Diagnosis and management of sacral Tarlov cysts

Standardized measurement of the piriformis muscle and the proximal portion of the sacral nerve roots using transvaginal ultrasound

To identify the sonomorphological appearance and to measure the thickness of the piriformis muscle (PM) and the proximal portion of the sacral nerve roots S1-S3 in healthy premenopausal women.This prospective multicentric observational study included a consecutive series of women undergoing transvaginal sonography (TVS) at 2 tertiary gynecological referral centers. Standardized assessment of the pelvic organs was performed, followed by an attempt to visualize the right and left PM and sacral nerve roots S1-S3 at their origin in proximity to the sacral neuroforamen. Visualization rates, diameters of the muscle and nerve thickness, and the time needed to identify the PM were recorded.305 patients were included in the study. In 293 women (96.1%), the PM was identified bilaterally. The median diameter of the PM was 18.3mm on the right side and 18.4mm on the left side. S1 nerve roots were successfully identified bilaterally in 224 (73.4%) patients. Their right and left median diameters were 4.8mm. Both S2 nerves were successfully identified in 215 (70.5%) patients. Their median diameter were 4.3mm on both sides. S3 nerve roots were successfully identified in 203 (66.6%) patients. Their median diameter were 3.2mm on both sides.We describe methods which allow consistent and rapid identification of the PM and the S1-S3 sacral nerve roots using TVS. Visualization of the PM and the proximal portion of the sacral plexus may be useful regarding identification of pathological changes in PM thickness and could help to distinguish perineural cysts from other gynecological pathologies.

Diagnosis and Treatment of Symptomatic Multiple Sacral Perineural Cysts-Technical Note

Introduction

Sacral perineural cysts are rarely symptomatic; however, they may occasionally cause various symptoms. As the patient exhibits multiple cysts, it often becomes difficult to determine if these cysts are symptomatic.

Technical Note

Six patients with multiple sacral cysts, identified using magnetic resonance imaging (MRI), were further examined using myelography and computed tomography (CT) immediately and 6-18 h after myelography. Symptomatic cysts were exclusively diagnosed as not enhanced immediately (filling defect sign) but displayed enhancement later (delayed filling sign/retention sign) compared to the subarachnoid space. A minimal laminectomy was performed on the target cyst. The dura and epineurium with the arachnoid of the cyst were then longitudinally incised along the nerve root, and the adhesion at the junction between the cyst and the dura mater was released. The incised epineurium and dura mater were sutured using 6-0 nylon and covered with multiple layers of polyglycolic acid seat and fibrin glue. A suction drain was placed for 1 or 2 days, and the patients were mobilized on postoperative day 1. Symptoms improved in all patients; however, the improvement ratio varied. At an average follow-up of 39 months, no recurrence was observed on the MRI.

Conclusions

This case series reports the diagnostic and surgical methods for multiple sacral perineural cysts and their outcomes. Delayed CT myelography is helpful in diagnosing symptomatic cysts. Moreover, all cysts with filling defect signs or delayed filling/retention signs demonstrated neural adhesions in the neck. Microsurgical fenestration and the release of adhesions are effective for the improvement of symptoms without recurrence.

Prevalence of Spinal Meningeal Diverticula in Autosomal Dominant Polycystic Kidney Disease

BACKGROUND AND PURPOSE

Patients with autosomal dominant polycystic kidney disease (ADPKD) develop cysts in the kidneys, liver, spleen, pancreas, prostate, and arachnoid spaces. In addition, spinal meningeal diverticula have been reported. To determine whether spinal meningeal diverticula are associated with ADPKD, we compared their prevalence in subjects with ADPKD with a control cohort without ADPKD.

MATERIALS AND METHODS

Subjects with ADPKD and age- and sex-matched controls without ADPKD undergoing abdominal MRI from the midthorax to the pelvis from 2003 to 2023 were retrospectively evaluated for spinal meningeal diverticula by 4 blinded observers. The prevalence of spinal meningeal diverticula in ADPKD was compared with that in control subjects, using t tests and correlated with clinical and laboratory data and MR imaging features, including cyst volumes and cyst counts.

RESULTS

Identification of spinal meningeal diverticula in ADPKD (n = 285, median age, 47; interquartile range [IQR], 37-56 years; 54% female) and control (n = 285, median age, 47; IQR, 37-57 years; 54% female) subjects had high interobserver agreement (pairwise Cohen κ = 0.74). Spinal meningeal diverticula were observed in 145 of 285 (51%) subjects with ADPKD compared with 66 of 285 (23%) control subjects without ADPKD (P < .001). Spinal meningeal diverticula in ADPKD were more prevalent in women (98 of 153 [64%]) than men (47 of 132 [36%], P < .001). The mean number of spinal meningeal diverticula per affected subject with ADPKD was 3.6 ± 2.9 compared with 2.4 ± 1.9 in controls with cysts (P < .001). The median volume (IQR, 25%-75%) of spinal meningeal diverticula was 400 (IQR, 210-740) mm3 in those with ADPKD compared with 250 (IQR, 180-440) mm3 in controls (P < .001). The mean spinal meningeal diverticulum diameter was greater in the sacrum (7.3 [SD, 4.1] mm) compared with thoracic (5.4 [SD, 1.8] mm) and lumbar spine (5.8 [SD, 2.0] mm), (P < .001), suggesting that hydrostatic pressure contributed to enlargement.

CONCLUSIONS

ADPKD has a high prevalence of spinal meningeal diverticula, particularly in women.

Nerve Cuff Reconstruction for Sacral Duct Tarlov Cyst

OBJECTIVE

To investigate factors influencing the long-term prognosis of patients with sacral Tarlov syndrome after nerve root cuff reconstruction.

METHODS

A total of 42 patients with sacral Tarlov cysts who underwent nerve root cuff reconstruction at the First Medical Center of the Chinese PLA General Hospital between December 2015 and December 2021 were retrospectively reviewed. All cases were confirmed using magnetic resonance imaging and pathology. All patients were followed up for 24 months after surgery. Improvement in self-evaluation of health was defined as a good prognosis, while a decline in self-evaluation of health was defined as a poor prognosis. The demographic characteristics and clinical data were compared between patients with good and poor prognoses. Multivariate logistic regression analysis was performed, taking poor prognosis as the dependent variable and parameters with P < 0.1 in the univariate analysis as independent variables to identify the risk factors.

RESULTS

Significant differences were observed in disease duration, lower limb weakness, defecation dysfunction, and defecation dysfunction between patients with good and poor prognoses. Multivariate logistic regression analysis showed that disease duration (Odds ratio: 0.961, 95% confidence interval: 0927-0.995) and defecation dysfunction (Odds ratio: 0.005, 95% confidence interval: 0.0-0.368) were independent risk factors for poor prognosis after nerve cuff reconstruction in patients with sacral Tarlov cysts (all P < 0.05).

