Spinal intradural arachnoid cysts are rare, benign intradural lesions of the spinal cord that can arise as a primary lesion or secondary due to inflammatory processes. Symptoms can range from an asymptomatic incidental finding to progressive myelopathy, with paresthesia and neuropathic pain. We present the case of an 80-year-old female with a longstanding history of back pain, urinary incontinence, difficulty ambulating and frequent falls, with rapid progression of her symptoms prior to presentation. Physical examination revealed lower extremity weakness, decreased sensation and increased deep tendon reflexes. Thoracic spine MRI showed an extra-axial cystic lesion extending from T4 to T10, causing severe compression of the spinal cord. We performed two separate thoracic laminectomies at T4-T5 and at T9-T10, with microsurgical fenestration of the dorsal arachnoid cyst performed under continuous intraoperative neurophysiologic monitoring. Intraoperative fluoroscopy and ultrasound were used for localization purposes. The patient was discharged on postoperative day 6 to an inpatient rehabilitation facility with no neurological complications. She presented a month later with significant improvement in ambulation and lower extremity strength.

PURPOSE: Preoperative stereotactic radiosurgery (SRS) for symptomatic brain metastases has arisen as a therapeutic option for patients with brain lesions, potentially reducing radionecrosis risk, leptomeningeal disease risk, as well as delays in systemic therapy after craniotomy. The purpose of our work is to analyze the current evidence regarding 1-year local control (LC) and RN rates in the preoperative and postoperative settings. METHODS AND MATERIALS: Population, Intervention, Control, Outcomes, Study Design/Preferred Reporting Items for Systematic Reviews and Meta-analyses and Meta-analysis of Observational Studies in Epidemiology guidelines were used to select articles in which patients had “large” brain metastases (>4 cm3 or >2 cm in diameter) solely treated with preoperative or postoperative SRS and 1-year LC and/or rates of RN reported. Radiosurgery was stratified by timing: preoperatively or postoperatively. Random effects meta-analyses using timing of SRS relative to surgery as covariates were conducted. Meta-regression and Wald-type tests were used to determine the effect of increasing tumor size on the summary estimate, where the null hypothesis was rejected for p < 0.05. RESULTS: Fifteen studies were included (of 314 screened), published between 2012 and 2018 with 854 brain metastases. Preoperative SRS was delivered in 229 lesions. The 1-year LC random effects estimate was 79.1% (95% confidence interval [CI]: 55.9–95.0%; I2 = 80%) for preoperative SRS and 80.5% (95% CI: 66.3–91.5%; I2 = 93%) for postoperative SRS (p=0.9). Radionecrosis incidence random effects estimate was 2.1% (95% CI: 0.1–8.6%; I2 = 36%) for preoperative SRS and 6.3% (95% CI: 1.1–15.4%; I2 = 90%) for postoperative SRS (p=0.52). CONCLUSIONS: Rates of 1-year LC and RN incidence are similar after preoperative SRS as compared to postoperative SRS for large brain metastases. Results from ongoing prospective clinical trials studying preoperative SRS are important to further investigate these two techniques.