Javascript required
Skip to content Skip to sidebar Skip to footer
Home / Diagnosis and Management of Sacral Tarlov Cysts Case Report and Review of the Literature

Diagnosis and Management of Sacral Tarlov Cysts Case Report and Review of the Literature

  • Loading metrics

Open Access

Peer-reviewed

Research Article

Management of Symptomatic Sacral Perineural Cysts

  • Jianqiang Xu,
  • Yongdong Lord's day,
  • Xin Huang,
  • Wenzhong Luan

PLOS

x

  • Published: June 29, 2012
  • https://doi.org/ten.1371/journal.pone.0039958

Abstract

Background

At that place has been no consensus on the optimal treatment of symptomatic sacral perineural cysts. Most previous reports concerning the management methods were either sporadic example 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 3 different modalities from 1998 through 2010. Six patients underwent microsurgical cyst fenestration and cyst wall imbrication. Seven patients underwent a modified surgical process, during which the cerebrospinal fluid leak aperture was located and repaired. Ii patients were treated with medication and physical therapy. Outcomes of the patients were assessed past 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 just 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 functioning 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 exist more simple and effective.

Citation: Xu J, Sun Y, Huang Ten, Luan Due west (2012) Management of Symptomatic Sacral Perineural Cysts. PLoS ONE 7(half-dozen): e39958. https://doi.org/x.1371/journal.pone.0039958

Editor: Isaac Yang, Academy of California Los Angeles, U.s.

Received: January 9, 2012; Accepted: May 29, 2012; Published: June 29, 2012

Copyright: © 2012 Xu et al. This is an open-access article distributed nether the terms of the Creative Eatables Attribution License, which permits unrestricted utilize, distribution, and reproduction in any medium, provided the original writer and source are credited.

Funding: The authors have no support or funding to report.

Competing interests: The authors have alleged that no competing interests be.

Introduction

Sacral perineural cysts, which were as well termed Tarlov cysts, are collections of cerebrospinal fluid (CSF) between the endoneurium and perineurium of the nerve root sheath most the dorsal root ganglion [ane]. These lesions are quite common as an incidental finding on magnetic resonance imaging (MRI), and near of them are asymptomatic [2]. In a serial of 500 consecutive MRI scans of the lumbosacral spine, Paulsen et al [3] recorded an incidence of iv.vi%, of which 20% were symptomatic. Approximately one% of sacral perineural cysts become large and crusade symptoms related to local pinch [3], which should be treated.

There has been no consensus on the optimal handling of symptomatic sacral perineural cysts since it was first described by Tarlov in 1938 [4]. Many methods have been applied to treat these symptomatic lesions, with variable results. Lumbar CSF drainage, lumboperitoneal shunt, and cyst subarachnoid shunt were not effective as a therapy for symptomatic Tarlov cysts [2], [5], [6]. CT-guided percutaneous aspiration of the cyst with infusion of fibrin glue yielded mixed results, and this method was associated with a high rate of aseptic meningitis [3], [7], [8]. Favorable results have been obtained with microsurgical cyst fenestration and imbrication in several reports [2], [iv], [9], [10].Even so, there remains some difficulties such as postoperative CSF leakage and the cyst recurrence [2]–[9].

Virtually previous reports concerning the direction methods were either sporadic case reports or series of limited cases [2], [iv], [5], [10]–[xiv]. We therefore retrospectively reviewed fifteen cases of sacral perineural cysts treated with dissimilar methods.

Methods

Between 1998 and 2010, 15 patients (nine men, six women) ranging from 23 to sixty years of historic period (mean, 37.8 yr) with symptomatic sacral perineural cysts were treated at General Hospital of Fengfeng Group (Table 1),whose follow-up is more than one year. The primary symptoms and neurological deficits included depression dorsum pain or sacrococcygodynia (northward = 12), sacral radiculopathy (due north = seven), numbness (n = 6), sensory disturbance of the sacral dermatome (due north = 9), claudication (n = 4), and bowel and bladder dysfunction (n = 6). Written informed consent was obtained from each patient. The study was approved past the Medical Ethical Commission of Peking University.

