Intramedullary Dermoid Cyst With Relatively Atypical Symptoms

A Case Report and Review of the Literature

Maryam Sanaullah; Sidra Mumtaz; Akhtar Amin Memon; Abdul Sattar Mohammad Hashim; Sanaullah Bashir

Disclosures

J Med Case Reports. 2013;7(104) 

In This Article

Discussion

Intraspinal dermoid cysts, also termed 'spinal cutaneous inclusion tumors' are rare, benign, slow-growing tumors that account for less than 1 percent of spinal tumors[8] and arise due to improper separation of the neuroectoderm from the surface ectoderm.

Inclusion dermoids are characterized either into congenital or implanted arrays, the former being more frequent as well as important. A frequent cause of development of such cysts is assertive admittance of the ectodermal cells subsequent to an injury.[9] The patient in this case denied any such history. The cyst presentation at different spinal levels shows a discrepancy. Two of the cases reported from India[2,3] revealed an intramedullary cyst at levels L4-S2 and C3-D2 respectively.

In the lumbosacral region, epidermoid tumor is more common, dermoid tumor is relatively uncommon and the intramedullary manifestation of a dermoid tumor is an exceptionally rare occurrence.[10,11]

They remain clinically silent until symptoms appear in the second or third decade of life.[12] Muthukumar et al. presented a case report that corresponded with the MRI findings, however, our case is atypical with regard to the absence of bladder symptoms.[2] Moreover, Shah et al. reported the case of a 3-year-old boy, indicating that symptoms may develop earlier in some cases.[4]

These cysts are often diagnosed when presenting clinically as neurologic manifestations, ranging from paresthesias to paralysis and sphincter complications.[13] In this case, the patient presented with numbness, weakness and paresis progressing to complete immobility. The case series of epidermoid and dermoid tumors of the spinal cord presented by Bradford evidenced most of the cases with urinary symptoms, either retention or incontinence,[11] however, the patient in our case denied any of these symptoms but rather presented with bowel disturbance. Gercek et al. also reported the case of a patient with a spinal dermoid cyst with a dissynergic bladder.[14]

This case gives an excellent clinical picture of a spinal intramedullary dermoid cyst without the classic symptoms of incontinence or signs of spinal dysraphisms.

Our case report also calls attention to the diagnosis of dermoid cyst in spinal surgical patients with the help of MRI and histopathological evaluations. Our patient was initially diagnosed as having TB of the spine due to conventional conjecture and overlapping symptoms. In the case of misdiagnosis, the rupture of the cyst can result in arachnoid, meningeal or cerebral irritation as a result of dissemination through cerebrospinal fluid pathways.[12]

The pus culture did not reveal any bacterial growth (including acid-fast bacilli (AFB)) and further excluded the diagnosis of TB of the spine.

The treatment of choice for the dermoid tumor is the total excision of the mass at an early stage. Total mass excision is possible for extramedullary dermoid cysts; however, in intramedullary dermoid cysts, the capsule adheres to the cord[13] and often leads to difficulties in their complete resection through surgery.[15] In our case, the tumor had well-demarcated boundaries hence total resection was accomplished.

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