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Luchtmann M, Klammer A, Iova MA, Roth A, Chanamolu VK, Mawrin C, Warnke JP. Thecaloscopy Reduces the Risk of Recurrent Perineural (Tarlov) Cysts after Microsurgical Resection. Neurol Int 2024; 16:450-458. [PMID: 38668130 PMCID: PMC11054917 DOI: 10.3390/neurolint16020033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 03/27/2024] [Accepted: 04/11/2024] [Indexed: 04/29/2024] Open
Abstract
Sacral Tarlov cysts (TCs), often asymptomatic, can cause significant pain and severe neurological dysfunction. Conventional treatments are generally associated with high recurrence and complication rates. Specifically, the substantial recurrence rates, which can reach as high as 50%, significantly impact long-term outcomes. Recent evidence increasingly supports the hypothesis that the formation of Tarlov cysts (TCs) may be associated with inflammatory processes within the nerve root sheath, further exacerbated by elevated cerebrospinal fluid (CSF) pressure. This retrospective study explores thecaloscopy, combined with surgical techniques, as a more effective alternative. We observed a total of 78 patients, 48 of whom underwent endoscopic fenestration of the arachnoid sheath in addition to microsurgical resection of the TC. We found that the fenestration of the arachnoid sheath at the level of lumbosacral spinal nerve root entry led to a significantly decreased risk of developing recurrent TCs (5/48 vs. 9/30). Only one of the patients suffered from a persistent new bladder dysfunction after microsurgical resection. This presented technique provides a promising treatment path for the future management of TCs, offering a safe and more effective treatment option compared to previous methods. Additionally, the advantages of the thecaloscopy provide pathophysiological implications regarding the development of perineural cysts.
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Affiliation(s)
- Michael Luchtmann
- Department of Neurosurgergy, Heinrich-Braun-Klinikum, 08060 Zwickau, Germany
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
- Leupold Institute for Applied Natural Sciences, University of Applied Science, 08056 Zwickau, Germany
- Vigdis Thompson Foundation, 08412 Werdau, Germany
| | - Angelika Klammer
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
- Vigdis Thompson Foundation, 08412 Werdau, Germany
| | - Mircea-Alin Iova
- Department of Neurosurgergy, Heinrich-Braun-Klinikum, 08060 Zwickau, Germany
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
| | - André Roth
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
| | - Vijay Kumar Chanamolu
- Department of Neurosurgergy, Heinrich-Braun-Klinikum, 08060 Zwickau, Germany
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
| | - Christian Mawrin
- Vigdis Thompson Foundation, 08412 Werdau, Germany
- Department of Neuropathology, Otto-von-Guericke University, 39120 Magdeburg, Germany
| | - Jan-Peter Warnke
- Department of Neurosurgery, Paracelsus-Klinikum, 08060 Zwickau, Germany
- Vigdis Thompson Foundation, 08412 Werdau, Germany
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Feigenbaum F, Parks SE, Martin MP, Ross TD, Kupanoff KM. Surgical Intervention is Associated with Improvement in Health-Related Quality of Life Outcomes in Patients with Symptomatic Sacral Tarlov Cysts: Results from a Prospective Longitudinal Cohort Study. World Neurosurg 2024:S1878-8750(24)00624-7. [PMID: 38636633 DOI: 10.1016/j.wneu.2024.04.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 04/09/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024]
Abstract
OBJECTIVE The treatment of symptomatic Tarlov cysts remains a controversial topic within neurosurgery. We describe our experience with patients who underwent surgical intervention for sacral Tarlov cysts at a single institution. General and disease-specific outcome measures were used to assess health-related quality of life. METHODS Patients who underwent surgical treatment for one or more sacral Tarlov cysts between 2018 and 2021 were included. The Tarlov Cyst Quality of Life (TCQoL), a validated disease-specific measure, was the primary outcome of the study. Secondary outcomes included general outcome measures: 36-Item Short Form Survey, the Oswestry Disability Index, and Visual Analog Scale. Patients were followed at 3, 6, and 12 months postoperative. Repeated measures analyses were used to assess change from preoperative to 12 months postoperative. RESULTS Data were obtained from 144 patients who underwent surgery for sacral Tarlov cysts, average age 52.3 ± 11.3 years, 90.3% female. Patients reported significant mean improvement on the TCQoL over time (preoperative 3.2±0.1; 3-months postoperative 2.1±0.1; 6-months 1.9±0.1; 12-months 1.9±0.1; P< 0.001). Patient age and duration of symptoms were not associated with outcome. 82.3% of patients reported improvement on TCQoL. There was not a significant difference in the proportion of patients reporting improvement on TCQoL by cyst size (small 90.9% vs. large 77.9%; P = 0.066). CONCLUSION Our longitudinal series demonstrated patient-reported improvement following surgery for symptomatic sacral Tarlov cysts using a validated disease-specific health-related quality of life scale through 12 months following surgery. Patient age and preoperative duration of symptoms were not correlated with outcome.
