Sacral perineural cysts: imaging and treatment options

A systematic review of the efficacy of surgical intervention in the management of symptomatic Tarlov cysts: a meta-analysis

Introduction: Tarlov cysts (TC) are sacral perineural cysts that are often found incidentally during spinal imaging. In a small fraction, symptomatic TC can cause pain, bowel, bladder and/or sexual dysfunction, as well as motor and sensory deficits. While many surgeons regard TCs as a non-operative entity, there have been suggestions that operative intervention in carefully selected symptomatic patients may be beneficial. The aim of this meta-analysis is to identify whether surgical treatment for symptomatic TCs is beneficial with an acceptable complication profile.Materials and methods: The authors conducted a systematic outcome analysis of symptomatic TCs treated either with surgery or conservatively managed.Results: Sixteen studies (N = 238) met the inclusion criteria for final meta-analysis. The literature search was performed using PubMed, Ovid MEDLINE, CINAHL, and EMBASE databases up to September 2017 and with an updated search in April 2019. The post-operative complication rate in patients undergoing surgical intervention was 16.9 (11.8 to 22.7) and cyst recurrence was 8.5 (3.5 to 15.4). When a complication occurred, the most frequent complication of surgical intervention was the development of a surgical site infection and/or CSF leak. Of the 15 studies reporting long-term follow-up, 81.0 (74.0-88.0) of patients remained symptom-free for more than 1 year (Mean: 27.5 months, SD = 11.5).Conclusion: We rigorously analyse the efficacy of open surgical decompression and repair of symptomatic TCs and corroborate the findings of sustained long-term resolution of symptoms.

Case Report: Microscope-assisted surgery of C7 nerve root cyst with neurological symptoms

Background

Cervical nerve root cysts are rare and easily missed or misdiagnosed in clinical practice. Although conventional surgery is effective for cervical nerve root cysts, it is limited by the small surgical field of view and operating range, relatively difficult procedure, and incomplete cyst resection. Microscope-assisted magnification of the surgical field of vision reduces the difficulty and ensures complete cyst resection.

Case presentation

A 58-year-old male patient was diagnosed with a cervical nerve root sleeve cyst on the right C7 vertebra with neurological symptoms. Microscope-assisted surgery was used as treatment. The cyst was completely removed by the microscope-assisted surgery, with satisfactory patient recovery. The surgery did not produce complications, such as spinal cord neurovascular injury, and the patient's symptoms disappeared quickly after surgery. During the 2-year follow-up, there was no complication and no recurrence.

Conclusion

Microscope-assisted surgery in treatment of the C7 nerve root cyst could achieve a complete resection.

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.

Tips and traps in neurological imaging: imaging the perimedullary spaces

The spinal canal is frequently a source of difficulties, traps and diagnostic errors. Pitfalls related to artifacts are resolved by using appropriate sequences. Good knowledge of the appearance of certain particular anatomical structures (the cauda equina roots, the radicular veins of the lumbar spine and conus medullaris, the dorsal root ganglion) and of frequent variants (fibrolipoma of the filum terminale, common root sheaths, root cysts) will avoid a good many errors. Dilatation of epidural veins in intracranial hypotension can simulate the contrast enhancement of a tumour. An increase in epidural fat can induce pathogenic stenosis of the dural sheath.

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.

A symptomatic lumbosacral perineural cyst -A case report-

Lumbosacral perineural cysts are formed by the arachnoid membrane of the nerve root at the lumbosacral level. Most of these cysts are asymptomatic and are found incidentally during computed tomography (CT) or magnetic resonance imaging (MRI) for other causes of chronic lower back pain. This type of cyst requires a differential diagnosis to distinguish it from other causes of radiating pain and neurological symptoms. In the present case, a symptomatic lumbosacral perineural cyst was found, and pain relief was achieved by non-surgical treatment. A lumbosacral perineural cyst was identified from a differential diagnosis of a lumbar disc disorder that presented as radiating pain and neurological symptoms.

Conservative management of perineural cysts

STUDY DESIGN

A case series and literature review are presented.

OBJECTIVE

To review relevant data for the management of perineural cysts, and present a case series of 2 patient with symptomatic perineural cysts treated by steroid therapy.

SUMMARY OF BACKGROUND DATA

Perineural cysts are usually an incidental finding, but rarely may cause mechanical nerve root compression. Surgical treatments for perineural cysts are complicated by postoperative pseudomeningocoele and intracranial hypotension, and reoccurrence of the cyst. There are no reported nonsurgical treatments for perineural cysts.

METHODS

We present a case series symptomatic perineural cysts.

RESULTS

Patients with lumbar and cervical perineural cysts were treated successfully with oral and epidural steroid therapy.

CONCLUSION

Steroid therapy may offer a nonsurgical alternative for the treatment of symptomatic perineural cysts.

Sacral intraspinal meningocele in a patient presenting with abdominal pain. Case report

Sacral meningoceles are typically asymptomatic. When they are symptomatic, patients commonly present with signs and symptoms of nerve root compression and back pain. The authors report the case of a 10-year-old girl with an intraspinal sacral meningocele who presented initially only with severe right lower quadrant pain. The patient underwent successful surgical treatment of the meningocele and experienced subsequent resolution of the abdominal pain. This is the first reported case of an intraspinal sacral meningeal cyst in which the only presenting symptom was abdominal pain and which was successfully treated with surgery. It is postulated that the sacral meningocele caused severe abdominal pain secondary to compression of the sacral parasympathetic fibers that pass through the sacral plexus on each side of the cord corresponding to the S-2 and S-3 levels.

Giant sacral meningeal diverticula: surgical implications of the “thecal tip” sign

✓ The surgical anatomy of giant sacral meningeal diverticula varies greatly depending on whether they develop ventral or dorsal to the thecal sac and spinal nerve roots. The ability to distinguish between the two lesion types preoperatively is therefore advantageous. The authors present a method of distinguishing ventral from dorsal meningeal diverticula on magnetic resonance imaging using the “thecal tip sign.” They also describe the differences in operative technique required for resection of each type of diverticular cyst.