Spinal cord compression by multiple cysticercosis

Surgical procedure

The patient required two separate laminectomies involving both the T4–T6 and T9–T11 levels for resection of spinal NCC cysts. At the T4–T6 levels, once the dura was opened, 12 cystic lesions of different sizes protruded through the arachnoid gap and were removed along with the arachnoid membrane [Figure 2]. However, at the T9–T11 level, on opening the dura, severe arachnoiditis due to spinal NCC made it difficult to identify the spinal cord, a decompression and NCC cyst excision were attempted but ultimately resulted in rupture of a cystic lesion. The dura at both levels was then sutured in a watertight fashion followed by routine closure.

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Figure 2: Image of the white colored cysts that were removed.

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Pathology and follow-up

The histopathological report confirmed spinal NCC [Figure 3]. Postoperatively, the patient was treated with corticosteroids and Albendazole (30 mg/kg/day) for 15 days.

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Figure 3: Hematoxylin and eosin staining indicated an eosinophilic outer cuticle layer and a single-layered sub-cuticle cell, representing typical cysticercosis findings, at magnification (a) ×100 and (b) ×50.

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Immediately postoperatively, the patient regained 2/5 motor function in the lower extremities. The MR 1 month later showed partial resolution of the preoperative cord compression at both the T4–6 and T9–11 levels. In addition, corticosteroids were continued for the next 3 months to reduce inflammation [Figure 4]. One year postoperatively, the patient was still paraparetic, but could take small steps with the help of a walker (e.g. motor 3–4/5 bilaterally).

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Figure 4: Postoperative T2-weighted magnetic resonance imaging. (a) Sagittal view showing the signal intensity of cerebrospinal fluid without septations in the upper thoracic level and partial resolution in the low level. (b and c) Axial view with a resolution of the compression in the upper level (b) and persistence of the cysts in the low level.

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Frequency of spinal NCC

Spinal NCC is rare (0.7%–3%) and occurs either in intradural intramedullary or intradural extramedullary locations. In most cases it is associated with intracranial lesions, suggesting that the predominant etiology is direct dissemination (e.g., drop lesions) through the cerebrospinal fluid (CSF). However, there are other cases of isolated spinal involvement, attributed to retrograde migration of NCC through the epidural venous plexus. In a prior study, 31.5% of patients in Mexico with spinal cysticerci had a previous history of subarachnoid cysticercosis.[4]

Location of spinal NCC

Spinal NCC most frequently involves the lumbar and thoracic regions. In two studies, Indian patients typically presented with solitary intramedullary NCC lesions, while Mexican patients mostly had multiple extramedullary NCC (e.g., 68.4%).[2,4]

Clinical presentation

Spinal NCC may result in spinal cord and/or nerve roots symptoms/signs attributed to arachnoiditis, and/or focal compression.[7] Differential diagnoses typically include: neuroenteric, arachnoid, dermoid, epidermoid and hydatid cysts, as well as cystic schwannoma, tuberculomas, or intradural tumors.[7] Enzyme-linked immunosorbent assay testing of CSF may be useful in establishing the diagnosis of spinal NCC.

Surgery for spinal NCC

Surgical treatment is indicated where patients exhibit severe neurological deficits or when definitive histopathology is required to establish the diagnosis. When removing these lesions microsurgically, it is best to preserve the cyst wall; nevertheless, sometimes this is difficult to achieve, particularly when severe arachnoiditis is present (e.g., as in this case at the T9–11 levels where the cyst ruptured). Medical treatment includes a combination of Albendazole and corticosteroids. Despite adequate therapy, some patients may still continue to exhibit severe perioperative/postoperative morbidity (i.e., resultant neurological sequelae), or mortality.[8]