Large intramedullary bronchogenic cyst of the cervical spine: illustrative case

Abstract

Background: Spinal bronchogenic cysts are rare entities arising from errors in embryogenesis and consisting of respiratory epithelial cells. To date, there are three other published accounts of intramedullary cysts, which were partially resected and thereby warrant close follow-up and monitoring. The authors present an illustrative case of a patient presenting with Klippel-Feil anomaly and a large intramedullary bronchogenic cyst in the upper cervical spine.

Observations: The authors noted fusion of the C5-6 laminae as they performed the C2-6 laminectomy. After dural opening, an intramedullary lesion with a smooth, fibrous component emerging from the dorsal spinal cord was immediately observed. The dorsal spinal columns were not involved with this cyst wall or the other smaller cysts, which all contained gray fluid. The cyst walls were partially resected and sent for pathological examination.

Lessons: Spinal developmental cysts are associated with other anatomical anomalies, such as Klippel-Feil anomaly, arising from errors in embryogenesis. For intramedullary lesions such as this patient's bronchogenic cyst, partial resection and decompression are the goals of surgery because aggressive debulking may lead to neurological compromise. Close imaging follow-up is warranted.

Keywords: CSF = cerebrospinal fluid; CT = computed tomography; MRI = magnetic resonance imaging; XR = radiograph; bronchogenic cyst; cervical spine; cystic; developmental cyst; intramedullary.

FIG. 1.

Preoperative MRI with and without contrast enhancement of the cervical spine. A: Sagittal T2-weighted precontrast image of the cervical spine showing a multinodular lesion and syrinx (asterisk). B: Axial T2-weighted precontrast cross-sectional image of the cervical spine. C: Sagittal T1-weighted postcontrast image of the cervical spine showing a heterogeneously enhancing nodular and cystic lesion. D: Axial T1-weighted postcontrast cross-sectional image of the cervical spine showing an enhancing nodular component (asterisk).

FIG. 2.

Intraoperative photos of cystic intramedullary spinal bronchogenic cyst. A: Visualization of the intramedullary lesion with fibrous cyst wall after dura opening (asterisk). B: Ventral spinal cord (arrow) and cyst components (asterisk) after excision of smooth muscle fibers. C: Gray, gelatinous cyst contents (asterisk). D: Partial resection of intramedullary lesion.

FIG. 3.

Photomicrographs of biopsied cyst wall. A: Image at magnification ×10 showing cyst wall section stained for cytokeratin 20 (CK20). This section is negative for CK20. B: Image at magnification ×10 showing cyst wall section positively staining for CK7. C: Image at magnification ×10 showing cyst wall section positively staining for and highlighting smooth muscle myosin layer beneath epithelium. D: Image at magnification ×40 showing stratified columnar ciliated epithelium.

FIG. 4.

Six-week postoperative MRI with and without contrast enhancement of the cervical spine. A: Sagittal T2-weighted precontrast postoperative image showing decrease in syrinx size. B: Axial T2-weighted precontrast cervical spine cross-section. C : Sagittal T1-weighted postcontrast image showing residual nodular lesion. D: Axial T1-weighted postcontrast image showing cervical spine cross-section of the enhancing lesion.