The diagnoses of sacral perineural cysts were confirmed for all patients by magnetic resonance imaging (MRI) studies. Besides the cysts, MRI also demonstrated additional pathological features in two cases. Tethered spinal string and intramedullary teratoma at L3 vertebral level were revealed in one case (Fig. 1) and tethered spinal cord with syringomyelia in the other (Fig. 2).

Patients were selected to be treated surgically if they met the following criteria: 1) the diameter of cyst is more i.5 cm;2) neurological symptoms and signs attributed to sacral perineural cysts that are serious enough to warrant treatment; three) no or little response to medical and physical therapy. To determine whether the cyst is the culprit responsible for the symptoms, a trial of CT guided aspiration first.

Before 2006, six patients underwent sacral laminectomies, microsurgical cyst fenestration, and cyst wall imbrication with placement of complimentary autologous fat or muscle grafts over the airtight wall. Since 2006, seven patients underwent a modified surgical process. After sacral laminectomies, the cysts were fenestrated with a scalpel, for the draining of the fluid contents .The cyst wall was partially removed. After the process mentioned to a higher place, we would exam the discontinuity through which CSF may leak from the subarachnoid infinite to the cyst. The identified aperture was then repaired with a piece of fat and fibrin gum, for the prevention of CSF leakage. We observed that, in all cases (north = 6), the discontinuity was at the place through which nervus root traversed out of the subarachnoid space and into the cyst. In case that the aperture could non be identified (due north = ane), the zone through which nerve root traversed the arachnoid was prophylactically covered with fat and fibrin glue. Later careful hemostasis, the cyst cavity and local defect were covered with absorbable Gelfoam and fibrin glue. The wound was closed in h2o-tight layers. Postoperative lumbar drainage was not used in all of the 7 patients because it was identified during the operation that CSF leakage stopped. In patients with additional pathological features (one patient with tethered spinal cord and a intramedullary teratoma in L3 vertebral level, the other patient with tethered spinal cord), these pathological entities were treated accordingly during the same functioning procedure. Conservative direction including the application of analgesic and non-steroid anti-inflammatory medication and physical therapy was administrated for ii patients who rejected surgical treatment.

Patient outcomes were assessed by comparing the preoperative and postoperative examination results. The follow-upwardly was conducted either by re-checking at outpatient dispensary or by telephone questionnaires, with an averaged catamenia as 40.ane months (range, 13 mo–10 yr ). All patients had MRI at greater than ane year, and the averaged fourth dimension of MRI for follow-up is twenty.7 months.

Results

All of the six patients treated with microsurgical cyst fenestration and imbrication earlier 2006 experienced either complete or substantial resolution of their pre-operative symptoms and neurological deficits immediately after surgery or during follow-upwards visits (Tabular array 1). However, there was i patient suffered form recurrent low dorsum pain and bladder dysfunction viii months afterward the performance, which was after confirmed by MRI report as the recurrence of the cyst (Fig. iii). This patient received second surgery thereafter, with no improvement of his symptoms. There was some other patient who experienced CSF leakage, which was cured completely with an bogus dural patch in the second surgery and postoperative lumbar drainage for nearly one week.

Of the 7 patients treated with the modified surgical procedure since 2006, six of them experienced complete or substantial relief of their preoperative symptoms and neurological deficits immediately after surgery or during follow-up visits (Table 1). There was only ane patient whose preoperative bladder dysfunction was worsened after the performance. The patient's condition recovered gradually to normal role one month later. Postoperative lumbar drainage for the prevention of CSF leakage was not administrated in all of the vii patients. In that location were no new postoperative neurological deficits, no CSF leaks, and no surgical infections. No recurrence was observed during the follow-upwards monitoring.

