Thoracic Intramedullary Ependymal Cyst - A case report

Abstract

Intramedullary ependymal cysts are rare in children, with a reported incidence of 0.8% in the thoracic spine. Ependymal cysts are more commonly seen in the conus medullaris of the spine. Symptoms depend on the size and location of the cyst and can include back pain, motor/sensory impairments, and bowel/bladder dysfunction. Case presentation: We present a case of a 14-year-old male child with bilateral lower extremity weakness, urinary dribbling and enuresis. His symptoms which were apparent for 4 years, have progressed 2 months before presentation and he was non- ambulatory at presentation. Objective assessment showed only flickering movements in lower key muscle groups bilaterally with visible decreased muscle bulk but patient had intact perianal sensation. Magnetic resonance imaging showed:  Anatomic vertebra alignment,  T3-T4 level involving T1 hypointense and T2/STIR hyperintense cord expansile lesion, measuring 1.6x3.5x1.6cm. No enhancement seen. Normal adjacent cord, soft tissue, and bony structures. Laminectomy, cyst fenestration, and partial ependymal cyst wall excision was done. Patient currently is continued on outpatient  follow-up and intensive physiotherapy. He had started to ambulate with walking stick at the start of fourth post- operative month. He also has the urinary complaints resolved. Conclusion: Ependymal cysts tend to be benign and slow growing. The lesions can present with a wide range of symptoms depending on the site of occurrence. MRI is the primary imaging modality for diagnosis. Options of treatment include cyst wall fenestration and marsupialization, which aim to prevent cyst refilling. Timely detection and removal of the cysts averts neurological damage and progressive disability. Postoperative rehabilitation is important part of management for spinal cord lesions with prolonged neurologic deficits at presentation.