J M Voyadzis , P Bhargava, F C Henderson

Department of Neurosurgery and Pathology, Georgetown University Medical Center, Washington, DC, USA.

PMID: 11453427 DOI: 10.3171/spi.2001.95.1.0025

Abstract

Object: Tarlov or perineurial cysts are lesions of the nerve root most often found in the sacral region. Although there is agreement that asymptomatic Tarlov cysts should be followed, it is still debated whether patients with symptomatic Tarlov cysts should be treated surgically. The authors assessed the outcome and efficacy of cyst wall resection in 10 patients with symptomatic Tarlov cysts. The medical literature is reviewed, theories of origin are evaluated, and suggestions as to their cause and pathogenesis are offered.

Methods: Ten consecutive patients harboring symptomatic Tarlov cysts were treated by the senior author between 1989 and 1999. All patients were assessed for neurological deficits and pain by neurological examination and visual analog scale, respectively. Computerized tomography myelography was performed in all patients to diagnose delayed filling of the cysts. A sacral laminectomy with resection of the sacral cyst or cysts was performed in all patients. Resected material from eight of 10 patients was submitted for histopathological evaluation. Seven (70%) of 10 patients obtained complete or substantial resolution of their symptoms, with an average follow up of 31.7 months. All of these patients had Tarlov cysts larger than 1.5 cm in diameter, producing radicular pain or bladder and bowel dysfunction. Three (30%) of 10 patients experienced no significant improvement. All three patients harbored Tarlov cysts smaller than 1.5 cm in diameter, producing nonradicular pain. Histopathological examination was performed on specimens from eight of 10 patients, which demonstrated nerve fibers in 75% of cases, ganglion cells in 25% of cases, and evidence of old hemorrhage in half.

Conclusions: Large cysts (> 1.5 cm) and the presence of associated radicular symptoms strongly correlate with excellent outcome. Tarlov cysts may result from increased hydrostatic pressure and trauma.

https://thejns.org/spine/view/journals/j-neurosurg-spine/95/1/article-p25.xml

https://pubmed.ncbi.nlm.nih.gov/11453427/

Xuesheng Zheng, Shiting Li, Hansong Sheng, Baohui Feng, Nu Zhang, Chaoran Xie

Department of Neurosurgery, Xinhua Hospital, Affiliated to Shanghai JiaoTong University School of Medicine, Shanghai, Zhejiang, People’s Republic of China

PMID: 26802871 DOI: 10.1016/j.wneu.2016.01.016

Abstract

Objective: Tarlov cyst is an abnormal expansion of the spinal nerve sleeve, and it communicates with the subarachnoid cavity via a perineural fistula. This study presents our experience of a balloon-assisted fistula sealing procedure in treating Tarlov cyst.

Methods: Twenty-two patients with symptomatic Tarlov cysts were surgically treated. An emulsion balloon was placed into the lumbar subarachnoid cistern through a trocar, so as to temporarily block cerebrospinal fluid flow, then the thecal sac was opened and the inlet of the fistula was sealed by suture of a muscular patch and reinforced by fibrin glue. Finally, the cyst wall was imbricated and the bony cavity was filled with pedicled muscle flaps.

Results: Comparing the preoperative and postoperative pain scores according to visual analog scale, 2 patients were slightly improved and 18 patients were substantially improved, including 3 completely pain-free cases. Only 2 patients were unchanged in pain, and both of them had multiple cysts. As a whole, the postoperative pain score was much better than the preoperative score (2.4 vs. 7.5; P < 0.01). Bladder weakness was slightly improved, and bowel dysfunction was almost unchanged after operation. During follow-up, cyst recurrence was found in 1 patient.

Conclusions: The balloon-assisted fistula sealing procedure is safe and effective for Tarlov cyst, especially for the single cyst. It is a good complement to the cyst wall imbricating procedure.

https://www.sciencedirect.com/science/article/abs/pii/S1878875016000954?via%3Dihub

https://pubmed.ncbi.nlm.nih.gov/26802871/

Wei Jiang, Zhenming Hu, Jie Hao

Department of Orthopaedic Surgery, The First Affiliated Hospital of Chongqing Medical University, 1 Youyi Rd, Chongqing 400016, China.

PMID: 28727710

Abstract

Background: Symptomatic Tarlov cysts are a common cause of chronic pain. Many methods have been reported to treat this disease, with variable results. Most previous reports concerning the treatment methods of symptomatic Tarlov cysts were either sporadic case reports or series of limited cases.