CONCLUSIONS

Patients with sacral Tarlov cysts undergoing nerve root cuff reconstruction, particularly those with longer preoperative disease duration and dysuria, are at increased risk of poor long-term prognosis.

Uncommon cause of radiculopathy: A case of symptomatic Tarlov cyst in an elderly female and literature review

Key Clinical Message

Tarlov cysts are uncommon causes of sacral radiculopathy, with particular predilection to second and third sacral roots, requiring timely diagnosis with lumbosacral MRI, and surgical management if symptomatic.

Abstract

Tarlov cysts or Type II meningeal cysts, are CSF-filled sacs located in the extradural space of the sacral spinal canal, commonly originating at the dorsal root ganglion. While they were first documented by Tarlov in 1938, their etiology remains uncertain, with theories suggesting trauma-induced bleeding or congenital abnormalities. These cysts, estimated to affect between 1% and 9% of the adult population, typically manifest as incidental findings but may lead to symptoms such as radiculopathies, sacral pain, and weakness in related sacral muscles. We present a case of a 63-year-old female presenting with recurrent left buttock pain and radiating leg discomfort. Physical examination revealed tenderness in the left buttock region, positive straight leg raise test, and minimal sensory deficits in the S1-S2 dermatomes. A provisional diagnosis of radiculopathy was made, prompting further evaluation with MRI, revealing a Tarlov cyst and absence of lumbar spinal canal stenosis or neural foraminal compromise. The patient declined intervention and was managed conservatively. This case highlights the diagnostic challenges and therapeutic considerations in managing symptomatic Tarlov cysts, emphasizing the importance of tailored treatment strategies.

Large symptomatic sacral Tarlov cyst in a paediatric patient: case report and technical note on a new variation of surgical technique to overcome one-way check-valve mechanism

PURPOSE

Symptomatic Tarlov cysts in children with a possible underlying one-way check-valve mechanism are very rare. We aim to introduce a new variation of the surgical technique to overcome a check-valve mechanism.

METHODS

A 15-years-old girl presented with double incontinence and anogenital numbness due to a large sacral Tarlov-cyst with possibly underlying one-way check valve mechanisms as suggested by preoperative computed tomography myelography. Intraoperatively, one-way check-valve was confirmed and could be eliminated by creating an artificial inner ostium between the Tarlov cyst and thecal sac with blunt perforation.

RESULTS

Postoperatively, the patient had established normal sphincter control and sensation in the anogenital region.

CONCLUSION

One-way check-valve mechanism might contribute to the symptomatology of large sacral Tarlov cysts in children. Our new variation of a surgical technique enables elimination of the check-valve mechanism without the necessity to open and close the typically very thin and fragile cyst surface and is therefore an efficacious and simple option in this situation.

A Case of Symptomatic Multiple Tarlov Cysts Treated with Microsurgical Wrapping Technique -Efficacy and Limitation of Surgical Procedure

Tarlov cysts (TCs) rarely cause clinical symptoms, such as leg pain, buttock pain, and bladder/bowel dysfunction. Surgery is considered when these symptoms persist despite medical treatments. Among several surgical procedures, microsurgical wrapping (MSW) is a relatively novel, simple technique with few complications, including cerebrospinal fluid leakage. Herein, we report a case of multiple TCs treated with MSW and present the mechanism of symptoms generated by TC and the procedure's limitations. A 58-year-old man complained of severe right leg and buttock pain for 3 months and was admitted to our hospital. His symptoms aggravated with sitting and standing and improved with the prone position. Spinal magnetic resonance imaging (MRI) demonstrated multiple sacral cysts containing intense cerebrospinal fluid. The cysts connect to the right S3 and S4 nerve roots. He was treated conservatively with medications; however, his symptoms were not improved. Therefore, MSW was performed for TCs connected to the S3 and S4 roots. The postoperative course was uneventful, and cerebrospinal fluid leakage did not occur. MRI performed 1 year after the operation demonstrated no recurrence of the TCs, and his leg pain was completely relieved; however, the buttock pain remained. MSW for TCs is effective for symptoms of adjacent nerve root compression; however, repairing the damaged nerve root in TCs is sometimes difficult. This may be a limitation of present surgical interventions because these symptoms may be difficult to treat even with other interventions.

A bibliometric and visualization study of global research trends in sacral Tarlov cyst from 2000 to 2022

Background

Symptomatic sacral Tarlov cyst (STC) exerts a significant negative impact on the patient's quality of life, highlighting the significance of the increasing number of studies on STC. However, bibliometric analyses in this research field are scarce. Thus, this study aims to provide a comprehensive knowledge structure and identify the research trends of STC through bibliometrics.

Methods

Articles related to STC from 2000 to 2022 were sourced from the Web of Science Core Collection database. VOSviewer 1.6.16, CiteSpace 6.1.6, GraphPad Prism 8.2.1 and R-package "bibliometrix" were used to analyse the data and generate knowledge maps.

Results

A total of 930 studies on STC from 2000 to 2022 were included. The findings revealed a consistent yet upward trend in the number of annual publications in this field. The United States, China and Turkey were the most prolific and influential countries contributing to this field, with the University of Illinois, the University of Maryland and the National Institute of Standards & Technology being the most notable research institutions. Key journals include World Neurosurgery [Impact Factor (IF) = 2.210], Journal of Vascular Surgery (IF = 4.860) and Journal of Neurosurgery-Spine (IF = 3.467). Additionally, Tarlov Mj, Tarlov E and Zachariah Mr exhibit the highest number of publications, making them the leading authors in this field. A twenty-year retrospection of research trends using keyword analysis reveals four principal directions, namely "definition", "pathogenesis", "diagnosis" and "treatment". Currently, therapeutic surgical intervention is the key treatment for this disease, with future treatments primarily hinging on minimally invasive methodologies rooted in microendoscopic and endoscopic techniques.

Conclusion

This pioneering, comprehensive scientific bibliometric study provides a holistic summary of STC research trends and hot spots spanning the past 22 years. The results identify existing research frontiers and chart maps for future studies, serving as a valuable reference for scholars vested in this field.

Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals

Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.

Sacral terminal filar cyst: a distinct variant of spinal meningeal cyst and midterm clinical outcome following combination resection surgery

Objective

Spinal meningeal cysts (SMCs) are currently classified into three types: extradural cysts without nerve root fibers (Type I), extradural cysts with nerve root fibers (Type II), and intradural cysts (Type III). However, the sacral terminal filar cyst is a distinct subtype with the filum terminale rather than nerve roots within the cyst. This study aimed to investigate the clinicoradiological characteristics and surgical outcomes of sacral terminal filar cysts.

