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21KF-050
An overlooking diagnosis of a spinal extradural arachnoid cyst(SEAC) in headache patients: A Case Report

Jeong Jeong3Young Ju Lee1, Dongwon Jo1, Yong-Jae Yoo1, Heesoo Kim1,2, Jee Youn Moon1,2

1. Department of Anesthesiology and Pain Medicine, Pain Center, Seoul National University Hospital, Seoul, Republic of Korea  

2. Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Republic of Korea 

3. Department of Anesthesiology and Pain Medicine, Pain Center, Boramae munincipal hospital, Seoul, Republic of Korea

Introduction
A spinal extradural arachnoid cyst (SEAC), which is rare exapnading lesions within the spinal canal that can occur extra- or intra- durally and that are commonly located in the posterolateral aspect of the thoracic or sacral spine displacing the spinal cord anteriorly, accounting for approximately 1% to 3% of spinal tumors.

Case
A 41-year- old woman presented with a chief complaint of periauricular headache and hand numbness first appeared from 30 years ago and often combined with right facial pain and right side of facial palsy-like symptoms. She have not had other procedural treatment but having medicated with oral medicines, like ibuprofen(NSAID) and naratriptan(a selective 5-HT1 receptor subtype agonist).
On neurological examination, she demonstrated no other specific neck neurologic symptoms. Furthermore, we performed a radiological examination of the patient, including brain MRI which shows tiny vascular protrusion in the right distal ICA but no significant defects and changes since 2018.
At the next time of admission, we found that the patient also had postural variation and exacerbating factors such as being her back. This time, the patient underwent C2 dorsal root ganglion block and atlantoaxial joint injection but the symptoms didn’t get better and furthermore starting to complaining hand and leg numbness. Additionally performed extended C-spine MRI showed compressing large cystic lesion at T11-L1 which was along with the marked pressure bone erosion and foraminal widening at this level. (figure 1-1, 1-2)
At the following day, the patient received again the cervical epidural block (CEB) at C7-T1 level, and then her symptoms reduced in half severity, improved dizziness and numbness. Based on the clinical results of the cervical epidural block is helpful in relieving symptoms, the patient underwent one more time and planned for the neurosurgical consultation meeting for the surgery options.

Conclusion
When we approach the history to the patient with headache, we should not overlook the symptom severity change depends on the postural variation which might be the key facts to differentiate the diagnosis.
If the atypical headache and other symptoms persists, not only C-spine and brain but also T or L spine MRI may be helpful. In our case, it was extended C-spine MRI which covers almost whole spine.