Taku Sugawara 1, Naoki Higashiyama 1, Shinya Tamura 2, Takuro Endo 1, Hiroaki Shimizu 3

Department of Neurosurgery, Akita University Hospital, Akita, Japan.

PMID: 34598157 DOI: 10.3171/2021.5.SPINE21179

Abstract

Objective: Perineural cysts, also called Tarlov cysts, are dilatations of the nerve root sleeves commonly found in the sacrum. The majority of the cysts are asymptomatic and found incidentally on routine spine imaging. Symptomatic sacral perineural cysts (SPCs) that induce intractable low-back pain, radicular symptoms, and bladder/bowel dysfunction require surgery. However, the surgical strategy for symptomatic SPCs remains controversial. The authors hypothesized that the symptoms were caused by an irritation of the adjacent nerve roots caused by SPCs, and developed a wrapping surgery to treat these cysts.

Methods: Seven patients with severe unilateral medial thigh pain and ipsilateral SPCs were included. Preoperative MRI showed that the cysts were severely compressing the adjacent nerve roots in all patients. After a partial laminectomy of the sacrum, the SPCs were punctured and CSF was aspirated to reduce their size, followed by dissection of the adjacent nerve roots from the SPCs. The SPCs were then wrapped with a Gore-Tex membrane to avoid reexpansion.

Results: All 7 patients experienced substantial relief of their symptoms. The average numeric rating scale pain score was reduced from an average preoperative value of 7.9 to 0.6 postoperatively. Postoperative MRI showed that all cysts were reduced in size and the adjacent nerve roots were decompressed. Regrowth of the treated cysts or recurrence of the symptoms did not occur during the entire follow-up period, which ranged from 39 to 90 months. No complications were noted.

Conclusions: The authors’ new wrapping technique was effective in relieving radicular symptoms for patients with symptomatic SPCs. The results suggested that the symptoms stemmed from compression of the adjacent nerve roots caused by the SPCs, and not from the nerve roots in the cysts.

https://thejns.org/spine/view/journals/j-neurosurg-spine/aop/article-10.3171-2021.5.SPINE21179/article-10.3171-2021.5.SPINE21179.xml

https://pubmed.ncbi.nlm.nih.gov/34598157/

P V Mummaneni 1, L H Pitts, B M McCormack, J M Corroo, P R Weinstein

Department of Neurological Surgery, University of California, San Francisco, School of Medicine, 94143-0112, USA.

PMID: 10917349 DOI: 10.1097/00006123-200007000-00016

Abstract

Objective: Providing relief of symptomatic radiculopathy resulting from sacral perineural cysts has proven difficult. Our goal was to improve the treatment of these cysts with microsurgical cyst fenestration and imbrication, while minimizing functional damage to neural tissues.

Methods: We retrospectively reviewed the records for eight adult patients with large (2-3-cm) sacral perineural cysts who were treated at the University of California, San Francisco, between October 1992 and April 1999. All patients presented with radicular pain that was refractory to medical treatment. Three patients also reported urinary incontinence. We performed sacral laminectomies with microsurgical cyst fenestration and cyst imbrication for all patients, using intraoperative electromyography to minimize damage to the sacral nerve roots. For seven patients, we reinforced the closures with epidural fat or muscle grafts and fibrin glue application. For five patients with cysts that communicated with the subarachnoid space in computed tomographic myelograms, we placed lumbar drains for cerebrospinal fluid diversion for several days postoperatively. We assessed outcomes, using telephone questionnaires and periodic postoperative physical examinations, 3 to 73 months after surgery.

Results: After surgery, radicular pain improved markedly for four patients and moderately for three patients; one patient with initial improvement experienced pain recurrence 9 months later. Bladder control improved markedly for two of the three patients with bladder dysfunction. There were no cerebrospinal fluid leaks and no new postoperative neurological deficits.