Methods

A total of 32 patients with sacral terminal filar cysts were enrolled. Clinical and radiological profiles were collected. All patients were surgically treated, and preoperative and follow-up neurological functions were evaluated.

Results

Chronic lumbosacral pain and sphincter dysfunctions were the most common symptoms. On MRI, the filum terminale could be identified within the cyst in all cases, and low-lying conus medullaris was found in 23 (71.9%) cases. The filum terminale was dissociated and cut off in all cases, and the cyst wall was completely resected in 23 (71.9%) cases. After a median follow-up period of 26.5 ± 15.5 months, the pain and sphincter dysfunctions were significantly improved (both P < 0.0001). The cyst recurrence was noted in only 1 (3.1%) case.

Conclusions

Sacral terminal filar cysts are rare, representing a distinct variant of SMCs. Typical MRI features, including filum terminale within the cyst and low-lying conus medullaris, may suggest the diagnosis. Although the optimal surgical strategy remains unclear, we recommend a combination of resection of the cyst wall and dissociation of the filum terminale. The clinical outcomes can be favorable.

Complex surgical reconstruction for spinopelvic instability caused by a giant Tarlov cyst eroding the sacrum: A case report

Background

Tarlov cysts (TC), also known as perineural cysts are meningeal dilations of the posterior nerve root sheath that typically affect sacral nerve roots. TC are usually asymptomatic and found incidentally. We present the case of a patient with an enlarging sacral TC causing pain from spinopelvic instability secondary to extensive bone erosion. Such illustrative case is intended to increase awareness of the potential need for complex spinopelvic reconstruction in atypical instances of large TC.

Case Description

A 29-year-old female presented to clinic reporting progressive bilateral sacroiliac joint pain that was essentially mechanical in nature. The patient had a normal neurological exam except for a known left drop foot with numbness in the left sural nerve distribution, both attributed to a previously resected peripheral nerve sheath tumor. Magnetic resonance imaging revealed a large multilobulated lesion with imaging characteristics consistent with TC adjacent to the left side of the sacrum, extending outward from the left S1 and S2 neural foramina and measuring 6.7 × 3.7 cm in the axial plane and and 5.6 cm in the sagittal plane. Six weeks of conservative management consisting of physical therapy and pain management was unsuccessful, and the patient reported worsening pain. Surgical reconstruction consisting of L5-S1 transforaminal lumbar interbody fusion, L4 to pelvis navigation-guided instrumentation and posterolateral fusion, and bilateral sacroiliac joint fusion was successfully performed.

Outcomes

At 12 weeks follow-up appointment after surgery, the patient reported resolution of sacroiliac mechanical pain.

Conclusions

Sacral TC are asymptomatic in their vast majority of cases but may occasionally cause neurological deficits secondary to mass effect. Rarely, however, giant TC can also lead to significant bone erosion or the sacrum with secondary spinopelvic instability. In this brief report, we describe a giant TC generating significant spinopelvic instability, which was successfully treated with complex spinopelvic reconstruction, leading to complete resolution of the reported axial mechanical pain.

Symptomatic sacral Tarlov cyst: Case report and review of literature

Tarlov cysts are a common finding in MRI. Most of them are asymptomatic but in some cases can cause pain in urogenital region. Diagnosis and treatment are controversial and most of the symptomatic cases are not well diagnosed and treated because of unawareness of neurosurgeons about them. Treatment of symptomatic TC is effective and good results have been published with percutaneous and surgical techniques. A case of a young woman with a symptomatic sacral cyst treated surgically successfully is presented and literature about it is reviewed.

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.

Multiple dimensions of radiographic reconstruction for the optimal operative strategy of sacral meningeal cysts

BACKGROUND AND PURPOSE

The contents and subtypes of sacral cysts are sophisticated in many cases. We applied multiple dimensional magnetic resonance imaging (MRI) reconstruction to preoperatively clarify the specific subtype of sacral meningeal cysts.

MATERIALS AND METHODS

We preoperatively used multimodal neural reconstruction MRI sequences to evaluate 76 patients with sacral cysts. The linear nerve roots were precisely traced based on sagittal or coronal images processed at various angles and levels which was conducive to the design of the operation strategy.

RESULTS

Cysts with nerve passage were detected in 47 cases (62%, 47/76), whereas cysts without nerve roots were detected in 24 cases (32%, 24/76). Five patients had mixed cysts with or without nerve roots. Intraoperative exploration results proved the high accuracy of image reconstruction; only one cyst without a nerve root was misdiagnosed prior to surgery.

CONCLUSION

MRI reconstruction based on the three-dimensional fast imaging employing steady-state acquisition T2 sequence precisely tracked the nerve roots of sacral cysts and guided the optimal strategy during surgery.

Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report

INTRODUCTION

Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts.

CLINICAL PRESENTATION

A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved.

CONCLUSION

CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.

Novel wrapping surgery for symptomatic sacral perineural cysts

OBJECTIVE

Perineural cysts, also called Tarlov cysts, are dilatations of the nerve root sleeves commonly found in the sacrum. The majority of the cysts are asymptomatic and found incidentally on routine spine imaging. Symptomatic sacral perineural cysts (SPCs) that induce intractable low-back pain, radicular symptoms, and bladder/bowel dysfunction require surgery. However, the surgical strategy for symptomatic SPCs remains controversial. The authors hypothesized that the symptoms were caused by an irritation of the adjacent nerve roots caused by SPCs, and developed a wrapping surgery to treat these cysts.

METHODS

Seven patients with severe unilateral medial thigh pain and ipsilateral SPCs were included. Preoperative MRI showed that the cysts were severely compressing the adjacent nerve roots in all patients. After a partial laminectomy of the sacrum, the SPCs were punctured and CSF was aspirated to reduce their size, followed by dissection of the adjacent nerve roots from the SPCs. The SPCs were then wrapped with a Gore-Tex membrane to avoid reexpansion.

RESULTS

All 7 patients experienced substantial relief of their symptoms. The average numeric rating scale pain score was reduced from an average preoperative value of 7.9 to 0.6 postoperatively. Postoperative MRI showed that all cysts were reduced in size and the adjacent nerve roots were decompressed. Regrowth of the treated cysts or recurrence of the symptoms did not occur during the entire follow-up period, which ranged from 39 to 90 months. No complications were noted.

CONCLUSIONS

The authors' new wrapping technique was effective in relieving radicular symptoms for patients with symptomatic SPCs. The results suggested that the symptoms stemmed from compression of the adjacent nerve roots caused by the SPCs, and not from the nerve roots in the cysts.