The 2 patients treated with medication and physical therapy had no or piffling response to these conservative measures, and their symptoms aggravated with time. MRI examinations showed that the cysts in the ii patients progress continuously. Ane patient's cyst had grown 0.5 cm (from 1.9 to 2.four cm) in diameter within four years(Fig. 4), the other's increased 0.5 cm (from ane.v to 2.0 cm )in diameter within 5 years.

Discussion

The development of computed tomography (CT) myelography and MRI has led to an improvement in our ability to diagnose perineural cysts [2]. Despite advancements in diagnosis, there remains a bang-up deal of controversy regarding the optimal handling of symptomatic perineural cysts [two], [4], [v], [9]–[15].The reported treatment options include: i) lumbar CSF drainage; 2) lumbar peritoneal shunt; 3) cyst subarachnoid shunt placement; four) CT-guided percutaneous aspiration of the cyst with or without infusion of fibrin glue; v) laminectomy for decompression of the cyst; 6) fractional cyst removal and neck ligation with or without nerve root resection;seven) partial cyst removal and cyst wall imbrication; 8) microsurgical cyst removal and cyst wall imbrication together with defect repairing with muscle, Gelfoam, or fibrin mucilage ; and nine) microsurgical fenestration of sacral perineural cysts to the thecal sac [2], [3], [5]–[eleven], [xiv], [16]. Those methods have been not satisfying because of variable rates of symptom resolution, cyst recurrence, besides every bit postoperative complications [2], [4]–[6], [8]–[11], [16].

Therefore, attempts to identify the aperture through which CSF may leak from the subarachnoid space to the cyst and repair it to stop CSF leak accept been performed at our infirmary since 2006. All of the seven patients treated with this surgical method obtained favorable results, although the aperture could not exist located in ane case. And there were no new postoperative neurological deficits, no CSF leaks, no surgical infections, and no recurrence. Postoperative lumbar drainage to prevent CSF leak was also not adopted. Based on our serial,the procedure with partial cyst removal and the discontinuity repair for preventing CSF leakage from the subarachnoid space to the cyst appear to be more simple and effective.

In our series at that place were two patients with boosted pathological features. One patient had tethered spinal cord and a intramedullary teratoma in L3 level, the other patient had tethered spinal cord with syringomyelia. Based on our knowledge, at that place have been no reports that sacral perineural cysts coexist with tethered spinal cord and intramedullary teratoma. It was difficult to evaluate which pathological entity caused the symptoms and neurological deficits in the two patients. Nosotros therefore treated surgically both perineural cysts and additional pathological entities during the same performance procedure.

In our series at that place were two patients who refused surgical treatment. During more than than iv years of follow-up monitoring, their cysts had grown significantly, and their symptoms adult worse with fourth dimension, which may implicated the need of surgical intervention for symptomatic sacral perineural cysts.

In determination, it seems unlikely to conclude the optimal treatment based on single studies without significant number of patients, like this series presented here. More reported cases and further studies on management of sacral perineural cysts are needed. We recommend that microsurgical operation should be a handling consideration and the method with partial cyst removal and the aperture repair for prevention of CSF leakage from the subarachnoid space seems to be more simple and effective.

Author Contributions

Conceived and designed the experiments: JX WL. Performed the experiments: YS XH. Analyzed the information: JX. Contributed reagents/materials/analysis tools: JX. Wrote the paper: JX.

