Management of Symptomatic Sacral Perineural Cysts: A New Surgical Method.

BACKGROUND: Microsurgical techniques are increasingly being recommended for the treatment of symptomatic Tarlov cysts (TCs) due to improved long-term outcomes compared to those of other strategies. However, these techniques are associated with a high risk of cyst recurrence and cerebrospinal fluid (CSF) leakage, resulting in the surgical strategy of TCs remaining controversial. We hypothesize that incomplete closure of the ostium between the cyst and the subarachnoid space is the probable cause of surgical failure. Accordingly, we present a novel method of cyst separation and ostium closure that aims to block the ostium more firmly and reliably. METHODS: Thirty-five consecutive patients (21 females) underwent the modified ostium obstruction surgery due to symptomatic TCs. We collected and compared their outcomes at the final follow-up to evaluate the surgical effect. RESULTS: Thirty-five patients had 74 TCs (S2 level, 48.7%; mean diameter, 2.0 ± 1.0 cm); ostia nerve root fibers were found in all TCs. The mean follow-up duration was 37.8 (range, 13.5-76.8) months. At the final follow-up, 33 patients experienced complete or substantial resolution of the preoperative symptoms. The symptom with the highest improvement rate was radicular pain. Both the modified evaluation criteria for the efficacy of lumbar function criterion and Japanese Orthopedic Association score 29 showed an overall improvement rate of 94.3%. Two patients experienced surgery-related neurological dysfunction. No cyst recurrence or CSF leakage was observed. Magnetic resonance imaging showed that all cysts disappeared or significantly reduced postoperatively. CONCLUSIONS: The microscopic fenestration of cysts and modified ostium obstruction described herein is a safe and effective strategy for management of patients with symptomatic TCs and is associated with a low incidence of cyst recurrence and CSF leakage since it achieves complete closure of cyst ostium.

Anaesthetic considerations for elective cesarean section in a patient with a giant Tarlov cyst.

Tarlov cysts are a pathological dilatation of the meninges. Their incidence is more frequent in women between 30 and 50 years of age. The imaging test of choice for diagnosis is MRI. Of unknown etiology, most cases are asymptomatic, but symptoms of radicular irritation, among others, may occur. The therapeutic possibilities are multiple, reserving surgical excision as the last option. We report a case of successful spinal anaesthesia for elective cesarean section in a patient with a giant Tarlov cyst but with potential airway compromise, in whom the risks of general anaesthesia would be increased. Anaesthetic management presents a challenge for the anesthesiologist, especially in situations where the patient presents an increased anaesthetic risk for general anaesthesia, as is the case in the obstetric patient.

Global incidence of spinal perineural Tarlov's cysts and their morphological characteristics: a meta-analysis of 13,266 subjects.

BACKGROUND: Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and symptoms. Purpose of this meta-analysis is to deliver global incidence and characteristics (location, size, and shape) of TCs. METHODS: Following PRISMA checklist, all major databases were searched by two authors for radiologic studies reporting incidence and morphologic features (location, size, and shape) of TCs. Anatomical Quality Assessment tool was applied for risk of bias evaluation. Meta-analysis of random-effects model was employed. Subgroup analysis for regional distribution, gender, sacral levels, age, correspondence with symptoms, and persistent genital arousal disorder (PGAD) were planned ahead. RESULTS: 22 radiologic studies of level 3 evidence involving 13,266 subjects were included. Global pooled prevalence of TCs was 4.18% (95% CI 2.47-6.30). Mean pooled sagittal diameter was 11.86 mm (95% CI 10.78-12.93). Sacral cysts strongly prevailed over the other segments. Of the sacral, S2 level was the most common (46.7% [95% CI 29.4-60.5]). Geographically, the highest incidence was found in Europe (6.07% [95% CI 1.49-13.00]), followed by North America (3.82% [95% CI 0.49-9.44]), and Asia (3.33% [95% CI 1.52-5.75]). TCs were more common in women than in men (5.84% vs 3.03%, p < 0.001, test of homogeneity, χ2). Subjects with PGAD had incidence of 37.87% (95% CI 2.45-81.75). TCs in pediatric population are rare-0.53% (95% CI 0.02-1.51). 15.59% of TCs corresponded with symptoms. CONCLUSIONS: Spinal perineural (Tarlov) cysts are found in a minority of population. S2 level of the sacral bone is affected most frequently. There is female predominance. Correspondence with symptoms is seen in less than one-fifth of TCs. Studies with stronger evidence level are needed to corroborate the results. The purported high incidence in PGAD requires confirmation in case-control studies for the risk-ratio calculation.