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Affiliation(s)
| | | | | | | | - Kristina M Kupanoff
- University of Arizona School of Medicine, Phoenix Campus, Phoenix, Arizona, USA
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Liu Y, Sun D, Gao Z, Wang Z, Jin B. Tarlov Cysts and Premature Ejaculation. Arch Sex Behav 2024; 53:1591-1594. [PMID: 38366312 PMCID: PMC10954956 DOI: 10.1007/s10508-024-02815-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 01/15/2024] [Accepted: 01/16/2024] [Indexed: 02/18/2024]
Abstract
Tarlov cysts adjacent to the spinal cord are usually asymptomatic and found incidentally via magnetic resonance imaging. On rare occasions, they increase in size to produce symptoms resembling disk herniation. We report a rare case of a sacral cyst resulting in premature ejaculation in a 32-year-old man who presented with pelvic pain and acquired premature ejaculation. Spinal nerve root decompression, excision of intraspinal Tarlov cyst, and spinal nerve root adhesion release surgery significantly improved his pain and premature ejaculation at a six-month follow-up.
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Affiliation(s)
- Yuanyuan Liu
- Southeast University School of Medicine, Nanjing, China
| | - Dalin Sun
- Andrology Department of Integrative Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China
| | | | - Zhongjiang Wang
- Department of Radiology, Zhongda Hospital, School of Medicine, Southeast University, Nangjing, China
| | - Baofang Jin
- Andrology Department of Integrative Medicine, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, 210009, China.
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Jiang Y, Dong L, Pan YQ, Zhao J, Li WF, Zhang TF, Zhang T, Dai DW. Efficacy of neuroendoscopic-assisted surgery in the management of symptomatic sacral perineural (Tarlov) cysts: a technical report. Front Surg 2024; 11:1307460. [PMID: 38486796 PMCID: PMC10937351 DOI: 10.3389/fsurg.2024.1307460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 02/12/2024] [Indexed: 03/17/2024] Open
Abstract
Introduction The Tarlov cysts are pathological enlargements of the cerebrospinal fluid spaces between the endoneurium and perineurium, which can cause intolerable sciatic pain, motor impairment of lower limbs, and bladder/bowel dysfunction. Currently, the treatment results are unsatisfactory due to the low cure rates and extensive surgical trauma. Thus, there is an ongoing exploration of surgical techniques for Tarlov treatment. In the current study, we present a novel neuroendoscopic-assisted technique that combines the fenestration, leakage sealing, and tamponade of the Tarlov cyst. Methods Between January 2020 and December 2021, a total of 32 Tarlov patients were enrolled and received neuroendoscopic-assisted surgery. Their pre- and post-surgical Visual Analogue Scale (VAS) scores, major complaints, and MR imaging were recorded for comparison. Results 27 of 32 patients (84.4%) patients demonstrated immediate pain relief as their VAS scores decreased from 5.6 ± 1.5 to 2.5 ± 1.1 (p < 0.01) on the first day after surgery. At the 3-month follow-up, the patients' average VAS score continued to decrease (1.94 ± 0.8). Meanwhile, saddle paresthesia, urinary incontinence, and constipation were relieved in 6 (50%), 4 (80%), and 5 (41.7%), respectively, according to patients self-report. No surgical-related complication was observed in any of the cases. Discussion We conclude that neuroendoscopic-assisted surgery is an effective surgical method for symptomatic Tarlov cysts with minimized complications.