References

  1. i. Nabors MW, Pait TG, Byrd EB, Karim NO, Davis DO, et al. (1988) Updated assessment and current classification of spinal meningeal cysts. J Neurosurg 68: 366–77.
    • View Article
    • Google Scholar
  2. 2. Guo D, Shu G, Chen R, Ke C, Zhu Y, et al. (2007) Microsurgical treatment of symptomatic sacral perineurial cysts. Neurosurgery 60: 1056–65.
    • View Commodity
    • Google Scholar
  3. 3. Paulsen RD, Phone call GA, Murtagh FR (1994) Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts). AJNR Am J Neuroradio 15: 293–nine.
    • View Article
    • Google Scholar
  4. 4. Acosta FL Jr, Quiñones-Hinojosa A, Schmidt MH, Weinstein PR (2003) Diagnosis and management of sacral Tarlov cysts. Case report and review of the literature. Neurosurg Focus 15: E15.
    • View Commodity
    • Google Scholar
  5. 5. Bartels RH, van Overbeeke JJ (1997) Lumbar cerebrospinal fluid drainage for symptomatic sacral nerve root cysts: An adjuvant diagnostic procedure and/or alternative treatment? Technical case report. Neurosurgery 40: 861–5.
    • View Commodity
    • Google Scholar
  6. 6. Morio Y, Nanjo Y, Nagashima H, Minamizaki T, Teshima R (2001) Sacral cyst managed with cyst-subarachnoid shunt: A technical case report. Spine 26: 451–3.
    • View Article
    • Google Scholar
  7. vii. Zhang T, Li Z, Gong W, Sun B, Liu S, et al. (2007) Percutaneous fibrin glue therapy for meningeal cysts of the sacral spine with or without aspiration of the cerebrospinal fluid. J Neurosurg Spine 7: 145–150.
    • View Article
    • Google Scholar
  8. eight. Patel MR, Louie W, Rachlin J (1997) Percutaneous fibrin gum therapy of meningeal cysts of the sacral spine. AJR Am J Roentgenol 168: 367–seventy.
    • View Article
    • Google Scholar
  9. nine. Mummaneni PV, Pitts LH, McCormack BM, Corroo JM, Weinstein PR (2000) Microsurgical treatment of symptomatic sacral Tarlov cysts. Neurosurgery 47: 74–9.
    • View Article
    • Google Scholar
  10. 10. Kunz U, Mauer UM, Waldbaur H (1999) Lumbosacral extradural arachnoid cysts: diagnostic and indication for surgery. Eur Spine J eight: 218–22.
    • View Article
    • Google Scholar
  11. 11. Caspar W, Papavero L, Nabhan A, Loew C, Ahlhelm F (2003) Microsurgical excision of symptomatic sacral perineurial cysts: A study of xv cases. Surg Neurol 59: 101–6.
    • View Article
    • Google Scholar
  12. 12. Prashad B, Jain AK, Dhammi IK (2007) Tarlov cyst: Instance report and review of literature. Indian J Orthop 41: 401–iii.
    • View Article
    • Google Scholar
  13. xiii. Smith ZA, Li Z, Raphael D, Khoo LT (2011) Sacral laminoplasty and cystic fenestration in the treatment of symptomatic sacral perineural (Tarlov) cysts: Technical case study. Surg Neurol Int 2: 129.
    • View Article
    • Google Scholar
  14. 14. Voyadzis JM, Bhargava P, Henderson F (2001) Tarlov cysts: a study of 10 cases with review of the literature. J Neurosurg(Spine 1) 95: 25–32.
    • View Article
    • Google Scholar
  15. fifteen. Lucantoni C, Than K D, Wang A C, Valdivia-Valdivia J K, Maher C O, et al. (2011) Tarlov cysts: a controversial lesion of the sacral spine. Neurosurg Focus 31: E14.
    • View Commodity
    • Google Scholar
  16. 16. Neulen A, Kantelhardt SR, Pilgram-Pastor SM, Metz I, Rohde Five, et al. (2011) Microsurgical fenestration of perineural cysts to the thecal sac at the level of the distal dural sleeve. Acta Neurochir 153: 1427–1434.
    • View Commodity
    • Google Scholar

dorronseensess.blogspot.com

Source: https://journals.plos.org/plosone/article?id=10.1371%2Fjournal.pone.0039958