Multiple perineural cysts in the cervical, thoracic, and lumbar vertebrae of a mature individual.

A 54-year-old female patient was admitted to our outpatient clinic with back and low back pain. There were no remarkable physical or neurological findings in the two-year follow-up period of the patient. There were 39 lesions at 17 levels (mean diameter: 5.93±2.77 [range, 1.00 to 12.2] mm) in entire vertebra in magnetic resonance imaging and more than one perineural cysts were observed adjacent to the same nerve root at several vertebrae levels. In this patient, conservative treatment was preferred.

Myelographic CT, A Check-Valve Mechanism, and Microsurgical Treatment of Sacral Perineural Tarlov Cysts.

OBJECTIVE: There is currently no consensus regarding surgical indications for symptomatic sacral perineural cysts. METHODS: Nine patients with symptomatic sacral perineural cysts underwent microsurgery. All patients fulfilled the following criteria: (1) cyst sizes larger than 15 mm; (2) cysts show the "delayed inflow" and/or "delayed outflow" of contrast on myelographic computed tomography (CT), and (3) neurological symptoms correlate with the primary cyst. RESULTS: On myelographic CT, all primary cysts showed the "delayed inflow" of contrast; the average cyst/thecal sac Hounsfield units (HU) ratio was 0.17. In 7 patients, the primary cyst showed "delayed outflow"; the average cyst/thecal sac HU ratio increased to 3.12 on images obtained 24 hours after contrast injection. Regarding the modified Rankin Scale, 67% of patients reported that their overall symptoms improved to normal activities after surgery. The most improved symptom was coccydynia (75% improvement, P = 0.017), followed by leg radiation pain (67% improvement, P = 0.027) and buttock pain (50% improvement, P = 0.068). Bowel/bladder dysfunction improved in 100% of patients, but newly developed in 1 patient (P = 0.32). Perineal pain only decreased in 33% (P = 0.41). CONCLUSIONS: To the best of our knowledge, this is the first study to have performed a quantitative analysis of the dynamics of cerebrospinal fluid in sacral perineural cysts using myelographic CT. Sixty-seven percent of patients benefited from surgery; however, our criteria may not be a necessary and sufficient condition for patient selection because 33% did not respond to surgery despite the successful elimination of the check-valve.

A Transforaminal Endoscopic Approach for Treatment of a Lumbar Perineural Cyst: Technical Note.

OBJECTIVE: Perineural cysts are a benign spine pathology but, when they become symptomatic and require surgical treatment, represent a significant challenge to the spine surgeon. Here we describe our experience with a novel endoscopic approach to the biopsy, drainage, resection of the cyst wall, and direct cyst fenestration to the subarachnoid space. METHODS: A transforaminal endoscopic approach to a large lumbar 2-3 perineural cyst is presented here in a 25-year-old patient. A step-by-step technique for the biopsy, drainage, and resection of the cyst wall is presented. RESULTS: The patient underwent cyst resection and fenestration into the subarachnoid space without complication, with immediate relief of his preoperative symptoms and after 1 year remains symptom-free. CONCLUSIONS: Surgical treatment of perineural cysts in the spine represent a significant challenge to the surgeon, principally due to the risk of spinal fluid leak in the postoperative period. Transforaminal endoscopic surgical access to this disease pathology is a novel minimally invasive surgical approach presented here that allows diagnosis and treatment of a perineural cyst and can be performed in an awake patient.

Perineural cyst with intracystic hemorrhage following aneurysmal subarachnoid hemorrhage: A case report.