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Affiliation(s)
- Ying Jiang
- Cerebrovascular Diseases Center, Department of Neurosurgery, Renji Hospital, Shanghai, China
| | - Lan Dong
- Department of Emergency, Shanghai Chang Zheng Hospital, Shanghai, China
| | - Yi-Qi Pan
- Department of Otorhinolaryngology, Shanghai Jiao-Tong University School of Medicine Ruijin Hospital, Shanghai, China
| | - Jun Zhao
- Department of Neurosurgery, Shanghai University of Medicine & Health Science Affiliated Zhoupu Hospital, Shanghai, China
| | - Wen-Fang Li
- Department of Emergency, Shanghai Chang Zheng Hospital, Shanghai, China
| | - Teng-Fei Zhang
- Department of Emergency, Shanghai Chang Zheng Hospital, Shanghai, China
| | - Ting Zhang
- Department of Emergency, Shanghai Chang Zheng Hospital, Shanghai, China
| | - Da-Wei Dai
- Department of Neurosurgery, Renji Hospital, Shanghai, China
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Ikeda N, Ito Y, Yokoyama K, Tanaka H, Yamada M, Sugie A, Takami T, Wanibuchi M, Kawanishi M. A Case of Symptomatic Multiple Tarlov Cysts Treated with Microsurgical Wrapping Technique -Efficacy and Limitation of Surgical Procedure. NMC Case Rep J 2024; 11:1-6. [PMID: 38328524 PMCID: PMC10846906 DOI: 10.2176/jns-nmc.2023-0213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 10/23/2023] [Indexed: 02/09/2024] Open
Abstract
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.
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Affiliation(s)
- Naokado Ikeda
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
- Neuroendoscope Center, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Yutaka Ito
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Kunio Yokoyama
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Hidekazu Tanaka
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Makoto Yamada
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Akira Sugie
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
| | - Toshihiro Takami
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiko Wanibuchi
- Department of Neurosurgery, Osaka Medical and Pharmaceutical University, Takatsuki, Osaka, Japan
| | - Masahiro Kawanishi
- Department of Neurosurgery, Ijinkai Takeda General Hospital, Fushimi, Kyoto, Japan
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Najib KS, Razavinejad SM, Yarmahmoodi F, Barzegar H. Unilateral diaphragmatic paralysis and complete brachial plexus injury in a complex birth injury: A rare case report mimicking Tarlov cyst and review of literature. Clin Case Rep 2024; 12:e8406. [PMID: 38173882 PMCID: PMC10762482 DOI: 10.1002/ccr3.8406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 10/11/2023] [Accepted: 10/30/2023] [Indexed: 01/05/2024] Open
Abstract
The rare occurrence of Tarlov cysts in pediatric patients, particularly in the context of complex birth injuries, necessitates thorough evaluation and tailored management approaches. A comprehensive understanding of the clinical significance and optimal treatment strategies for this unique combination is crucial to ensure effective and individualized care for affected children.
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Affiliation(s)
| | | | - Fatemeh Yarmahmoodi
- Assistant Professor of Radiology, Medical Imaging Research CenterShiraz University of Medical SciencesShirazIran
| | - Hamide Barzegar
- Neonatal Research CenterShiraz University of Medical SciencesShirazIran
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Feigenbaum F, Parks SE, Martin MP, Chapple KM. Surgical Intervention is Associated with Improved Outcomes in Patients with Symptomatic Cervical Spine Tarlov Cysts: Results from a Prospective Cohort Study. World Neurosurg 2024; 181:e405-e410. [PMID: 37866779 DOI: 10.1016/j.wneu.2023.10.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 10/10/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023]
Abstract
BACKGROUND Tarlov cysts are known contributors to radiculopathy but are often misdiagnosed and mismanaged due to a paucity of information. This is particularly true of cervical spine Tarlov cysts because most attention has been focused on sacral cysts. In this study, we describe our longitudinal experience with patients who underwent surgery for cervical spine Tarlov cysts. We hypothesized that patients undergoing surgical treatment for cervical spine Tarlov cysts would report improvement following surgery. METHODS We conducted a prospective study of patients who underwent surgical treatment for cervical Tarlov cysts between 2010 and 2021. The Short-Form 36-item survey (SF-36) was administered at the preoperative and follow-up visits. Repeated measures analyses were used to assess changes from preoperatively to postoperatively. RESULTS A total of 37 patients with cervical spine cysts were included in the study. Follow-up data were available for 27 patients with a median follow-up of 1 year. Of the cohort, 97.3% were women, with an average age of 47.5 ± 10.3 years. Patients reported statistically significant improvement in 2 of the 4 SF-36 physical health domains (physical function, P< 0.001; and bodily pain, P < 0.001) and 2 of the 4 mental health domains (vitality/energy, P < 0.003; and social functioning, P = 0.007). Patients also reported less interference in work, education, and retirement activities at follow-up (P = 0.017). CONCLUSIONS Our longitudinal series consisted of patients with symptomatic cervical spine Tarlov cysts, which, to the best of our knowledge, is the largest series described. Significant improvements in the SF-36 domains were documented, indicating these patients can be successfully treated surgically.
