic. Following that, the patient's symptoms apparently improved. Later, the patient was evaluated by an orthopedic surgeon who thought that the patient might have a herniated disk in the cervical region. Subsequently, an MRI scan was performed. The MRI demonstrated an intradural extramedullary cystic mass consistent with an arachnoid cyst, extending from C7 down to T5.

At that time, the patient's neurological examination reportedly demonstrated increased reflexes. At that time, the evaluation showed 2+ reflex in upper and lower extremities. There was no Babinski. The patient since then was intermittently followed based on the medical entries made in the system in the records in 11/9, 2/10, and 2/13. The patient apparently remained quite stable over that time as far as her symptoms are concerned.

Assessment and Recommendations:

The patient sent her records to us for further review and make recommendations.

The patient then specifically asked to us whether or not this was consistent with an arachnoid cyst diagnosis. She also wanted to know how she should be careful in her daily activities. She also wants to know if the surgery is recommended to prevent further symptoms or worsening of the symptoms. Finally, she wanted to know what would the constituted worsening of her clinical size.

The patient's clinical picture is consistent with an arachnoid cyst. The arachnoid cyst appears to extend from C7 down to T5 with significant compression of the spinal cord from dorsally with displacement of the spinal cord towards the right side. The patient's medical records do not show any significant neurological compromise, although the patient subjectively initially complained of interscapular pain, pain in the shoulder area as well as numbness in the right upper extremity.

The patient is still asymptomatic and remains so since 2009. The patient may continue with the serial observations as she has been doing before. However, if the patient's symptoms are getting worse or if the patient has any detectable weakness, then a surgery would be indicated. The surgical procedure proposed here would be an operation from the back with an incision extending from the mid portion of the cervical spine to the lower part of the thoracic spine with multilevel laminoplasty operation including C6-T6 levels with marsupialization of the cyst with excision of the cyst wall and decompression of the spinal cord.

Operation is recommended if the patient's symptoms are getting worse to not only prevent further worsening, but also to improve the patient's current symptomatology. I would not recommend any specific restrictions in her daily activities, If the patient decided to choose watchful observation with serial imaging studies. The risks of the surgery includes bleeding, infection, weakness, paralysis, loss of bowel or bladder control, coma, even death as a result of surgical procedure, but I think that these risks are very small and the patient likely to benefit from the surgical intervention. The most likely complication would be cerebrospinal fluid leakage, which is usually easily treatable.

The patient would like travel to Johns Hopkins Hospital for an evaluation and possible surgical treatment.
I will be glad to see the patient.

The further worsening of the symptoms would include worsening numbness in upper lower extremities, worsening weakness in her upper and lower extremities, bowel or bladder dysfunction, gait impairment, and difficulty with walking.


Ziya L. Gokaslan, M.D. F.A.C.S.