Conclusion: Microsurgical cyst fenestration and imbrication are effective treatments for long-term relief of refractory painful radiculopathy and urinary incontinence associated with large sacral perineural cysts.

https://academic.oup.com/neurosurgery/article-abstract/47/1/74/2925839?redirectedFrom=fulltext

https://pubmed.ncbi.nlm.nih.gov/10917349/

Axel Neulen, Sven R Kantelhardt, Sara M Pilgram-Pastor, Imke Metz, Veit Rohde, Alf Giese

Department of Neurosurgery, Center of Neurological Medicine, University of Göttingen, Göttingen, Germany.

PMID: 21562735 PMCID: PMC3111602 DOI: 10.1007/s00701-011-1043-0

Abstract

Background: Surgery for symptomatic sacral perineural cysts remains an issue of discussion. Assuming micro-communications between the cyst and thecal sac resulting in a valve mechanism and trapping of CSF as a pathomechanism, microsurgical fenestration from the cyst to the thecal sac was performed to achieve free CSF communication.

Methods: In 13 consecutive patients (10 female, 3 male), MRI revealed sacral perineural cysts and excluded other pathologies. Micro-communication between the thecal sac and the cysts was shown by delayed contrast filling of the cysts on postmyelographic CT. Surgical fenestration achieved free CSF communication between the thecal sac and cysts in all patients. The patient histories, follow-up examinations and self-assessment scales were analyzed. Symptoms at initial presentation included lumbosacral pain, pseudoradicular symptoms, genital pain and urinary dysfunction. Mean follow-up was 10.7 ± 6.6 months.

Findings: Besides one CSF fistula, no surgical complications were observed. Five patients did not improve after surgery; in four of these cases multiple cysts were found, but small and promptly filling cysts remained untreated. Seven patients reported lasting benefit following surgery; three of these had single cysts, and all had cysts >1 cm. One patient initially benefited from cyst fenestration but experienced recurrent pain within 2 months postoperatively. Re-myelography revealed delayed contrast filling of the recurrent cyst; however, surgical revision did not lead to an improvement despite successful fenestration and collapse of the cyst revealed by postoperative imaging.

Conclusions: Microsurgical fenestration of sacral perineural cysts to the thecal sac is a surgical approach that has shown success in the treatment of lumbosacral pain, pseudoradicular symptoms, genital pain and urinary dysfunction associated with sacral perineural cysts. Our analysis, however, shows that mainly patients with singular large cysts benefit from this treatment.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3111602/

https://pubmed.ncbi.nlm.nih.gov/21562735/

Parmenion P Tsitsopoulos, Niklas Marklund, Konstantin Salci, Anders Holtz, Maria Mani.

Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden.
Department of Clinical Sciences, Neurosurgery, Lund University, Skåne University Hospital, Lund, Sweden.

PMID: 30547125 PMCID: PMC6261769 DOI: 10.21037/jss.2018.07.02

Abstract

Background: The optimal treatment of symptomatic perineural (Tarlov) cysts is controversial. Numerous surgical techniques have been proposed with conflicting results. A series of Tarlov cysts treated with a novel surgical approach is presented.

Methods: Patients with surgically treated symptomatic perineural cysts during 2013-2016 were included. The main indications for surgery were persistent radicular symptoms, pelvic pain, urinary and/ or bowel disturbances. At surgery, the cyst was opened and fenestrated. The cyst wall was then closed with packing, fibrin glue and a pedicled vascularized fasciocutaneous flap rotated into the area for obliteration of the dead space. Patients were followed-up with clinical visits and repeat magnetic resonance imaging (MRI) scans.

Results: Seven consecutive patients were included. The mean age was 50.3 years (range, 25-80 years) and the mean duration of symptoms was 49.3 months (range, 3-130 months). With one exception, all patients had urine and/or bowel problems (incontinence) preoperatively. A lumbar drain was inserted in five patients. The mean follow-up period was 15.4 months. Symptoms improved in 4/7 patients, in two cases no clinical difference was noted while one patient deteriorated. In two cases, a spinal cord stimulator was eventually implanted. In all seven cases, a significantly decreased cyst size was noted on MRI.

