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.

Hydrocephalus associated with multiple Tarlov cysts.

Tarlov cysts (TCs) consist of dilated nerve root sheaths filled with cerebrospinal fluid (CSF) and are most frequently found in the sacrum. It is estimated that 25% of detected TCs cause chronic pain and intestinal and urogenital symptoms due to compression of the sacral nerve root fibers inside the TC. Unfortunately, symptomatic TCs are frequently overlooked. It is assumed that TCs result from pathologically increased hydrostatic pressure (HP) in the dural sac that forces CSF into the nerve root sheaths. We hypothesize that in patients with TCs, increased spinal hydrostatic pressure is always associated with increased intracranial pressure. This hypothesis of increased cerebrospinal pressure might explain why patients with sacral TCs frequently report distant symptoms, such as headaches and pain in the neck and arms. In this paper, we describe a case report that provides evidence for this hypothesis. A 30-year-old man presented for the first time in our clinic complaining of lower back, leg, thoracic, neck, and arm pain; headaches; and bladder, bowel, and sphincter symptoms. He was born prematurely and suffered cerebral intraventricular bleeding followed by progressive hydrocephalus. Progression was stabilized with acetazolamide and lumbar punctures. At 19 years of age, his head circumference had further increased and he reported back pain and headaches. Fundoscopy showed no papilledema, and lumbar puncture for CSF evacuation improved the headaches and back pain. The former medical team chose not to insert a ventriculo-external shunt. Brain magnetic resonance imaging (MRI) showed significant dilation of all the ventricles. No CSF flow obstruction between the ventricles was observed. Surprisingly, MRI of the lumbar and sacral spine showed multiple large TCs. This case report indicates that hydrocephalus with a patent aqueduct may be associated with TCs because the increased intracranial pressure is transferred to the spinal canal. While increased intracranial pressure causes dilation of the ventricles, the associated increased spinal pressure may cause dilation of multiple spinal nerve root sheaths to form TCs. Furthermore, while the increased volume of the ventricles gradually compresses the neurons and axons of the brain against the bony skull, simultaneously, the increased pressure inside the nerve sheaths may also gradually compress the neurons and axons located inside the dorsal root ganglia and spinal nerves, resulting in neuropathic pain, sensory abnormalities, and neurogenic bladder and bowel symptoms. Hydrocephalus patients reporting neuropathic pain should be screened for the presence of TCs.

Giant Tarlov Cyst of Infancy.

We report an 8-month-old female infant with complaints of irritability and recent inability to sit in a stable position. On physical examination, a palpable mass in the left upper quadrant of her abdomen was evident. Sonography and magnetic resonance imaging showed a giant cyst, consisting of 2 communicating compartments: dorsal and ventrolateral. The dorsal part compressed the conus medullaris, and the ventrolateral part compressed the left kidney. Partial cyst wall resection and imbrication for the dorsal pouch were done, and diagnosis of Tarlov cyst was confirmed via the visualization of the endocystic nerve root during surgery. Familiarizing physicians with this unusual presentation of Tarlov cyst may help them in early recognition of this lesion, and subsequent surgery might be considered to prevent clinical sequela. To our knowledge, a lumbar Tarlov cyst presenting as a giant abdominal cyst in an infant has not been reported in the English-language literature.

[Perineural cysts]. / Torbiele okolokorzeniowe.

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 occurence was estimated at 1.5- 13.2%, with its significant majority occuring in women. Cyst development may be the result of ischemia, hemorrhage, inflammation or trauma. Cysts are usually asymptomatic theefore they are likely to bo detected accidentally. However, in approximately 1/4 of the cases, the cyst puts so much pressure on the nerve and the neighbouring nerve roots that it becomes symptomatic (causes pain). The presence of clinical symptoms may be an indication for conservative treatment (i.e. analgesics, rehablitation, cyst puncture) or surgery (usually laminectomy).

Tarlov cysts: long-term follow-up after microsurgical inverted plication and sacroplasty.

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.

Surgical excision of symptomatic sacral perineurial Tarlov cyst: case series and review of the literature.

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.

Quiste perineural simulando masa anexial en estudio de paciente infértil / Perinerural cyst simulating an adnexal mass in the study of an infertile patient

Los quistes perineurales o de Tarlov son por lo general hallazgos incidentales durante un estudio de imagen que no requieren tratamiento a menos que produzcan síntomas. Tienen una incidencia baja en la población general y esto puede deberse a un error en su diagnóstico, ya que simulan otras lesiones quísticas de la pelvis.Presentamos el caso de una paciente de 38 años en estudio por infertilidad primaria que en control ecográfico, se aprecia lesión quística pélvica de 4 cm, de situación medial, y aparentemente independiente de anejos y útero. Tras dicho hallazgo, se vitrifican los embriones y se deriva al servicio de medicina interna y de neurocirugía para completar estudio.La TC abdomino-pélvica informa de la presencia formaciones quísticas que dependen de los agujeros de conjunción sacros y que se confirman en la RMN. Dichas formaciones son compatibles con el diagnóstico de quiste meníngeo extradural.Al no presentar clínica, se decide tratamiento conservador. La paciente regresa a la unidad de reproducción para completar tratamiento de infertilidad (AU)