Objective: This study aimed to further optimize the management for patients with symptomatic Tarlov cysts (TCs) by analyzing the results of 82 patients who were treated with different strategies.

Study design: Three different strategies were applied to 82 patients with symptomatic TCs and their clinical effects were evaluated in 13 months to 12 years follow-up.

Setting: A pain management practice, a medical center, major metropolitan city, China.

Methods: From June 2003 to August 2015, a total number of 82 patients with symptomatic TCs were treated with 3 different methods (microsurgical cyst fenestration and imbrication, C-arm fluoroscopy guided percutaneous fibrin gel injection, and conservative management) in the first affiliated hospital of Chongqing Medical University. The pain severity was assessed according to visual analog scale (VAS), and imaging changes were evaluated by magnetic resonance imaging (MRI). Patient improvements in pain and neurologic function were evaluated during a follow-up the period of 13 months to 12 years.

Results: All the patients who underwent microsurgical cyst fenestration and imbrication had either complete (7 patients, 50%) or substantial (7 patients, 50%) resolution of their preoperative symptoms and neurological deficits. However, 3 patients (21%) had cerebrospinal fluid (CSF) leakage and 3 patients (21%) suffered from recurrent symptoms. In C-arm fluoroscopy guided percutaneous fibrin gel injection group, 34 patients (61%) had complete resolution and 22 patients had (39%) substantial resolution, and no CSF leakage or recurrence occurred. Only 3 patients (25%) got substantial resolution in the conservative management group, but 9 patients (75%) had aggravation.

Limitations: An observational study with a relatively small sample size.

Conclusions: C-arm fluoroscopy guided percutaneous fibrin gel injection therapy could be recommend as a better consideration for symptomatic TCs.

https://www.painphysicianjournal.com/linkout?issn=&vol=20&page=E653

https://pubmed.ncbi.nlm.nih.gov/28727710/

Dongsheng Guo, Kai Shu, Rudong Chen, Changshu Ke, Yanchang Zhu, Ting Lei

Department of Neurosurgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.

PMID: 17538380 DOI: 10.1227/01.NEU.0000255457.12978.78

Abstract

Objective: The aim of this study was to investigate the microsurgical results of symptomatic sacral perineurial cysts of 11 patients and to discuss the treatment options of the past 10 years.

Methods: We retrospectively reviewed the records of 11 patients with symptomatic sacral perineurial cysts who underwent microsurgical treatment at Tongji Hospital, Huazhong University of Science and Technology from 1993 through 2006. The philosophy was to perform total or partial cyst wall removal, to imbricate the remaining nerve sheath if possible, and to repair local defect with muscle, Gelfoam (Pharmacia & Upjohn, Kalamazoo, MI), and fibrin glue. Patient outcomes were assessed by comparing the preoperative and postoperative examination results. The average follow-up time obtained from return visits to the neurosurgery clinic or by telephone questionnaires ranged from 2 months to 13 years. A literature search and analysis of current treatment options were performed.

Results: Nine of the 11 patients (82%) experienced complete or substantial relief of their preoperative symptoms. One patient (Patient 4) experienced worsening of bladder dysfunction after surgery and recovered slowly to subnormal function during the subsequent 2 months. The symptoms of Patient 9 did not resolve, and magnetic resonance imaging showed that the cyst had reoccurred. The patient underwent reoperation 3 months later without any improvement. One patient (Patient 11) experience a cerebrospinal fluid leakage complication. Neither new postoperative neurological defects nor infection were observed in our series. In the literature, there are six different treatment options under debate and controversially discussed.

Conclusion: Microsurgical treatment yielded the best long-term resolution of patient symptoms to date and should be recommended to appropriately selected patients.

https://academic.oup.com/neurosurgery/article-abstract/60/6/1059/3775797?redirectedFrom=fulltext

https://pubmed.ncbi.nlm.nih.gov/17538380/

Hanshuo Zhu, Lin Shen, Zheng Chen, Min Yang, Xuesheng Zheng

Department of Neurosurgery, XinHua Hospital, Shanghai JiaoTong University School of Medicine, Shanghai, China.

Abstract

Background: Giant presacral Tarlov cysts (TCs) with pelvic extension are extremely rare and have many special features that differ from normal TCs in examination, diagnosis, symptoms, and treatment. We report 3 rare cases of giant presacral TCs with pelvic extension and review the pertinent literature.