Percutaneous Spinal Endoscopic Treatment of Symptomatic Sacral Tarlov Cysts

OBJECTIVE

To examine the surgical procedure for and the clinical efficacy of using spinal endoscopy for sacral Tarlov cyst treatment.

METHODS

A retrospective analysis of patients with sacral Tarlov cysts who underwent spinal endoscopy treatment from August 2018 to January 2020 at the Department of Neurosurgery, Xuanwu Hospital, China, was carried out.

RESULTS

Spinal endoscopy treatment was performed in 15 patients with sacral Tarlov cysts (6 males, 9 females). Mean patient age was 41.3 years (range, 19-67 years). Mean follow-up period was 15.6 months (range, 12-26 months). Clinical presentations of patients included sacrococcygeal and lower limb pain (n = 14), paresthesia (n = 7), lower limb motor disorder (n = 1), bowel dysfunction (n = 4), and urinary dysfunction (n = 3). Surgeries were successfully completed in all patients. Pain was significantly alleviated after surgery in 12 (85.7%) patients. Visual analog scale scores before surgery, at 1 day and 3 months after surgery, and at last follow-up were 5.9 ± 1.2, 2.9 ± 1.5, 2.3 ± 1.3, and 2.6 ± 1.0. The postoperative visual analog scale scores were significantly decreased compared with the preoperative score (all P < 0.01). Among the patients with paresthesia, 4 (57.1%) experienced improved symptoms. Muscle strength recovered from grade 4 to grade 5 after surgery in 1 patient with lower limb motor disorder. Two (50%) of 4 patients with bowel dysfunction and 2 (66.7%) of 3 patients with urinary dysfunction experienced functional improvement. Postoperative magnetic resonance imaging showed that cyst filling was satisfactory, and cyst recurrence was not observed.

CONCLUSIONS

Spinal endoscopy shows preliminary clinical efficacy for treatment of sacral Tarlov cysts and is safe and effective.

Functional recovery following resection of large Tarlov cyst malformation: a multicentre longitudinal cohort study

OBJECTIVE

The authors report their experience with 44 consecutive patients who underwent cyst fenestration and wall repair or cerebrospinal fluid communication closure for the management of sacral Tarlov cysts.

METHODS

The procedure was performed on 32 women and 12 men with a mean age of 42 years. Clinical complaints in all patients included lumbar-sacral aching, sphincter dysfunction perineal pain, and sexual intercourse pain. The patients' symptoms had developed within a mean time period of 45 months. Five patients had a previous cyst puncture. In all patients, the cyst was exposed through a sacral laminectomy. In 30 patients, the cyst was partially resected its wall repaired, and in the remaining patients, the cyst was fenestrated, and the cerebrospinal fluid communication was located and tamponaded. Thirty-seven patients had intraoperative EMG monitoring. While the perineal pain, urinary, or sexual dysfunction improved in all patients, eleven patients reported lasting pain control following surgery. The cyst was reduced in all resected cases and seven of 14 patients with CSF tamponade. The mean length of the follow-up period was 57 months.

CONCLUSIONS

Either cyst repair or CSF tamponade can be sufficient for alleviating symptoms in patients with Tarlov cyst. Advice should be given to patients regarding expectations for pain improvement after surgery.

Elimination of the check-valve mechanism of the sacral Tarlov cyst using a rotation flap technique in a pediatric patient: technical note

OBJECTIVE

Symptomatic Tarlov cysts in children are not sufficiently reported and treatment methods for Tarlov cysts are still controversial. The goal of this manuscript is to introduce a new variation of the surgical technique.

METHODS

We performed surgery to eliminate the one-way check valve mechanism of the Tarlov cyst in a 7-year-old female who presented with urinary and fecal incontinence. A relatively large S3 nerve root cyst showed a one-way check valve on computed tomography myelography. The inlet of the check valve was enlarged with rotation flap reconstruction.

RESULTS

Two months after surgery, the patient had established normal sphincter control. MRI performed two years later showed that the treated cyst was collapsing, and no recurrence occurred.

CONCLUSIONS

Rotation flap enlargement of the check valve inlet is a safe and efficacious option for the treatment of pediatric patients with sacral Tarlov cysts.

Symptomatic perineural cyst after spontaneous subarachnoid hemorrhage: A case report

RATIONALE

Tarlov or perineurial cysts are nerve root lesions often found in the sacral region. Most perineural cysts (PCs) remain asymptomatic throughout a patient's life. While their pathogenesis is still unclear, trauma resulting in hemorrhaging into subarachnoid space has been put forward as a possible cause of these cysts. Recently, we worked with a patient experiencing symptomatic PCs after spontaneous subarachnoid hemorrhage.

PATIENT CONCERNS

A 45-year-old man had a coil embolization procedure performed after being diagnosed with a subarachnoid hemorrhage from a ruptured anterior communicating artery. His symptoms were relieved after the procedure, but 7 days later he reported worsening pain in the left perineal area. The pain was intermittent at its onset and exacerbated by sitting, walking, and coughing.

DIAGNOSES

Two weeks after the embolization procedure, a lumbar spine MRI revealed 2 PCs at the S1 and S2 level affecting the left S2 root with high signal intensity in T2 and T1 images, suggestive of bleeding within the cyst.

INTERVENTIONS

We operated using a posterior approach. Cyst fenestration was done after S1 laminectomy. We aspirated approximately 1 cc of old blood.

OUTCOMES

His pain was relieved immediately after cyst removal and no neurologic deterioration occurred during the postoperative period.

LESSONS

Subarachnoid hemorrhage can be the source of the development of pain from asymptomatic PCs, making them symptomatic. Surgical extirpation is 1 treatment option for these symptomatic PCs.

Findings of subarachnoid fat after trauma to a tarlov cyst

Subarachnoid fat is an uncommon finding that has several etiologies. It is important to determine the etiology in order to plan appropriate treatment. We present a case report of an 80-year-old female brought to the emergency department after a fall with complaints of headache and pain in the sacral region. Computed tomography and magnetic resonance images of the head demonstrated fat in the subarachnoid space. Computed tomography and magnetic resonance images of the sacrum demonstrated a Tarlov cyst with a sacral fracture extending into the cyst, likely representing the origin of the fat in the subarachnoid space. This case demonstrates a rare etiology of fat in the subarachnoid space.

Tarlov Cysts Misdiagnosed as Adnexal Masses in Pelvic Sonography: A Literature Review

Introduction: A Tarlov cyst (TC) is a perineural cyst filled with cerebrospinal fluid that originates from the dorsal ganglion or the spinal posterior nerve root. TCs are usually asymptomatic and incidentally found in the sacral region. Endopelvic extension of TCs is uncommon and can be misdiagnosed as an adnexal mass on gynecological ultrasound imaging.

