Surgical management of sacral meningeal cysts by obstructing the communicating holes with muscle graft

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.

Accurate diagnosis and treatment of sacral meningeal cysts without spinal nerve root fibres: identifying leakage orificium using high-resolution spherical arbitrary-dimensional reconstructing magnetic resonance imaging

Objective

This study aimed to develop an arbitrary-dimensional nerve root reconstruction magnetic resonance imaging (ANRR-MRI) technique for identifying the leakage orificium of sacral meningeal cysts (SMCs) without spinal nerve root fibres (SNRFs).

Methods

This prospective study enrolled 40 consecutive patients with SMCs without SNRFs between March 2021 and March 2022. Magnetic resonance neural reconstruction sequences were performed for preoperative evaluation. The cyst and the cyst-dura intersection planes were initially identified based on the original thin-slice axial T2-weighted images. Sagittal and coronal images were then reconstructed by setting each intersecting plane as the centre. Then, three-dimensional reconstruction was performed, focusing on the suspected leakage point of the cyst. Based on the identified leakage location and size of the SMC, individual surgical plans were formulated.

Results

This cohort included 30 females and 10 males, with an average age of 42.6 ± 12.2 years (range, 17-66 years). The leakage orificium was located at the rostral pole of the cyst in 23 patients, at the body region of the cyst in 12 patients, and at the caudal pole in 5 patients. The maximum diameter of the cysts ranged from 2 cm to 11 cm (average, 5.2 ± 1.9 cm). The leakage orificium was clearly identified in all patients and was ligated microscopically through a 4 cm minimally invasive incision. Postoperative imaging showed that the cysts had disappeared.

Conclusion

ANRR-MRI is an accurate and efficient approach for identifying leakage orificium, facilitating the precise diagnosis and surgical treatment of SMCs without SNRFs.

Intrasacral meningoceles: Clinical presentation, surgical management, and postoperative outcome: The Giannina Gaslini Hospital's experience

INTRODUCTION

Intrasacral meningoceles are cysts associated with herniating arachnoid with no nerve root within due to an area of weakness of the dura mater. They are thought to be congenital, but they are usually not symptomatic until adulthood. Surgical treatment is generally indicated in the presence of symptoms.

METHODS

We selected cases belonging to the IB category of Nabors et al.'s classification who underwent surgery between 2008 and 2021 at Giannina Gaslini Hospital. Exclusion criteria were prior history of trauma, infections, or operations. Patients' clinical details, associated conditions, surgical techniques, peri- and postoperative complications, and outcomes were collected retrospectively from clinical charts. We compared our series to literature: keywords "intrasacral meningocele" were used on the search engine MEDLINE - Pubmed.

RESULTS

We identified 23 cases: 5 of the 14 symptomatic patients had a complete resolution, and 5 had a substantial clinical improvement after surgery. Cyst recurrence and major postoperative complication occurred in none. Among 59 articles considered for evaluation, 50 were excluded and remaining 9 articles underwent full-text analysis.

DISCUSSION AND CONCLUSION

The pathogenesis of instrasacral meningoceles is still not completely understood and the spectrum of symptoms is wide. A posterior surgical approach with sacral laminectomy is preferred, although in selected cases it is possible to perform a supplemental anterior approach (sometimes endoscopic). In our surgical series, the largest one published in the literature, a good clinical outcome was achieved in most patients with no cyst's recurrence, pointing out the importance of surgical interruption of communication between cyst and subdural space.

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.