Microsurgical treatment of sacral perineural (Tarlov) cysts: case series and review of the literature

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Tarlov cysts (TCs) occur most commonly on extradural components of the sacral and coccygeal nerve roots. These lesions are often found incidentally, with an estimated prevalence of 4%–9%. Given the low estimated rates of symptomatic TC and the fact that symptoms can overlap with other common causes of low-back pain, optimal management of this entity is a matter of ongoing debate. Here, the authors investigate the effects of surgical intervention on symptomatic TCs and aim to solidify the surgical criteria for this disease process.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>The authors performed a retrospective review of data from consecutive patients who were surgically treated for symptomatic TCs from September 2011 to March 2013. Clinical evaluations and results from surveying pain and overall health were used. Univariate statistical analyses were performed.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>Twenty-three adults (4 males, 19 females) who had been symptomatic for a mean of 47.4 months were treated with laminectomy, microsurgical exposure and/or imbrication, and paraspinous muscle flap closure. Eighteen patients (78.3%) had undergone prior interventions without sustained improvement. Thirteen patients (56.5%) underwent lumbar drainage for an average of 8.7 days following surgery. The mean follow-up was 14.4 months. Univariate analyses demonstrated that an advanced age (p = 0.045), the number of noted perineural cysts on preoperative imaging (p = 0.02), and the duration of preoperative symptoms (p = 0.03) were associated with a poor postoperative outcome. Although 47.8% of the patients were able to return to normal activities, 93.8% of those surveyed reported that they would undergo the operation again if given the choice.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>This is one of the largest published studies on patients with TCs treated microsurgically. The data suggest that patients with symptomatic TCs may benefit from open microsurgical treatment. Although outcomes seem related to patient age, duration of symptoms, and extent of disease demonstrated on imaging, further study is warranted and underway.</jats:p></jats:sec>

Atypical findings of perineural cysts on postmyelographic computed tomography: a case report of intermittent intercostal neuralgia caused by thoracic perineural cysts

“…However, regarding cyst enlargement, the ball-valve theory has achieved consensus as an underlying mechanism, suggesting that enlargement is caused by restricted CSF outflow from the cyst as a result of CSF pulsatile and hydrostatic forces [9, 10]. The first CT results in our case suggested that CSF inflow into the two cysts exceeded outflow, which supports this theory.…”

“…It was difficult to prove a causal relationship between the perineural cysts and the intercostal neuralgia; however, we concluded that the chest wall pain was caused by the pressure of the largest cyst at left T10 for several reasons: 1) this cyst was considerably larger and involved the nerve root fibers that were causing the symptoms; 2) this cyst showed an imbalance between CSF inflow and outflow; 3) because the pain was intermittent and alleviated when the patient was lying down, the cause of the pain was expected to be easily resolved, considering its relationship to head position; and 4) we found no other causal abnormality to explain the neuralgia other than the cyst. If the patient’s symptoms reappear in the future, we would reconsider invasive treatment as the patient would meet the criteria for surgery [9]. …”

Incomplete cauda equina syndrome secondary to haemorrhage within a Tarlov cyst

“…Particularly promising outcomes have been associated with the use of microsurgical techniques which have been reported to provide symptomatic relief in up to 47.8%–86.6% of cases 21 22. However, it is important to note that these figures arise from studies with small sample sizes and are often retrospective in nature 21. Therefore, the generalisability of these findings to all patients is limited.…”

Electromyography and A Review of the Literature Provide Insights into the Role of Sacral Perineural Cysts in Unexplained Chronic Pelvic, Perineal and Leg Pain Syndromes

“…This is because of the fragility of the tissues and the elevated pressure in the spinal canal [10]. Finally, a high frequency of headaches might also reflect increased pressure in the cerebrospinal canal [1,2,8,11,18,33].…”

“…A MRI of the cervicodorsal spine was therefore reviewed, if available. Because the headaches that were often reported in our patient group might have reflected an increase in pressure inside the cerebrospinal canal [2,18], a complete ophthalmologic examination that included optic disc biometry was performed by an expert ophthalmologist. The examination used optical coherence tomography (Spectralis OCT, Heidelberg) and static automated perimetry (Humphrey Field Analyzer, Zeiss or Octopus 300, Heig-Streit) to detect and grade possible papilledema.…”