Methods: We performed a search for all clinical studies of TCs that mimicked adnexal masses that had been published through October 12, 2020. We placed no restrictions on language or year of publication in our search, and we performed searches with the following keywords: perineural cyst, Tarlov cyst, sclerotherapy, management, and prognosis. We included all misdiagnosed cases or cases considered as adnexal masses on pelvic sonography.

Results: We identified 21 cases of TCs mimicking adnexal masses and conducted a comprehensive analysis of these 21 cases to assess the epidemiology, symptoms, initial diagnoses, provisional ultrasound diagnoses, confirmative modalities, sizes, locations, treatments, and outcomes. The 21 cases included 16 symptomatic cases (76%) and 5 cases with incidental findings (24%), and the average patient age was 41.3 years. The initial diagnosis was performed with ultrasonography in all cases. The most frequent misdiagnosis was unspecified adnexal mass. Confirmative diagnostic modalities were MRI only (67%), CT only (5%), and both MRI and CT (28%). Treatments were surgery (33%), conservative treatment (19%), percutaneous intervention (5%), and alcohol sclerotherapy (5%). In two symptomatic cases misdiagnosed as pelvic masses, cystectomy was performed and leakage of cerebrospinal fluid occurred, necessitating repair of the leak. In one of the asymptomatic patients, cauda equina syndrome occurred after alcohol sclerotherapy for misdiagnosed TC. However, the patient improved with no neurologic deficit after 18 months of conservative treatment.

Conclusion: The possibility of large TCs should be considered when assessing adnexal masses in sonography. Since TCs can masquerade as pelvic masses, they should be considered if the mass appears tubular/cystic or multilocular/multiseptate, does not move with respiration, and originates from the sacrum in sonography with or without neurologic symptoms. Accurate diagnosis can prevent medical mismanagement and reduce patient discomfort.

Pragmatic approach to neuraxial anesthesia in obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system

Neuraxial anesthesia provides optimal labor analgesia and cesarean delivery anesthesia. Obstetric patients with disorders of the vertebral column, spinal cord and neuromuscular system present unique challenges to the anesthesiologist. Potential concerns include mechanical interference, patient injury and the need for imaging. Unfortunately, the existing literature regarding neuraxial anesthesia in these patients is largely limited to case series and rare retrospective studies. The lack of practice guidance may lead to unwarranted fear of patient harm and subsequent avoidance of neuraxial anesthesia for cesarean delivery or neuraxial analgesia for labor, with additional risks of exposure to general anesthesia. In this narrative review, we use available evidence to recommend a framework when considering neuraxial anesthesia for an obstetrical patient with neuraxial pathology.

Spinal cord stimulation for the treatment of chronic pelvic pain after Tarlov cyst surgery in a 66-year-old woman: A case report

Tarlov cysts are extradural meningeal cysts with collections of cerebrospinal fluid within the nerve sheath. These cysts are uncommon but tend to present more often in women. Symptomatic Tarlov cysts can lead to a variety of neurologic symptoms and painful conditions, including chronic pelvic pain. There is no consensus regarding the best treatment for symptomatic cysts. Surgical management has high rates of complication, including chronic pain, but better long-term results for symptom and cyst resolution. We describe a patient who developed worsening pelvic pain and lumbar radiculopathy after surgical management of her Tarlov cysts. Medication failed to relieve the pain, as did a variety of other procedures, before the patient ultimately received significant pain relief from high-frequency spinal cord stimulation. This case may provide guidance for physicians when managing patients suffering from symptomatic Tarlov cysts, or worsening pain symptoms after surgical management of these cysts.

Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia

BACKGROUND

Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms.

OBJECTIVE

To evaluate the prevalence of S2-S4 Tarlov cysts at the pudendal nerve origin (S2-S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst.

STUDY DESIGN

A retrospective study was performed on 242 patients with pudendal neuralgia referred for pelvic magnetic resonance imaging from January 2010 to November 2012. Dedicated magnetic resonance imaging review evaluated for presence, level, site, and size of Tarlov cysts. Among those with demonstrable cysts, subsequent imaging data were collected and correlated with the patients' clinical site of symptoms. Statistical analysis was performed using χ², Pearson χ², and Fisher exact tests to assess significance.

RESULTS

Thirty-nine (16.1%) patients demonstrated at least 1 sacral Tarlov cyst; and of the 38 patients with complete pain records, 31 (81.6%) had a mismatch in findings. A total of 50 Tarlov cysts were identified in the entire patient cohort. The majority of the Tarlov cysts were found at the S2-S3 level (32/50; 64%). Seventeen patients (44.7%) revealed unilateral discordant findings: unilateral symptoms on the opposite side as the Tarlov cyst. In addition, 14 (36.8%) patients were detected with bilateral discordant findings: 11 (28.9%) had bilateral symptoms with a unilateral Tarlov cyst, and 3 (7.9%) had unilateral symptoms with bilateral cysts. Concordant findings were only demonstrated in 7 patients (18.4%). No significant association was found between cyst size and pain laterality (P = .161), cyst volume and pain location (P = .546), or cyst size and unilateral vs bilateral pain (P = .997).

CONCLUSION

The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.

Surgical management of symptomatic Tarlov cysts: cyst fenestration and nerve root imbrication-a single institutional experience

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.

Epiduroscopic decompression of a symptomatic perineural cyst: A case report

RATIONALE

Perineural cysts in the spinal canal are usually asymptomatic. However, symptoms can occur when the cyst becomes large enough to compress a nerve root. There are still no established treatment options for this disease. In this report, we describe a case of successful decompression of the large symptomatic perineural cyst using epiduroscope.

PATIENT CONCERNS

A 42-year-old male patient visited our pain center complaining of discomfort and pain in his right posterior thigh. Magnetic resonance imaging of the patient showed a large perineural cyst (53 × 31 × 21 mm) compressing the right S1 nerve. No other abnormalities that would explain the patient's symptoms were identified.

DIAGNOSIS

Perineural cyst at the right S1 nerve.

INTERVENTIONS

We performed an epiduroscopic decompression of the perineural cyst. After advancing the epiduroscope and locating the cyst, we used the laser to make a hole in the cyst wall. Then, the epiduroscope was advanced into the cyst, and the cystic fluid was aspirated.

OUTCOMES

The symptoms of the patient were relieved after the procedure, without any complications. There was no recurrence of symptoms until 6 months after the procedure.

LESSONS

The epiduroscope is a minimally invasive method which can be used safely for decompression of symptomatic perineural cysts in the spinal canal.

