Ross C Puffer, Marcus J Gates, William Copeland 3rd, William E Krauss, Jeremy Fogelson

Department of Neurosurgery, MayoClinic, Rochester, Minnesota

Abstract
Background and importance: Tarlov cysts, also known as perineural cysts, have been described as meningeal dilations of the spinal nerve root sheath between the peri- and endoneurium at the dorsal root ganglion. Most often they are found in the sacrum involving the nerve roots. Normally asymptomatic, they have been reported to present with radiculopathy, paresthesias, and even urinary or bowel dysfunction. Sacral insufficiency has not been a well-documented presentation.

Clinical presentation: The patient is a 38-year-old female who started to develop left low back pain and buttock pain that rapidly progressed into severe pain with some radiation down the posterior aspect of her left leg. There was no recent history of spine or pelvic trauma. These symptoms prompted her initial emergency department evaluation, and imaging demonstrated a large Tarlov cyst with an associated sacral insufficiency fracture. She was noted to have a normal neurological examination notable only for an antalgic gait. She was taken to surgery via a posterior approach and the cyst was identified eccentric to the left. The cyst was fenestrated and the nerve roots identified. Given her large area of bone erosion and insufficiency fractures, fixation of the sacroiliac joints was deemed necessary. Fusion was extended to the L5 vertebral body to buttress the fixation. She tolerated the procedure well and was discharged from the hospital on postoperative day 3.

Conclusion: Tarlov cysts of the sacrum can lead to significant bone erosion and subsequent insufficiency fractures, requiring fenestration and in some cases, complex sacropelvic fixation.

PMID: 28521343 DOI: 10.1093/ons/opw025

https://academic.oup.com/ons/article-abstract/13/3/E4/2804543?redirectedFrom=fulltext

Konstantinos Paterakis, Alexandros Brotis, Maria Bakopoulou, Christos Rountas, Efthymios Dardiotis, Georgios M Hadjigeorgiou, Kostas N Fountas, Apostolos Karantanas

World Neurosurg. journal

Medical School, University of Thessaly, Thessaly, Greece; Department of Neurosurgery, University Hospital of Larissa, Thessaly, Greece

Department of Radiology, University Hospital of Larissa, Medical School, University of Thessaly, Thessaly, Greece.

Department of Diagnostic Radiology, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece.

Abstract

Background: Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst.

Case description: A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intracranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst’s neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed.

Conclusions: Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.

PMID: 30880195 DOI: 10.1016/j.wneu.2019.02.222

https://www.sciencedirect.com/science/article/abs/pii/S1878875019307041?via%3Dihub

M R Mijalcic, B Djurovic, I Cvrkota, M Jokovic, V Bascarevic, M Micovic 

Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia.

Abstract

Perineural cysts, also known as Tarlov cysts, are benign lesions increasingly found in patients undergoing neuroimaging studies. These cysts can very rarely be identified in children and even then, they are not so likely to be responsible for some neurological deficit. It seems to be of scientific and clinical importance to present a pediatric case with Tarlov cyst. We report a case of a patient, a 7-year-old boy, previously treated for nocturnal enuresis (bedwetting), who later developed signs and symptoms of classic urinary incontinence. Magnetic resonance imaging (MRI) showed a relatively large extradural cyst at the level of S2. The cyst was approached by laminectomy of L5 to S2, excised, and completely removed from the belonging nerve root. The patient has established normal sphincter control without even a single episode of involuntary discharge of urine. A surgery is a powerful, safe, and efficacious option for treatment in pediatric patients with sacral Tarlov cysts.

PMID: 30810854 DOI: 10.1007/s00381-019-04105-3

https://link.springer.com/article/10.1007%2Fs00381-019-04105-3

Baichuan Wang, Feifei Pu, Qiang Wu, Zhicai Zhang, Zengwu Shao

World Neurosurg journal

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

Abstract

Background: A presacral Tarlov cyst is an unusual cause of abdominal pain. The unusual location of a presacral Tarlov cyst can lead to misdiagnosis and inappropriate treatment. To guide appropriate diagnosis and treatment, we reviewed causes, clinical presentations, radiologic features, and management options of this extremely rare lesion.