Conclusions: Cyst fenestration and the use of a vascularized fasciocutaneous flap successfully obliterated all cysts, with satisfactory clinical efficacy. Larger and comparative studies are warranted to clarify the long-term effects of this surgical technique in patients with symptomatic Tarlov cysts.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6261769/

https://pubmed.ncbi.nlm.nih.gov/30547125/

Mohammed Yassine Haouas, Mohamed Khoulali, Zinelabidine En-Nhaili, Hani El-Johani, Mounir Rghioui, Robin Srour.

Université Hassan II, Faculté de Médecine et de Pharmacie, CHU Ibn Rochd, Service de Neurochirurgie, Casablanca, Maroc.

Hôpitaux Civils de Colmar, Hôpital Pasteur, Service de Neurochirurgie, Colmar, France.

PMID: 31489076 PMCID: PMC6711676 DOI: 10.11604/pamj.2019.33.98.10760

Abstract

Tarlov cyst or perineural cyst is a local dilation of the subarachnoid space formed within the nerve root and filled with cerebrospinal fluid. There is no consensus on the best treatment of syntomatic sacral perinervous cysts. Many methods have been used to treat these symptomatic lesions, with variable results. We report a case series including 20 patients undergoing surgery for sacral Tarlov cyst.

Our results were satisfactory; 80% of patients improved without neurological worsening in the post-operative period. Our surgical technique (sacral laminectomy+cyst puncture+establishment of dural sheat) described for the first time in this study seems to have been effective in the 20 cases reported in our study.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6711676/

https://pubmed.ncbi.nlm.nih.gov/31489076/

Jianqiang Xu, Yongdong Sun, Xin Huang, Wenzhong Luan

Department of Neurosurgery, General Hospital of Fengfeng Group, Handan, China.

PMID: 22768183 PMCID: PMC3386964 DOI: 10.1371/journal.pone.0039958

Abstract

Background: There has been no consensus on the optimal treatment of symptomatic sacral perineural cysts. Most previous reports concerning the management methods were either sporadic case reports or a series of limited cases. This study is to further optimize the management for patients with symptomatic sacral perineural cysts by analyzing the outcomes of a cohort of patients who were treated with different strategies.

Methods and findings: We reviewed the outcomes of 15 patients with symptomatic sacral perineural cysts who were managed by three different modalities from 1998 through 2010. Six patients underwent microsurgical cyst fenestration and cyst wall imbrication. Seven patients underwent a modified surgical procedure, during which the cerebrospinal fluid leak aperture was located and repaired. Two patients were treated with medication and physical therapy. Outcomes of the patients were assessed by following up (13 months to 10 years). All of the six patients treated with microsurgical cyst fenestration and cyst wall imbrication experienced complete or substantial relief of their preoperative symptoms. However, the symptoms of one patient reappeared eight months after the operation. Another patient experienced a postoperative cerebrospinal fluid leakage. Six of the seven patients treated with the modified surgical operation experienced complete or substantial resolution of their preoperative symptoms, with only one patient who experienced temporary worsening of his preoperative urine incontinence, which disappeared gradually one month later. No new postoperative neurological deficits, no cerebrospinal fluid leaks and no recurrence were observed in the seven patients. The symptoms of the two patients treated with conservative measures aggravated with time.

Conclusions: Microsurgical operation should be a treatment consideration in patients with symptomatic sacral perineural cysts. Furthermore, the surgical procedure with partial cyst removal and aperture repair for prevention of cerebrospinal fluid leakage seemed to be more simple and effective

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3386964/

https://pubmed.ncbi.nlm.nih.gov/22768183/

Zuowei Wang, Fengzeng Jian, Zan Chen, Hao Wu, Xingwen Wang, Wanru Duan, Kai Wang, Jian Guan 2, Zhenlei Liu

Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Neurospine Center, China International Neuroscience Institute, Beijing, China.

PMID: 34775092 DOI: 10.1016/j.wneu.2021.11.019

Abstract

Objective: To examine the surgical procedure for and the clinical efficacy of using spinal endoscopy for sacral Tarlov cyst treatment.

Methods: A retrospective analysis of patients with sacral Tarlov cysts who underwent spinal endoscopy treatment from August 2018 to January 2020 at the Department of Neurosurgery, Xuanwu Hospital, China, was carried out.