[Surgical treatment of sacral Tarlov cysts: about 20 cases]

Tarlov cyst or perineural cyst is a local dilation of the subarachnoid space formed within the nerve root and filled with cerebrospinal fluid. There is no consensus on the best treatment of syntomatic sacral perinervous cysts. Many methods have been used to treat these symptomatic lesions, with variable results. We report a case series including 20 patients undergoing surgery for sacral Tarlov cyst. Our results were satisfactory; 80% of patients improved without neurological worsening in the post-operative period. Our surgical technique (sacral laminectomy+cyst puncture+establishment of dural sheat) described for the first time in this study seems to have been effective in the 20 cases reported in our study.

Management of perineural (Tarlov) cysts: a population-based cohort study and algorithm for the selection of surgical candidates

Objective

Perineural cysts, also known as Tarlov cysts, are cerebrospinal fluid-filled growths that develop at the intersection of a dorsal root ganglion and posterior nerve root. They are typically an asymptomatic and incidental finding during routine spine imaging. For symptomatic perineural cysts, there is little evidence on which treatment is most effective or when it is indicated. The aim of this study was to review our experience from a population-based cohort of patients with symptomatic perineural cysts and to propose an algorithm that could be used in the selection of surgical candidates.

Methods

A retrospective review was conducted of all adult (≥ 15 years) patients with symptomatic perineural cysts who were referred to Karolinska University Hospital between 2002 and 2018.

Results

Thirty-nine patients were included. The most common symptom was sciatica (n = 22). Cyst aspiration was performed in 28 patients, 24 of whom showed clinical improvement and were offered surgery. Microsurgical cyst fenestration was performed in 17 patients, 16 of whom showed clinical improvement at long-term follow-up. There were no surgical complications. Ten of the patients who were offered surgery chose to be treated conservatively instead, four of whom showed progression of symptoms at long-term follow-up.

Conclusions

Microsurgical cyst fenestration seems to be a safe and effective option for symptomatic relief in patients with perineural cysts. Based on the results from our series and those of others, we propose an algorithm for the selection of surgical candidates.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04000-5) contains supplementary material, which is available to authorized users.

Imaging features of Benign Perianal lesions

Magnetic resonance imaging provides detailed visualisation, identification and extent assessment of many anal disorders. While many studies are performed in the evaluation of malignant processes such as anorectal carcinoma, the primary focus of this pictorial review is benign lesions, which involve the anal canal and perianal spaces. This pictorial review will illustrate the MRI appearances of a variety of benign conditions, which predominantly affect the anal canal, including abscess, fistulae, lipomas, developmental cysts and inflammatory conditions. MRI aids in the identification and characterisation of these abnormalities, of coexisting complications and differentiation from other perineal abnormalities. This pictorial review highlights the spectrum of non-malignant processes involving the perianal region.

Spontaneous Intracranial Hypotension Presenting As Cervicogenic Headache: Case Report and Review of Literature

BACKGROUND

Spontaneous intracranial hypotension is uncommon. There is a lack of understanding of its exact pathophysiology along with significant variability in its clinical management.

CASE DESCRIPTION

The authors report the case of a previously well man with cervicogenic headache associated with magnetic resonance imaging features of intracranial hypotension. The salient features of this case include the details of various treatments prescribed for his condition and the therapeutic difficulties encountered.

CONCLUSION

Owing to the infrequency of the diagnosis, the challenges of clinical management for this patient are discussed in relationship to current literature. Next, the highlights of this unusual case in an individual add to the growing body of literature reports for better understanding of this disease.

Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review

PURPOSE

Tarlov cysts (TCs) are dilations of nerve roots arising from pathologically increased hydrostatic pressure (HP) in the spinal canal. There is much controversy regarding whether these cysts are a rare source of pain or often produce symptoms. The aim of this review was to identify the reasons that symptomatic TCs (STCs) are easily overlooked.

METHODS

The literature was searched for data regarding pathogenesis and symptomatology.

RESULTS

TCs may be overlooked for the following reasons: (1) STCs are considered clinically irrelevant findings; (2) it is assumed that it is clinically difficult to ascertain that TCs are the cause of pain; (3) MRI or electromyography studies only focus on the L1 to S1 nerves; (4) TCs are usually not reported by radiologists; (5) degenerative alterations of the lumbosacral spine are almost always identified as the cause of a patient's pain; (6) it is not generally known that small TCs can be symptomatic; (7) examinations and treatments usually focus on the cysts as an underlying mechanism; however, essentially, increased HP is the main underlying mechanism for producing symptoms. Consequently, STCs may relapse after surgery; (8) bladder, bowel and sphincter dysfunction are not inquired about during history taking. (9) Unexplained pain is often attributed to depression, whereas depression is more likely the consequence of debilitating neuropathic pain. (10) The recognition of STCs is subject to gender bias, confirmation bias and cognitive dissonance and unconscious bias in publishing.

CONCLUSION

There are several reasons STCs are underdiagnosed, mostly due to persistent misconceptions and biases. These slides can be retrieved under Electronic Supplementary Material.

A systematic comparative outcome analysis of surgical versus percutaneous techniques in the management of symptomatic sacral perineural (Tarlov) cysts: a meta-analysis

OBJECTIVE

Symptomatic perineural or Tarlov cysts (TCs) are a rare cause of chronic low-back pain. Given the rarity of the disease, there is no literature consensus regarding the optimal management of these cysts.

METHODS

The authors conducted a systematic comparative outcome analysis of symptomatic TCs treated with surgery (group A, 32 studies, n = 333) or percutaneous interventions (group B, 6 studies, n = 417) analyzing the demographic characteristics, baseline characteristics of the cysts, clinical presentations, types of interventions, complication rates, and the recurrence rate in both treatment groups. The literature search was performed using the PubMed, MEDLINE, Cochrane, and Ovid databases up to 2018. The MeSH search terms used were "Tarlov cyst," "sacral perineural cyst," "sacral nerve root cyst," "meningeal cyst of the sacral spine," "extra meningeal cyst with spinal nerve root fibers," "spinal extradural arachnoid pouch," and "cyst of the sacral nerve root sheath." The authors used statistical tests for two proportions using the "N-1" chi-square test with the free version of MedCalc for Windows for comparison among the groups.

RESULTS

Overall symptomatic improvement was reported in 83.5% of patients in both groups; however, exacerbation of preprocedural symptoms was significantly higher in group B than group A (10.1% vs 3.3%, p = 0.0003). The overall complication rates in the surgical and nonsurgical groups were 21% and 12.47%, respectively. Transient sciatica was the most common complication in both groups (17% vs 8%, respectively; p = 0.017). The incidence of cyst recurrence was much lower in group A than group B (8% vs 20%, p = 0.0018). The mean follow-up duration for the surgical group was 38 ± 29 months (25 studies, n = 279), while that for the nonsurgical group was 15 ± 12 months (4 studies, n = 290) (p < 0.0001).