RATIONALE: Most perineural cysts are asymptomatic and discovered incidentally at the time of imaging. Although enlargement of the perineural cyst (PC) through a ball-valve mechanism and resultant compression of the adjacent neural or bony structures are known to be a source of pain in PCs, the reason why asymptomatic PCs become symptomatic is unclear. The authors report a case of PC, which was presumed to become symptomatic after subarachnoid hemorrhage without enlargement of the pre-existing PC. PATIENT CONCERNS: A 47-year-old woman complained of lumbosacral pain after neck clipping for a ruptured cerebral aneurysm. DIAGNOSES: Magnetic resonance imaging (MRI) revealed a PC with intracystic hemorrhage at the S2 level. In comparison with the size of the PC on computed tomography performed 3 years ago, there was no change in the size. Electrodiagnostic studies performed 6 weeks after the onset of the pain showed subacute right S2 radiculopathy. INTERVENTIONS: With conservative treatment, her pain gradually diminished. OUTCOMES: When the lumbosacral pain improved, follow-up MRI showed that a fluid-fluid level within the PC disappeared. LESSONS: Hemorrhage from the subarachnoid space, such as spontaneous aneurysmal SAH, into the pre-existing PC can cause an asymptomatic PC to become symptomatic without getting enlarged. Stretching of the nerve root due to hemorrhage or irritation of the nerve root due to an inflammatory reaction to blood products can make asymptomatic PCs symptomatic without enlargement of PCs.

Tarlov cyst-a rare lesion in children: case report.

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.

Prevalence of simple and complex sacral perineural Tarlov cysts in a French cohort of adults and children.

OBJECTIVE: To determine the prevalence of simple and complex sacral perineural Tarlov cysts (TCs) in a cohort of children and adults. MATERIAL AND METHODS: Retrospective observational epidemiological study assessing 1100 consecutive sacral magnetic resonance (MR) studies, including 100 children and adolescents. All patients underwent 1.5T MR imaging with T1 and T2 weighted image acquisitions in sagittal and axial planes. All perineural cysts affecting the sacral nerve roots S1-S4 were quantitatively and qualitatively assessed. RESULTS: Two hundred and sixty-three sacral TCs were found in 132 adult patients (13.2%), with a female predominance (68%). None was found in children. The prevalence of TCs increased with age. The average number of cysts per patient was 2.0±1.2 with a maximum of 6 cysts in a single patient. Most of the cysts (87.5%) showed a homogenous central fluid collection and a parietal course of the nerve fibers. Complex patterns were present in 33 cysts (12.5%) within which 28 cysts showed endocystic crossing of nerve fibers and 5 cysts contained internal septations. Seventy cysts (26.6%) eroded the adjacent bone and 13 cysts (4.9%) extended to the pelvis. CONCLUSION: The prevalence of sacral TCs in our cohort corresponded to 13%, with a female predominance. Interestingly no TCs were found in children or adolescents (<18 years). In relation to the non-negligible percentage of complex cysts with internal septations, or endocystic crossing of nerve fibers, pre-interventional characterization of sacral TCs might help to choose an appropriate procedure in the treatment of rare symptomatic variants.

Balloon-Assisted Fistula Sealing Procedure for Symptomatic Tarlov Cysts.

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.

Reconstruction of nerve root sheaths for sacral extradural spinal meningeal cysts with spinal nerve root fibers.

This study analyzed the clinical characteristics and outcomes of sacral extradural spinal meningeal cysts with spinal nerve root fibers treated by reconstruction of the nerve root sheaths. The relationships between the cysts and spinal nerve root fibers were examined microscopically, the cysts were partially excised, and the defects were oversewn to reconstruct the nerve root sheaths. The Improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological function. Thirty-eight patients were included in this study, with a mean age of 41.4 ± 15.57 years. The mean IJOA score was 18.8 ± 1.32 preoperatively and 19.6 ± 0.65 postoperatively, which was a significant difference (t=-3.77, P=0.001). These results indicate a significant improvement in neurological function after surgery. The most significant improvement in neurological function was sensation (z=-2.86, P=0.004), followed by bowel/bladder function (z=-2.31, P=0.02).

