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Presented by Peter Illei, M.D. and prepared by Amy Duffield, M.D., Ph.D.
Case 4: This 77 y.o. white male patient with a history of multiple previous lumbar spine operations.
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1. Question
Week 313: Case 4
This 77 y.o. white male patient with a history of multiple previous lumbar spine operations (x3) for an unknown spinal tumor presented with progressive worsening of low back pain, severe left lower extremity pain and weakness and bowel and bladder dysfunction. The patient’s myelogram and post myelogram CT scan demonstrated a complete block behind the L2 vertebral body. Furthermore, the patient had a large disc herniation of the L2-3 level on the right side with compression on the right L3 nerve root. The patient also had significant bilateral foraminal sclerosis at the L4-5 level with compression of both L5 nerve roots. During surgery an intradural extramedullary tumor was identified at L4-5 and submitted for frozen section analysis.images/EIC 1 6_11_07.jpg
images/EIC 2 6_11_07.jpg
images/EIC 3 6_11_07.jpg
images/EIC 4 6_11_07.jpgCorrect
Answer: Epidermoid cyst
Histology: none provided
Discussion: Sections show acellular keratinaceous debris with dispersed calcification. No viable epithelium is identified. Immunostain for cytokeratin (AE1/AE3) is positive and confirms the keratinaceous nature of the material. These findings are compatible with contents of an epidermal cyst.
There are two variants of ectodermally derived cysts in the central nervous system that are both lined by keratinizing squamous epithelium. The epidermoid cysts lack skin appendages, whereas the dermoid cysts contain them. Both cysts are thought to be developmental in origin, however, there are also acquired ones (mostly epidermoid) that usually follow traumatic or iatrogenic (surgery, lumbar puncture etc.) implantation.
Epidermoid cysts can arise at any age, are found along the entire neuroaxis with a predilection for the cerebellopontine angle. Intraspinal tumors are typically intradural and extramedullary in location.
Incorrect
Answer: Epidermoid cyst
Histology: none provided
Discussion: Sections show acellular keratinaceous debris with dispersed calcification. No viable epithelium is identified. Immunostain for cytokeratin (AE1/AE3) is positive and confirms the keratinaceous nature of the material. These findings are compatible with contents of an epidermal cyst.
There are two variants of ectodermally derived cysts in the central nervous system that are both lined by keratinizing squamous epithelium. The epidermoid cysts lack skin appendages, whereas the dermoid cysts contain them. Both cysts are thought to be developmental in origin, however, there are also acquired ones (mostly epidermoid) that usually follow traumatic or iatrogenic (surgery, lumbar puncture etc.) implantation.
Epidermoid cysts can arise at any age, are found along the entire neuroaxis with a predilection for the cerebellopontine angle. Intraspinal tumors are typically intradural and extramedullary in location.