CONCLUSIONS

The authors noted that although the surgical interventions were associated with higher postprocedural complication rates, long-term efficacy and success in terms of cyst resolution were superior following surgery compared to percutaneous procedures in the management of symptomatic TCs. There was no difference in symptom recurrence with either of the techniques.

Depressive symptomatology in a female patient with Tarlov cyst

Introduction:

The spinal perineurial cyst is a rare anomaly of the nervous system. It is also known as Tarlov cyst, since it was described for the first time by Isadore M. Tarlov. The pathology is defined as a cystic dilatation between the perineurium and endoneurium of spinal nerve roots, located at the level of the spinal ganglion and filled with cerebrospinal fluid but without communication with the perineurial subarachnoid space.

Case report:

We present the case of a 56-year-old female who reported sudden onset of symptoms of a depressive symptomatology accompanied with acute pain in the lumbar area. Lumbosacral magnetic resonance imaging scan revealed Tarlov cysts.

Discussion:

Radiological investigations in patients with depressive symptomatology may be substantial.

Multiple Sacral Perineurial Cysts Presented Symptoms Triggered by Nonaneurysmal Perimesencephalic Subarachnoid Hemorrhage

The origin and pathogenesis of perineurial cysts remain unclear. Here, we report a rare case of multiple sacral perineurial cysts presented symptoms triggered by nonaneurysmal perimesencephalic subarachnoid hemorrhage (SAH). A 48-year-old male presented with a severe headache of sudden onset. Brain computed tomography revealed a SAH in the basal cistern; however, no abnormal vascular lesion was detected. Four days after the onset of the SAH, he suffered from left buttock pain, followed by urinary dysfunction and paresthesia in the left S2 and S3 dermatomes. Magnetic resonance (MR) imaging demonstrated multiple cystic lesions at the left S1 and bilateral S2 sacral roots. The two cysts at the S2 level exhibited high signal intensity on both T₁- and T₂-weighted images, suggesting the content of the cysts included a hematoma. He was treated with intravenous injections of steroids, and the symptoms recovered completely within 2 months. Follow-up MR imaging revealed remarkable shrinkage of the cysts. Sacral perineurial cysts should be listed in the differential diagnosis if the patient suffers from low back pain or sacral radiculopathy after the onset of SAH.

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature

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 intractranial 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.

Effectiveness of Surgical Treatment for Tarlov Cysts: A Systematic Review of Published Literature

OF BACKGROUND DATA

In the general population, it has been estimated that 1.5% of people have ≥1 Tarlov cysts, with about 13% of those being symptomatic. Despite a range of options for treatment, there is debate about when, and how to optimally treat individuals with Tarlov cysts among clinicians, and among policy decision makers.

OBJECTIVE

To summarize the current evidence on surgical treatment of Tarlov cysts.

STUDY DESIGN

A systematic review was completed.

METHODS

Nine databases were searched. Abstracts and full-texts were assessed by 2 reviewers. To be included, studies had to assess safety, efficacy, or effectiveness of treating Tarlov cysts, had to be written in English or French, and had to be a randomized, quasi-randomized, observational cohort, case control, or case series design including ≥2 participants. Logistic regression analysis was undertaken on the patient-level data collected to assess the association of patient and cyst characteristics on treatment success.

RESULTS

In total, 31 studies were included in this systematic review; all were case series. Among the 646 participants included in these 31 studies, 210 experienced complete resolution of symptoms (32%), 327 had partial resolution (50%), 106 did not have any improvement or worsening of symptoms (16%), and 3 had their symptoms worsen after surgery (0.4%). A number of adverse events were reported after surgery; however, all were temporary. The analysis of 49 patients with data on cyst size resulted in the odds of complete resolution of symptoms being lower for patients with larger cysts (odds ratio=0.53, P-value=0.107) although this finding is not statistically significant. For those with a cyst >1.5 cm the odds of complete resolution were (odds ratio=0.36, P-value=0.190) compared with those with a cyst <1.5 cm.

CONCLUSIONS

The evidence suggests that surgery for symptomatic Tarlov cysts may be an effective option for partially or completely relieving symptoms. Contrary to previous findings larger cysts were not associated with completely relieving symptoms.

Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature

Background:

Symptomatic Tarlov cysts are extremely rare, and there is no consensus regarding their optimal surgical management. Here, we encountered a patient with a symptomatic sacral Tarlov cyst and reviewed the appropriate literature.

Case Description:

A 40-year-old male presented with right lower extremity pain and hypoesthesia in the right S2 dermatome. The lumbosacral MR demonstrated a right S2 Tarlov cyst compressing the S2–S3 perineural sheaths. After the patient underwent microscopic cystectomy with obliteration of the subarachnoid connection to the cyst, the patient's symptoms resolved. Here, we reviewed our operative approach, and others proposed in the literature for the surgical management of these lesions.

Conclusions:

Here, we present a 40-year-old male who was symptomatic from a right S2 Tarlov cyst compressing the S2–S3 perineural sheaths and successfully underwent microscopic cystectomy with obliteration of the subarachnoid connection. Additionally, the appropriate Tarlov cyst literature was reviewed.

Management of symptomatic sacral perineural cysts with microsurgery and a vascularized fasciocutaneous flap

Background

The optimal treatment of symptomatic perineural (Tarlov) cysts is controversial. Numerous surgical techniques have been proposed with conflicting results. A series of Tarlov cysts treated with a novel surgical approach is presented.

Methods

Patients with surgically treated symptomatic perineural cysts during 2013-2016 were included. The main indications for surgery were persistent radicular symptoms, pelvic pain, urinary and/ or bowel disturbances. At surgery, the cyst was opened and fenestrated. The cyst wall was then closed with packing, fibrin glue and a pedicled vascularized fasciocutaneous flap rotated into the area for obliteration of the dead space. Patients were followed-up with clinical visits and repeat magnetic resonance imaging (MRI) scans.

Results

Seven consecutive patients were included. The mean age was 50.3 years (range, 25-80 years) and the mean duration of symptoms was 49.3 months (range, 3-130 months). With one exception, all patients had urine and/or bowel problems (incontinence) preoperatively. A lumbar drain was inserted in five patients. The mean follow-up period was 15.4 months. Symptoms improved in 4/7 patients, in two cases no clinical difference was noted while one patient deteriorated. In two cases, a spinal cord stimulator was eventually implanted. In all seven cases, a significantly decreased cyst size was noted on MRI.

Conclusions

Cyst fenestration and the use of a vascularized fasciocutaneous flap successfully obliterated all cysts, with satisfactory clinical efficacy. Larger and comparative studies are warranted to clarify the long-term effects of this surgical technique in patients with symptomatic Tarlov cysts.