Methods: We performed an English-language literature search using PubMed to identify reports of patients with presacral Tarlov cysts. The diagnosis was based on classic radiologic signs. Seven patients described in 7 publications met the inclusion criteria and were analyzed in conjunction with 3 new patients described by our team.

Results: A congenital arachnoidal defect may be the primary causative factor of a presacral Tarlov cyst. Lumbosacral pain, leg pain, and bowel and bladder dysfunction are common clinical complaints, while abdominal pain is uncommon. Myelography and magnetic resonance imaging are considered useful diagnostic techniques. Myelography provided the definitive diagnosis for 33% of the patients, and magnetic resonance imaging was diagnostic for 67%. Surgical interventions may be appropriate for symptomatic presacral lesions. Two patients who received conservative treatment continued to experience their presenting symptoms, whereas 7 patients who underwent surgical treatment experienced favorable outcomes.

Conclusions: Although extremely rare, presacral Tarlov cysts should be suspected in patients with abdominal pain, especially when pain occurs along with other neurologic symptoms. This review provides a systematic description of this rare disease, which may be helpful in guiding the appropriate diagnosis and treatment.

PMID: 29102753 DOI: 10.1016/j.wneu.2017.10.135

https://www.sciencedirect.com/science/article/abs/pii/S1878875017318636?via%3Dihub

Ahmed Elsawaf, Tariq Elamam Awad, Salem S Fesal

European Spine Journal

Department of Neurosurgery, Suez Canal University, Ismailia, Egypt.

Abstract
Object: Symptomatic sacral perineural cysts are extremely rare. The aim of this retrospective study is to investigate the outcome of 15 consecutive patients treated by microsurgical resection of the cyst and to review the literature.

Methods: The authors retrospectively reviewed their clinical data archive from 2002 to 2014. Fifteen patients who were operated on due to symptomatic sacral perineural cysts were enrolled in the study. Patients’ symptoms, radiographs, intra-operative findings, and clinical results were evaluated. All 15 patients underwent microsurgical excision of the cyst. The literature on this topic available in PubMed was also reviewed.

Results: There were 5 men and 10 women included in the study, with a mean age of 31 years (range 7-60 years). Preoperative symptoms include low back pain, coccydynia, buttock pain, perianal pain and radicular pain. All of the patients underwent surgical resection. The mean follow-up was 54 months (range 3-160 months). All the patients experienced complete or substantial resolution of the preoperative local and radicular pain after surgery.

Conclusions: Cyst excision is an effective and safe technique for symptomatic sacral perineural (Tarlov) cysts. Careful patient selection is vital to the management and treatment of this difficult and controversial pathology.

https://link.springer.com/article/10.1007%2Fs00586-016-4584-3

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

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

Medical University of Lublin.

Martine Medical Center in Gadansk, Poland.

Abstract

Perineural cyst (Tarlov cyst) is a lesion in a form of fluid-filled sacks, usually located within the nerve root sheath at the posterior root of a spinal nerve, whose wall is formed by: endoneurium, peripheral nerve fibers, and ganglion cells, and areolar tissue. Depending on the studied population, the frequency of lesion occurrence was estimated at 1.5- 13.2%, with its significant majority occurring in women. Cyst development may be the result of ischemia, hemorrhage, inflammation, or trauma. Cysts are usually asymptomatic therefore they are likely to be detected accidentally. However, in approximately 1/4 of the cases, the cyst puts so much pressure on the nerve and the neighboring nerve roots that it becomes symptomatic (causes pain). The presence of clinical symptoms may be an indication for conservative treatment (i.e. analgesics, rehabilitation, cyst puncture) or surgery (usually laminectomy).

