# Case Report: Scalpel Sign and Dorsal Arachnoid Cyst—The Importance of an Accurate Diagnosis

## TL;DR

This case report highlights the importance of recognizing the 'scalpel sign' in diagnosing a rare spinal condition called dorsal arachnoid web, which can lead to improved outcomes with timely surgery.

## Contribution

The report emphasizes the diagnostic value of the scalpel sign and advanced MRI sequences in identifying dorsal arachnoid web, a rare and often misdiagnosed condition.

## Key findings

- The scalpel sign on MRI was crucial for diagnosing a dorsal arachnoid web in a patient with progressive neurological symptoms.
- Surgical resection of the arachnoid web led to significant postoperative improvement in motor function and gait.
- High-resolution 3D-CISS MRI sequences provided better diagnostic accuracy than conventional MRI for this condition.

## Abstract

Background and Clinical Significance: Thoracic dorsal arachnoid web (DAW) is a rare intradural extramedullary condition characterized by a thin band of arachnoid tissue compressing the dorsal spinal cord. A hallmark imaging feature is the “scalpel sign”, which refers to anterior displacement of the thoracic spinal cord with dorsal cerebrospinal fluid (CSF) accumulation, producing a sagittal profile resembling a surgical scalpel. Although highly specific for DAW, this sign may also appear in other intradural conditions such as idiopathic ventral spinal cord herniation and arachnoid cysts. The clinical presentation is typically progressive and nonspecific, including lower limb weakness, sensory changes, gait disturbances, and, less frequently, sphincter dysfunction. Diagnosis is often delayed due to the subtle nature of the lesion and limited resolution of conventional Magnetic Resonance Imaging (MRI). High-resolution Three-Dimensional Constructive Interference in Steady State (3D-CISS) sequences improve diagnostic accuracy by highlighting indirect signs such as spinal cord deformation and dorsal CSF flow obstruction. Case Presentation: We report the case of a 57-year-old woman presenting with chronic cervico-dorsalgia, bilateral lower limb weakness, paresthesia, and progressive gait instability. Neurological examination revealed spastic paraparesis and hyperreflexia. Conventional MRI was inconclusive. However, sagittal T2-weighted and 3D-CISS sequences demonstrated the scalpel sign at the T4–T5 level, with anterior cord displacement and dorsal subarachnoid space enlargement. Surgical exploration confirmed the presence of a dorsal arachnoid web, which was resected. Postoperative follow-up showed clear improvement in motor function and gait. Conclusions: DAW should be considered in cases of unexplained thoracic myelopathy or cervico-dorsalgia with neurological signs. Early recognition of the scalpel sign using advanced MRI sequences is critical for timely diagnosis and surgical planning, which may lead to significant clinical improvement.