Treatment of a symptomatic cervical perineural cyst with ultrasound-guided cervical selective nerve root block: A case report

RATIONALE

Symptomatic cervical perineural cysts are extremely rare, and they cause radicular pain by compressing the cervical nerve root. Several methods have been applied to manage the radicular pain induced by cervical perineural cysts, including medication, percutaneous procedures, and surgery. However, these methods are associated with various outcomes and complications. The percutaneous procedure is simple and easy to perform, but if the perineural cyst wall is punctured, it can lead to secondary complications, which include aseptic meningitis and intracranial hypotension.

PATIENT CONCERNS

A 51-year-old woman presented with a dull pain in the left shoulder and a tingling sensation in the left dorsal arm, hand, and middle finger.

DIAGNOSIS

The patient was diagnosed with left C7 radicular pain caused by a perineural cyst.

INTERVENTIONS

The left C7 radicular pain did not respond to treatment with medication. Therefore, a left C7 nerve root block with local anesthetics and steroids was performed under ultrasound guidance. Adjunctively, real-time fluoroscopy with contrast was used to avoid intravascular injection.

OUTCOME

The symptoms resolved without any complications.

LESSONS

In this case, perineural cyst-induced radicular pain, which was resistant to medication, was treated using ultrasound guided cervical selective nerve root block with local anesthetics and steroids. Ultrasound guidance can enable successful cervical selective nerve root block without perineural cystic wall puncture. Therefore, ultrasound-guided cervical nerve root block is an effective treatment option for radicular pain caused by a symptomatic perineural cyst.

A Rare Cause of Thoracic Spinal Cord Compression by Multiple Large Tarlov Cysts

Spinal extradural arachnoid cyst (SEAC) is a rare cause of spinal cord compression. Bifocal location of thoracic and sacral SEACs is rarely reported in the literature. We report a case of thoracic spinal cord compression by SEAC associated with asymptomatic multiple sacral Tarlov cysts (TC). The surgical management and postoperative outcome of the patient are discussed. A 34-year-old woman was referred to the hospital for acute thoracic pain with a history of chronic long-standing back pain. She complained of walking difficulties. Neurological examination demonstrated incomplete spastic paraplegia with sensory level in T9. Magnetic resonance imaging revealed a large cystic formation from T7-11 and at the level of the sacrum. We performed laminectomies at the level of interest from T7-11. The cysts were dissected from the underlying dura after removal of the cerebrospinal fluid. We found nerve tissue in the cysts. We excised the cyst and preserved the nerve roots. Subsequently, a duraplasty was performed with autologous grafts from the lumbar fascia. The condition of the patient improved after surgery and he was recovering well at follow-up. Although the surgical treatment of TC is controversial, especially at the sacral lumbar level, decompression at the dorsal level in this case is indisputable.

Can patients with symptomatic Tarlov cysts be differentiated from patients with specific low back pain based on comprehensive history taking?

BACKGROUND

Tarlov cysts (TCs) are expanded nerve root sheaths that occur near the dorsal root ganglion and result from increased intraspinal hydrostatic pressure. TCs most frequently affect the lumbosacral plexus and therefore may cause specific symptoms such as perineal pain and neurogenic bladder, bowel, and sphincter problems. It has been estimated that 1% of the population has symptomatic Tarlov cysts (STCs). However, STCs appear to be underdiagnosed, with the pain reported by patients commonly attributed to degenerative alterations seen on MRI. The aim of the present study is to investigate the utility of a comprehensive questionnaire for use by physicians in establishing the diagnosis of STCs.

METHODS

We compared questionnaire responses regarding patient history between 33 patients diagnosed with symptomatic TCs and 42 patients with chronic low back pain and sciatica due to disc problems or degenerative or inflammatory disorders. The diagnosis of STCs was confirmed using nerve conduction studies (NCS) and electromyography (EMG) of the sacral myotomes by an expert neurophysiologist.

RESULTS

The questionnaire responses revealed specific differences in perineal symptoms (perineal pain, dyspareunia, coccygodynia), bowel symptoms (constipation, diarrhea), bladder symptoms (hesitation, retention, frequency), and anal sphincter problems (anal pain, mild fecal incontinence). Additionally, sitting, walking, and straining aggravated pain more frequently in STC patients, and STC patients were more often forced to stop working and/or reduce their social activities.

CONCLUSIONS

Including the above-listed items in the patient history might facilitate differentiation of low back pain and sciatica due to STCs from that due to disc problems or degenerative or inflammatory disorders.

Symptomatic Tarlov Cysts: Surgical Treatment by Subcutaneous Infusion Port

BACKGROUND

The treatment of Tarlov cysts is challenging and difficult. The objective of our study was to describe the security and efficacy of the subcutaneous infusion port for drainage of symptomatic Tarlov cysts.

METHODS

The authors executed a retrospective review of data from 5 symptomatic Tarlov cysts patients who were treated using a subcutaneous infusion port from June 2014 to July 2017. Numerical Rating Scale scores and the Japanese Orthopedic Association scores of back pain were analyzed. Complications and adverse effects on postoperative days 1, 7, 14, and 28 were also analyzed. The mean follow-up was 12.6 months.

RESULTS

Five adults (3 females and 2 males) who had been symptomatic received a subcutaneous infusion port. After treatment, all patients experienced pain relief and pain alleviation lasted from 1 day to 3 years without complications and adverse effects.

CONCLUSIONS

A subcutaneous infusion port is a useful treatment option for symptomatic Tarlov cysts. When the patients' symptoms returned and the cysts repressurized, we quickly and simply drained the cysts by using the infusion port.

Non-cardiac manifestations of Marfan syndrome

Because of the widespread distribution of fibrillin 1 in the body, Marfan syndrome (MFS) affects virtually every system. The expression of this single dominantly inherited gene is variable within a family, and between families. There is some genotype-phenotype correlation which is helpful in guiding long-term prognosis, and management. In general gene mutations have been reported in clusters, with those having mainly ocular manifestations occurring in exons 1 to 15 of this 65-exon gene; those causing cardiac problems often involving cysteine replacement in a calcium binding EGF-like sequence; the most severe mutations occurring in exons 25-32, causing neonatal MFS diagnosed at birth, and severe enough to cause death frequently before the age of 2. Other correlations will certainly be found in future. This condition is progressive, and the manifestations unfold according to age. For example, if the lens is going to dislocate this usually occurs by age 10; scoliosis usually presents itself between the ages of 8 and 15; height should be monitored carefully between the onset of puberty and cessation of growth approximately age 17 or 18. Holistic care should be offered by one doctor who oversees the patient's welfare. This should be a paediatrician, paediatric cardiologist, or general practitioner in the case of an affected child. Thereafter, the physician in charge of the most seriously affected system should be aware that other systems need to be managed through a referral network.