Symptomatic calcified perineural cyst after use of bone morphogenetic protein in transforaminal lumbar interbody fusion: a case report.

BACKGROUND CONTEXT: Human recombinant bone morphogenetic protein-2 (BMP-2) is commonly used in spinal surgery to augment arthrodesis, and a number of potential complications have been documented. PURPOSE: To present the case of a delayed radiculopathy that occurred because of a calcified perineural cyst that formed after an L4-L5 transforaminal lumbar interbody fusion (TLIF) in which BMP-2 was used. STUDY DESIGN/SETTING: Case report of a 70-year-old man presented with back and right lower extremity pain. METHODS: A 70-year-old man who had previously undergone a right L4-L5 TLIF presented 20 months after surgery with progressively radiating right leg pain. Imaging revealed a right-sided L4-L5 cystic lesion posterior to the interbody cage. The patient underwent reexploration, and a calcified mass was discovered. RESULTS: Histopathology revealed fragments of organized collagenous connective tissue, new collagen, and partially calcified fragments of fibrocartilage, bone, and ligament. CONCLUSIONS: This is the first reported case of a symptomatic calcified perineural cyst developing after a fusion procedure in which BMP-2 was used. The presence of connective tissue with metaplastic bone formation and maturation within the lesion suggests that formation of the cyst was secondary to application of BMP-2, as it possesses both osteogenic and chondrogenic capabilities.

Surgical treatment of sacral perineural cyst--case report.

A 67-year-old man presented with persistent penis and scrotum pain due to S-2 and S-3 radiculopathy caused by a sacral perineural cyst. The cyst was treated with microsurgical partial cyst removal and cyst wall imbrication, together with closure of the point through which cerebrospinal fluid (CSF) flowed from the subarachnoid space into the cyst cavity. His pain resolved without recurrence of the cyst or complications. Symptomatic perineural cysts are quite rare. Surgical closure of the point through which CSF flows from the subarachnoid space into the cyst cavity is the most important intervention for symptomatic perineural cysts. If the source of CSF leakage cannot be detected, placement of a cyst-subarachnoid shunt should be considered in addition to partial cyst removal and cyst wall imbrication.

Tarlov cysts: a controversial lesion of the sacral spine.

The primary aim of our study was to provide a comprehensive review of the clinical, imaging, and histopathological features of Tarlov cysts (TCs) and to report operative and nonoperative management strategies in patients with sacral TCs. A literature review was performed to identify articles that reported surgical and nonsurgical management of TCs over the last 10 years. Tarlov cysts are often incidental lesions found in the spine and do not require surgical intervention in the great majority of cases. When TCs are symptomatic, the typical clinical presentation includes back pain, coccyx pain, low radicular pain, bowel/bladder dysfunction, leg weakness, and sexual dysfunction. Tarlov cysts may be revealed by MR and CT imaging of the lumbosacral spine and must be meticulously differentiated from other overlapping spinal pathological entities. They are typically benign, asymptomatic lesions that can simply be monitored. To date, no consensus exists about the best surgical strategy to use when indicated. The authors report and discuss various surgical strategies including posterior decompression, cyst wall resection, CT-guided needle aspiration with intralesional fibrin injection, and shunting. In operative patients, the rates of short-term and long-term improvement in clinical symptoms are not clear. Although neurological deficit frequently improves after surgical treatment of TC, pain is less likely to do so.

Microsurgical fenestration of perineural cysts to the thecal sac at the level of the distal dural sleeve.

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.

[Diagnostic and clinical behaviour with Tarlov cyst in gynaecology practice].

The following presents cases from the gynaecological practice which resulted in a surgical intervention due to the detection of cystic formations of origin out of the reproductive system. Although rare, Tarlov cyst has its place in the differential diagnostic plan of ovarian formations. MRI scan remains an alternative to the ultrasound imagery and is the main diagnostic method for obtaining the right diagnosis. This further aids the set of actions appropriate with patients suffering from Tarlov cyst. Thus, unnecessary abdominal surgical interventions are not to be undertaken.