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Affiliation(s)
- Frank Feigenbaum
- Department of Neurosurgery, Feigenbaum Neurosurgery, Dallas, Texas, USA.
| | - Susan E Parks
- Department of Neurosurgery, Feigenbaum Neurosurgery, Dallas, Texas, USA
| | - Madelene P Martin
- Department of Neurosurgery, Feigenbaum Neurosurgery, Dallas, Texas, USA
| | - Kristina M Chapple
- Department of Surgery, University of Arizona College of Medicine - Phoenix, Phoenix, Arizona, USA
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Chen Z, Lin C. Tarlov cyst with self-healing cauda equina syndrome following combined spinal-epidural anesthesia: a case report. BMC Anesthesiol 2023; 23:352. [PMID: 37907852 PMCID: PMC10617098 DOI: 10.1186/s12871-023-02311-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 10/15/2023] [Indexed: 11/02/2023] Open
Abstract
BACKGROUND Cauda Equina Syndrome (CES) after Combined Spinal-Epidural Anesthesia (CSEA) is a rare disease that most of the time need surgery to relieve spinal cord compression. CASE PRESENTATION A 34-year-old male patient underwent a procedure for prolapse and hemorrhoids (PPH) under CSEA. Anesthesia and surgery were uneventful. However, the patient gradually experienced urinary retention, lower abdomen and back pain, changes in bowel habits and neurological dysfunction of the lower limbs when the catheter was removed. It was later determined that the patient had Tarlov cyst at the left S1 level in the sacral canal. Finally, the patient completely recovered 20 days after drug conservative therapy onset. CONCLUSION This case suggests that CES might occur even after ordinary CSEA. The risk factors are drug neurotoxicity to ropivacaine and Tarlov cyst, which helped to accumulate ropivacaine. The development of ultrasound-guided CSEA and an ultrasound atlas of the spinal canal are required.
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Affiliation(s)
- Zhexuan Chen
- Jieyang People's Hospital, Jieyang, Guangdong Province, China
| | - Chuxi Lin
- Jieyang People's Hospital, Jieyang, Guangdong Province, China.
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Gardocki RJ, Chandler PJ, Vaughan WE, Zuckerman SL, Abtahi AM, Stephens BF. Endoscopic transforaminal treatment of a thoracic perineural cyst: a case report. Eur Spine J 2023; 32:2679-2684. [PMID: 36813905 DOI: 10.1007/s00586-023-07582-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/25/2023] [Accepted: 02/04/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND AND IMPORTANCE To describe the first case of a thoracic perineural cyst successfully treated using a direct thoracic transforaminal endoscopic approach. METHODS Case report. CLINICAL PRESENTATION A 66-year-old male presented with right-sided radicular pain in a T4 distribution. MRI of the thoracic spine revealed a right T4 perineural cyst caudally displacing the root in the T4-5 foramen. He had failed attempts at nonoperative management. The patient underwent an all endoscopic transforaminal perineural cyst decompression and resection as a same-day surgical procedure. Postoperatively, the patient noted near complete resolution of the preoperative radicular pain. A thoracic MRI with and without contrast was performed 3 months after surgery and showed no evidence of the preoperative perineural cyst and no symptom recurrence was noted by the patient. CONCLUSION This case report presents the first safe and successful report of an all endoscopic transforaminal decompression and resection of a perineural cyst in the thoracic spine.