Results: Spinal endoscopy treatment was performed in 15 patients with sacral Tarlov cysts (6 males, 9 females). Mean patient age was 41.3 years (range, 19-67 years). Mean follow-up period was 15.6 months (range, 12-26 months). Clinical presentations of patients included sacrococcygeal and lower limb pain (n = 14), paresthesia (n = 7), lower limb motor disorder (n = 1), bowel dysfunction (n = 4), and urinary dysfunction (n = 3). Surgeries were successfully completed in all patients. Pain was significantly alleviated after surgery in 12 (85.7%) patients. Visual analog scale scores before surgery, at 1 day and 3 months after surgery, and at last follow-up were 5.9 ± 1.2, 2.9 ± 1.5, 2.3 ± 1.3, and 2.6 ± 1.0. The postoperative visual analog scale scores were significantly decreased compared with the preoperative score (all P < 0.01). Among the patients with paresthesia, 4 (57.1%) experienced improved symptoms. Muscle strength recovered from grade 4 to grade 5 after surgery in 1 patient with lower limb motor disorder. Two (50%) of 4 patients with bowel dysfunction and 2 (66.7%) of 3 patients with urinary dysfunction experienced functional improvement. Postoperative magnetic resonance imaging showed that cyst filling was satisfactory, and cyst recurrence was not observed.

Conclusions: Spinal endoscopy shows preliminary clinical efficacy for treatment of sacral Tarlov cysts and is safe and effective.

https://www.sciencedirect.com/science/article/abs/pii/S1878875021017204?via%3Dihub

https://pubmed.ncbi.nlm.nih.gov/34775092/

K Murphy, A L Oaklander, G Elias, S Kathuria, D M Long

• Department of Radiology (K.M., G.E.), University of Toronto, Toronto, Ontario, Canada.
• Departments of Neurology (A.L.O.) Pathology (Neuropathology) (A.L.O.), Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.
• From the Department of Radiology (K.M., G.E.), University of Toronto, Toronto, Ontario, Canada.
• Russell H Morgan Department of Radiology and Radiological Science (S.K.), Johns Hopkins Hospital, Baltimore Maryland.
• Neuroscience Consults (D.M.L.), Lutherville, Maryland.

PMID: 26405086 PMCID: PMC4752851 DOI: 10.3174/ajnr.A4517

Abstract

Background and purpose: There has been a steady progression of case reports and a small surgical series that report successful surgical treatment of Tarlov cysts with concomitant relief of patients’ symptoms and improvement in their neurological dysfunction, yet patients are still told that these lesions are asymptomatic by physicians. The purpose of this study was to analyze the efficacy and safety of intervention in 213 consecutive patients with symptomatic Tarlov cysts treated by CT-guided 2-needle cyst aspiration and fibrin sealing.

Materials and methods: This study was designed to assess outcomes in patients who underwent CT-guided aspiration and injection of ≥1 sacral Tarlov cyst at Johns Hopkins Hospital between 2003 and 2013. In all, 289 cysts were treated in 213 consecutive patients. All these patients were followed for at least 6 months, 90% were followed for 1 year, and 83% were followed for 3-6 years. The aspiration-injection procedure used 2 needles and was performed with the patients under local anesthesia and intravenous anesthesia. In the fibrin-injection stage of the procedure, a commercially available fibrin sealant was injected into the cyst through the deep needle (Tisseel VH).

Results: One year postprocedure, excellent results were obtained in 104 patients (54.2% of patients followed), and good or satisfactory results were obtained in 53 patients (27.6%). Thus, 157 patients (81.8%) in all were initially satisfied with the outcome of treatment. At 3-6 years postprocedure, 74.0% of patients followed were satisfied with treatment. There were no clinically significant complications.

Conclusions: The aspiration-injection technique described herein constitutes a safe and efficacious treatment option that holds promise for relieving cyst-related symptoms in many patients with very little risk.

http://www.ajnr.org/content/37/2/373.long

https://pubmed.ncbi.nlm.nih.gov/26405086/