What is the recommended treatment for a patient with a spinal cyst?

Treatment of Spinal Cysts

The recommended treatment for spinal cysts depends on symptomatology, with surgical intervention indicated for symptomatic cysts causing neurological deficits, while asymptomatic or mildly symptomatic cysts should be managed conservatively. 1

Diagnostic Approach

• Initial evaluation should include both brain MRI and non-contrast CT scan to properly classify the cyst type and location 2
• MRI with 3D volumetric sequencing (such as FIESTA, 3D CISS, or BFFE) provides enhanced resolution for detection of extra-axial cysts in ventricles or subarachnoid spaces 2
• For patients with suspected spinal cysts, MRI is the diagnostic procedure of first choice as it demonstrates the exact location, extent, and relationship of the cyst to the spinal cord 3
• CT-Myelography may be valuable to demonstrate communication between the subarachnoid space and the cyst, which is important for surgical planning 3

Treatment Algorithm Based on Symptomatology

For Asymptomatic or Mildly Symptomatic Cysts:

• Conservative management is strongly recommended for asymptomatic or mildly symptomatic cysts 1
• Patient counseling and reassurance about the benign nature of the finding is essential 1
• Follow-up MRI after 1 year to demonstrate stability may be reasonable, but long-term imaging follow-up is not necessary for asymptomatic cysts 1
• Most perineural cysts (>80%) remain stable in size over time 1

For Symptomatic Cysts:

Parenchymal Cysts:

• For patients with 1-2 viable parenchymal cysticerci, albendazole monotherapy for 10-14 days is recommended (15 mg/kg/day divided into 2 daily doses, maximum 1200 mg/day) 2
• For patients with >2 viable parenchymal cysticerci, combination therapy with albendazole (15 mg/kg/day) and praziquantel (50 mg/kg/day) for 10-14 days is recommended 2

Intraventricular Cysts:

• Surgical removal by minimally invasive neuroendoscopy is recommended for cysts in lateral and third ventricles 4
• When surgical removal is technically difficult, shunt surgery for hydrocephalus is suggested 4
• In patients with untreated hydrocephalus, management of elevated intracranial pressure alone (not antiparasitic treatment) is recommended 2

Spinal Arachnoid Cysts:

• Surgical treatment is the standard approach for symptomatic spinal arachnoid cysts 3, 5
• The aim of surgical treatment is neural decompression and prevention of refilling of the cyst 3
• Complete resection of the cyst and closure of the communication between cyst and subarachnoid space is the optimal approach 3
• Surgical techniques include:
  • Cyst resection (most common, 68% of cases) 5
  • Ligation of the connecting pedicle (21% of cases) 5
  • Fenestration/marsupialization (11% of cases) 5

Pre-treatment Precautions

• All patients should undergo fundoscopic examination prior to initiation of anthelmintic therapy 2
• For patients likely to require prolonged corticosteroids, screening for latent tuberculosis infection is suggested 2
• Screening or empiric therapy for Strongyloides stercoralis is suggested for patients likely to require prolonged corticosteroids 2

Follow-up Recommendations

• MRI should be repeated at least every 6 months until resolution of the cystic component for patients who received antiparasitic therapy 2
• For asymptomatic cysts managed conservatively, routine clinical follow-up without mandatory imaging is recommended 1
• Consider repeat imaging only if there is clinical deterioration 1
• Postoperative MRI is recommended to confirm complete resolution of surgically treated cysts 5

Outcomes and Prognosis

• Surgical outcomes are generally favorable in patients without preoperative cord damage 3
• Patient-reported outcomes typically show improvement in quality of life parameters following surgical intervention 5
• Complications are rare but may include delayed wound infection (reported in approximately 5% of cases) 5
• Recurrence is possible following surgery, particularly if the cyst wall is not completely resected 6

Special Considerations

• The optimal surgical approach should consider the cyst location, size, and relationship to neural structures 7
• For synovial cysts, underlying spinal instability and facet joint arthropathy have strong associations with symptom worsening and cyst formation 6
• Cervical synovial cysts are extremely rare but should be considered in patients with cervical myelopathy 8