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Affiliation(s)
- Raymond J Gardocki
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Philip J Chandler
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA.
| | - Wilson E Vaughan
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
| | - Scott L Zuckerman
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amir M Abtahi
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Byron F Stephens
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Medical Center East, South Tower, Suite 4200, Nashville, TN, 37232-8774, USA
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
- Center for Musculoskeletal Research, Vanderbilt University Medical Center, Nashville, TN, USA
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Muthu S, Chandrasekaran S. Conservative Management of Symptomatic Sacral Tarlov Cyst - A Rare Case Report. J Orthop Case Rep 2023; 13:57-60. [PMID: 37398541 PMCID: PMC10308964 DOI: 10.13107/jocr.2023.v13.i06.3694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/13/2023] [Indexed: 07/04/2023] Open
Abstract
Introduction Tarlov cysts are rare perineural cysts noted as an incidental finding in approximately 1% of lumbar magnetic resonance imaging (MRI) arising from extradural components near the dorsal root ganglion. Due to its localization, it may cause sensory symptoms in some cases. However, most of these cysts are asymptomatic. Case Report We present the case of a 55-year-old woman with complaints of severe pain localized to the inner aspect of the thigh and gluteal region for the past 6 months, which has not been relieved by conservative management. On examination, there was a loss of sensation around the S2 and S3 dermatome with preserved motor functions. MRI showed a cystic lesion occupying the spinal canal with a size of about 1.3 × 0.7 cm with remodeling changes around the S2 vertebra. The cyst appears hypointense on T1 and hyperintense T2-weighted images. The diagnosis of the symptomatic Tarlov cyst was made and was managed with an epidural steroid injection. The patient was relieved of symptoms and remained asymptomatic till the latest follow-up at 1 year. Conclusion Symptomatic presentation of Tarlov cyst though rare should be considered and managed appropriately if identified as the source of symptoms. Conservative management with epidural steroids is a successful method in the management of smaller cysts without motor symptoms.
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Affiliation(s)
- Sathish Muthu
- Department of Orthopaedics, Government Medical College, Dindigul, Tamil Nadu, India
- Orthopaedic Research Group, Coimbatore, Tamil Nadu, India
- Department of Biotechnology, Faculty of Engineering, Karpagam Academy of Higher Education, Coimbatore, India
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Urquiaga JF, Bagdady K, Zhang JK, Mercier PJ, Mattei TA. Complex surgical reconstruction for spinopelvic instability caused by a giant Tarlov cyst eroding the sacrum: A case report. N Am Spine Soc J 2023; 14:100212. [PMID: 37168322 PMCID: PMC10165128 DOI: 10.1016/j.xnsj.2023.100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 02/15/2023] [Accepted: 03/12/2023] [Indexed: 05/13/2023]
Abstract
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.
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Affiliation(s)
- Jorge F. Urquiaga
- Corresponding author. Division of Neurological Surgery, Saint Louis University School of Medicine, 1008 S. Spring Ave, 3rd Floor, St. Louis, MO 63110, USA. Tel.: (314) 977-4750; fax: (314) 977-1821.
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Abstract
BACKGROUND The aim of this retrospective study was to describe a novel, simple surgical technique for the treatment of symptomatic Tarlov cysts. METHODS A total of 40 patients with symptomatic Tarlov cysts, admitted to our tertiary center between 1998 and 2019 constituted the study group. All patients underwent microsurgical puckering of the cyst, the technique we described to prevent a recurrence. Patients' symptoms, radiological findings, intraoperative findings, and clinical results were evaluated. RESULTS Of the 40 patients (5 males, 35 females) whose charts were reviewed, the mean age was 28.4 (range, 17-61) years. The mean follow-up was 8 (range, 3 months to 21 years) years. Preoperatively, the most common symptoms were leg pain and numbness of the lower extremity. Postoperatively, no major complications were observed. Clinical progression was halted in all patients; 33 (82%) patients recovered completely and seven (17%) patients reported partial recovery. Cystic cavity persisted radiologically in five (12%) patients, decreased in size in 30 (75%) patients, and regressed completely in the remaining five (12%) patients. None of the patients had permanent neurological deficits. CONCLUSION Puckering of the cyst membrane is a safe and easy-to-perform surgical technique for symptomatic Tarlov cysts. This technique can be used almost in all cases instead of the commonly used microsurgical cyst excision or cyst fenestration.