Perineural or Tarlov cysts are usually detected as incidental findings during an imaging study and do not require treatment unless symptomatic. The incidence of perineural cysts in the general population is low. Because these cysts simulate other cystic lesions of the pelvis, their low incidence may be due to diagnostic error.We present the case of a 38-year-old woman who was under investigation for primary infertility. An ultrasound scan revealed a 4-cm pelvic cystic lesion, situated medially and apparently independently from the annexes and uterus. Subsequently, the embryos were vitrified and were sent to the internal medicine and neurosurgery services for examination.The abdominopelvic CT scan showed the presence of cystic formations in the intervertebral foramina of sacrum, which were confirmed by magnetic resonance imaging. These formations were compatible with a diagnosis of extradural meningeal cyst.Because the patient was asymptomatic, we decided to provide conservative treatment. The patient was referred back to the fertility unit to complete the fertility treatment (AU)

Comparative outcomes of the two types of sacral extradural spinal meningeal cysts using different operation methods: a prospective clinical study.

This prospective study compares different clinical characteristics and outcomes of patients with two types of sacral extradural spinal meningeal cysts (SESMC) undergoing different means of surgical excision. Using the relationship between the cysts and spinal nerve roots fibers (SNRF) as seen under microscope, SESMCs were divided into two types: cysts with SNRF known as Tarlov cysts and cysts without. The surgical methods were tailored to the different types of SESMCs. The improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological function of the patients. Preoperative IJOA scores were 18.5 ± 1.73, and postoperative IJOA scores were 19.6 ± 0.78. The difference between preoperative and postoperative IJOA scores was statistically significant (t = -4.52, p = 0.0001), with a significant improvement in neurological function after surgery. Among the improvements in neurological functions, the most significant was sensation (z=-2.74, p=0.006), followed by bowel/bladder function (z=-2.50, p=0.01). There was a statistically significant association between the types of SESMC and the number (F=12.57, p=0.001) and maximum diameter (F=8.08, p=0.006) of the cysts. SESMC with SNRF are often multiple and small, while cysts without SNRF tend to be solitary and large. We advocate early surgical intervention for symptomatic SESMCs in view of significant clinical improvement postoperatively.

Prevalence of sacral spinal (Tarlov) cysts in persistent genital arousal disorder.

INTRODUCTION: Neither consistent etiology nor treatment have been established for Persistent Genital Arousal Disorder (PGAD), which is characterized by uninvited, unwelcome, and distressing genital sensation. Sacral (Tarlov) cysts, which form on dorsal (sensory) roots, most commonly of S2 and S3 in the sacral spine, are reported to produce genital symptoms that bear similarities to those described for PGAD. AIMS: The present study ascertained the incidence of Tarlov cysts in the sacral spine of women with PGAD symptoms. METHODS: Women in a PGAD internet support group were asked to submit MRIs of their sacral region to the investigators, who evaluated the MRIs for the presence or absence of Tarlov cysts. MAIN OUTCOME MEASURES: The presence or absence of Tarlov cysts at the level of the sacral spine. RESULTS: Tarlov cysts were present in 12 of the first 18 (66.7%) MRIs submitted to the investigators by women who suffer from PGAD symptoms. By contrast to this incidence, that of Tarlov cysts reported in the literature for large samples of the population observed for various disorders (e.g., lumbosacral pain) is 1.2-9.0%. CONCLUSION: Tarlov cysts have been described in the literature as producing paresthesias and genital sensory disturbances. Hence, at least some cases of PGAD might be considered to be a Tarlov cyst-induced paresthesia. Based on the relatively high occurrence of Tarlov cysts currently observed in women who suffer from PGAD symptoms, it would seem advisable to suspect Tarlov cysts as a possible organic etiological factor underlying PGAD.

Spontaneous intracranial hypotension presenting as a reversible dorsal midbrain syndrome.

A 47-year-old woman with postural headache, episodic stupor, and vertical gaze palsy had brain imaging findings consistent with spontaneous intracranial hypotension (SIH), including severe descent of the mesodiencephalic structures and diffuse pachymeningeal enhancement. The source of the cerebrospinal fluid leakage was a ruptured dorsal perineural cyst. Clinical symptoms improved after a targeted epidural blood patch was performed. Dorsal midbrain syndrome has not been reported previously as a manifestation of SIH. Perhaps distortion of structures in this brain region can occur in SIH as it does in obstructive hydrocephalus.