https://pubmed.ncbi.nlm.nih.gov/30531671/

https://medpress.com.pl/shop/index.php?id_product=1324&controller=product&id_lang=1

Kieran P Murphy and Susannah Ryan

BMJ Case reports
Medical Imaging, University Health Network, Toronto, Ontario, Canada
Royal College of Surgeons in Ireland School of Medicine, Dublin, Ireland

Abstract

A 65-year-old patient presenting with left labial and perirectal pain was diagnosed with bilateral Tarlov cysts. Upon treatment of the left Tarlov cyst (the right was asymptomatic) using image-guided aspiration and subsequent injection of the cyst with fibrin sealant, the cyst reduced in size. To our knowledge, there are currently no other documented cases in which the Tarlov cyst reduced in size following this procedure. This case would seem to suggest that clinicians are poorly informed with regard to Tarlov cysts. These cysts are more common in Caucasian women, many of whom are told their cysts are not responsible for their pain or that they are not treatable. However, there is clear evidence that some Tarlov cysts are symptomatic and minimally invasive procedures have been developed to treat them. As they primarily occur in women, it is possible gender bias may also play a role in the delayed diagnosis of the patient’s pain.

http://dx.doi.org/10.1136/bcr-2018-227256

Khalid Medani, Shokry Lawandy, Rudolph Schrot, Jose N Binongo, Kee D Kim, Ripul R Panchal

J Spine Surg. 2019 Dec; 5(4): 496–503.

Department of Neurological Surgery, University of California Davis, Sacramento, CA, USA.
Department of Neurological Surgery, Sutter Medical Center Sacramento, Sacramento, CA, USA.
Touro University College of Osteopathic Medicine, Vallejo, CA, USA.
Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA.

Abstract

Background: Tarlov cyst disease is a collection of cerebrospinal fluid between the endoneurium and perineurium of spinal, usually sacral, nerve roots. These cysts can become symptomatic in 20% of patients, causing lower back pain, radiculopathy, bladder and bowel dysfunction necessitating medical or surgical intervention. Different surgical and non-surgical modalities have been described for the treatment of symptomatic Tarlov cysts. However, there has been no published study that examined types of surgical techniques side by side. Our study presents a preliminary experience in the surgical management of symptomatic Tarlov cysts using two surgical techniques: cyst fenestration and nerve root imbrication.

Methods: Retrospective chart review and analysis was done for all patients who underwent surgical intervention for symptomatic Tarlov cyst(s) in the period 2007-2013. Operative reports, preoperative and postoperative clinic visit reports were reviewed. The surgical techniques of cyst fenestration and nerve root imbrication were each described in terms of intraoperative parameters, hospital course and outcome. Modified MacNab criteria were used for evaluation of the final clinical outcome.

Results: Thirty-six surgical patients were identified. Three had repeat surgery (total of 39 operations). The median age was 51 years (range, 26-84 years). Eighty-six percent were females. The presenting symptoms were low back pain (94%), sensory radiculopathy (69%), bladder and bowel dysfunction (61%), sexual dysfunction (17%) and motor dysfunction (8%). Cyst fenestration was performed in 12 patients (31%) and nerve root imbrication was done in 27 (69%). All patients in the fenestration group but only 67% in the imbrication group had fibrin glue injection into the cyst or around the reconstructed nerve root. The overall surgery-related complication rate was 28%. The complication rate was 5/12 (42%) in the fenestration group and 6/27 (22%) in the imbrication group. At the time of the last clinic visit, improved clinical outcome was noted in 9/11 (82%) and 20/25 (80%) in the fenestration and the imbrication group, respectively.

Conclusions: Cyst fenestration and nerve root imbrication are both surgical techniques to treat symptomatic Tarlov cyst(s), and both can result in clinical improvement.

PMID: 32043000 PMCID: PMC6989930 DOI: 10.21037/jss.2019.11.1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6989930/