V06-06: Interdisciplinary Approach to Dermoid Cyst of the Spine: How Can Urologists Help Neurosurgeons?
Spinal intradural dermoid cysts are rare benign lesions that can produce local mass effect. Traditionally treatment has been open removal of symptomatic lesions by neurosurgeons. However, local recurrence is common due to the difficulty of removing all elements surgically, especially in delicate spaces around the cord and nerve roots. In the present video, we report a case of a spinal dermoid cyst presenting with a tethered cord-like syndrome including fecal incontinence and perineal and lower extremity numbness. We highlight how the endoscopic skills of urologists can be used to treat this difficult neurosurgical problem. To our knowledge, flexible endoscopy in the intradural space has not been previously described in humans.
After multidisciplinary discussions, we devised a plan to use a 16 Fr flexible cystoscope with low-pressure gravity saline irrigation to access the spinal canal via incision of the pseudomeningocele. Given the soft texture of the dermoid cysts, a 5-6 Fr Penumbra thromboembolectomy device was felt to be suitable to suction the tumor and was inserted through the cystoscope for real-time visualization of cyst removal. Continuous neuromonitoring was used to identify any changes in intracranial pressure. The neurosurgery team was adequately prepared to convert to an open surgery in the event of neurological changes.
By post-operative day 1, the patient reported complete resolution of her neurological presenting symptoms, and she was discharged uneventfully by post-operative day 3. A post-operative MRI demonstrated almost complete resection of the lesion. At 3-year follow-up, the patient was found to have some regrowth of dermoid cyst in the lumbar region on MRI. However, her symptoms have remained unchanged since her surgery, and she continues to be followed conservatively. Should her symptoms worsen, repeat endoscopic resection can be considered.
For the first time, we report the successful utilization of endoscopy in the intradural space. Indeed, urologic technologies and skills have potential novel applications in non-urologic surgeries. Interdisciplinary cooperation can provide effective treatment options that would not otherwise be possible. Patient selection and cautious planning play an important role in devising innovative surgical approaches. In this particular case, the patient benefited from thoughtful collaboration between urologists and neurosurgeons.