Case description: We report 3 cases of giant presacral TCs with rare pelvic extension and analyzed the symptoms, diagnoses, and surgical procedures. Operations with the key point of blocking the inlet of the fistula from inside the dural sac were performed in all 3 cases. All 3 patients revealed alleviation of previous symptoms with no serious complications. Postoperative magnetic resonance imaging showed all the cysts were well blocked with no cyst recurrence.

Conclusions: Giant TC with pelvic extension is extremely rare and often is discovered on gynecological ultrasound, where it might be misdiagnosed as adnexal mass. Different from patients with normal TCs, these patients also may present with abdominal symptoms like hydronephrosis, abdominal, or pelvic pain due to the cyst’s ventral mass effect. Thus, patients with abdominal and back symptoms at the same time should be paid particular attention for lumbosacral magnetic resonance imaging examination to avoid misdiagnosis. Surgical procedures are recommended for symptomatic cases. However, cyst resection by laparotomy is doomed to postoperative recurrence because the fistula still exists. We describe a simple procedure with the key point of blocking the inlet of cyst fistula, which is more applicable and minimizes the probability of cyst recurrence.

PMID: 32344135 DOI: 10.1016/j.wneu.2020.04.112

https://www.sciencedirect.com/science/article/abs/pii/S1878875020308196?via%3Dihub

https://pubmed.ncbi.nlm.nih.gov/32344135/

M Ruibal Moldes, J Sánchez Rodríguez-Losada, D López García, V Casas Agudo, J M Janeiro País, M González Martín

Abstract

Tarlov cysts or perineural cyst are lesions of the nerve roots located at the sacral level and uncertain aetiology. Most of these cysts remain asymptomatic with no clinical relevance. The symptomatic cysts are uncommon and the usual symptoms are pain or radiculopathy. We report the case of a 53-year-old woman witha symptomatic cyst (with a history of frequency and urgency syndrom), that disappears after surgery.

PMID: 19143297 DOI: 10.1016/s0210-4806(08)73984-6

https://www.sciencedirect.com/science/article/abs/pii/S0210480608739846?via%3Dihub

https://pubmed.ncbi.nlm.nih.gov/19143297/

Ralf Weigel, Manolis Polemikos, Nesrin Uksul, Joachim K Krauss

Department of Neurosurgery, Medical School Hannover, Carl-Neuberg Straße 1, 30625, Hannover, Germany.
Neurosurgical Department, St. Katharinen Hospital, Frankfurt Am Main, Germany.

Abstract
Purpose: Surgical treatment of Tarlov cysts is still a matter of debate. Published literature thus far includes mainly small case series with retrospective evaluation and short-term follow-up. We present a novel microsurgical technique that combines the decompression of the nerve fibers with the prevention of recurrence. The long-term follow-up is provided.

Methods: The indication for surgery was incapacitating pain refractory to medical therapy for at least 6 months. The surgical technique consisted in microsurgical opening of the cyst, relief of CSF followed by secured inverted plication of the cyst wall, packing of remnant space with fat graft, and sacroplasty. Pain and neurological deficits were evaluated according to a modified Barrow National Institute score (BNI score, 0-5) and the Departmental Neuro Score (DNS score, 0-20).

Results: A total of 13 patients (9 women, 4 men) were operated and followed up to 14 years (mean FU 5.3 years). Mean age at surgery was 51.8 (±14) years. Pain and neurological deficits improved significantly in 11/13 patients (BNI score pre-OP 5 vs 3.1 ± 1.2 at 1-year-FU, and 2.8 ± 1.2 at last follow-up visit; DNS score pre-OP 5.5 ± 1.5 vs 2.8 ± 2.1 at 1-year follow-up, and 2.6 ± 2.2 at last follow-up visit. Two patients needed revision surgery due to reoccurrence of the cyst. One patient suffered deterioration of preexisting neurological deficit.

Conclusions: The inverted plication technique combined with sacroplasty is a promising technique. It improves pain and neurological deficits on the long term in the majority of patients with symptomatic Tarlov cysts.

PMID: 27554352 DOI: 10.1007/s00586-016-4744-5

https://pubmed.ncbi.nlm.nih.gov/27554352/

https://link.springer.com/article/10.1007%2Fs00586-016-4744-5