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Affiliation(s)
- Kemal Yucesoy
- Faculty of Medicine, Department of Neurosurgery, Dokuz Eylul University, Izmir, Turkey
| | - Murat Yilmaz
- Faculty of Medicine, Department of Neurosurgery, Dokuz Eylul University, Izmir, Turkey
| | - Hulagu Kaptan
- Faculty of Medicine, Department of Neurosurgery, Dokuz Eylul University, Izmir, Turkey
| | - Ersin Ikizoglu
- Faculty of Medicine, Department of Neurosurgery, Dokuz Eylul University, Izmir, Turkey
| | - Mert Arslan
- Faculty of Medicine, Department of Neurosurgery, Dokuz Eylul University, Izmir, Turkey
| | - Serhat R Erbayraktar
- Faculty of Medicine, Department of Neurosurgery, Dokuz Eylul University, Izmir, Turkey
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Almansa AH, Infante AMJ, Cutillas AMR, Álvarez LG. Symptomatic sacral Tarlov cyst: Case report and review of literature. Neurocirugia (Astur : Engl Ed) 2023; 34:101-104. [PMID: 36754756 DOI: 10.1016/j.neucie.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/11/2022] [Indexed: 02/08/2023]
Abstract
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.
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Mehan A, Ruchika FNU, Chaturvedi J, Gupta M, Venkataram T, Goyal N, Sharma AK. Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better. Surg Neurol Int 2023; 14:95. [PMID: 37025521 PMCID: PMC10070324 DOI: 10.25259/sni_79_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
Background Tarlov cysts are sacral perineural cysts arising between the peri and endoneurium of the posterior spinal nerve root at the Dorsal Root Ganglion and have a global prevalence rate of 4.27%. These are primarily asymptomatic (only 1% with symptoms) and typically arise in females between the ages of 50-60. Patients' symptoms include radicular pain, sensory dysesthesias, urinary and/or bowel symptoms, and sexual dysfunction. Non-surgical management with lumbar cerebrospinal fluid drainage and computerized tomography-guided cyst aspiration typically provide only months of improvement before recurring. Surgical treatment includes a laminectomy, cyst, and/or nerve root decompression with fenestration of the cyst and/ or imbrication. Early surgery for large cysts provides the longest symptom-free periods. Case Description A 30-year-old male presented with a very large magnetic resonance-documented Tarlov cyst (Nabors Type 2) arising from bilateral S2 nerve root sheaths with marked pelvic extension. Although he was initially treated with a S1, S2 laminectomy, closure of the dural defect, and excision/marsupialization of the cyst, he later required placement of a thecoperitoneal shunt (TP shunt). Conclusion A 30-year-old male with large Nabors Type 2 Tarlov cyst arising from both S2 nerve root sheaths required a S1-S2 laminectomy, dural closure/marsupialization, and imbrication of the cyst, eventually followed by placement of a TP shunt.
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Affiliation(s)
- Abhishek Mehan
- Medical Student, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - FNU Ruchika
- Department of General Surgery, Medical College, Jagadguru Jayadeva Murugarajendra (JJM), Medical College, Davangere, Karnataka, India
| | - Jitender Chaturvedi
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
- Corresponding author: Jitender Chaturvedi, Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand,
| | - Mohit Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Tejas Venkataram
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Nishant Goyal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Anil Kumar Sharma
- Department of Neurosurgery, All India Institute of Medical Sciences, Raipur, Chhattisgarh, India
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Matsuura Y, Gates J, Morgenstern P, Stock J, Reid-Adam J. Urology case report: Multifactorial bladder dysfunction in the setting of down syndrome. Urol Case Rep 2022; 46:102294. [PMID: 36561490 PMCID: PMC9763370 DOI: 10.1016/j.eucr.2022.102294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/28/2022] [Accepted: 11/30/2022] [Indexed: 12/12/2022] Open
Abstract
A 16-year-old male patient with Down syndrome diagnosed with AKI and urinary tract infection was treated with meropenem for ESBL-positive E. coli in urine culture. Persistently elevated creatinine and persistent post-void residual (PVR) of >300 mL led to further testing, which revealed urethral stricture and a lower sacral Tarlov cyst. Due to no complete improvement with urethral dilatation, he underwent laminectomy and Tarlov cyst fenestration. Creatinine normalized, with increased urine output and robust flow. Due to a PVR of >100 mL, he received behavioral therapy, including sitting and timed voiding, and the PVR was reduced to <5 mL.
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16
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Huang Q, Li J, Zhou Q, Li H, Yang X, Peng L, Chen L, Qi S, Lu Y. Management of Symptomatic Sacral Perineural Cysts: A New Surgical Method. World Neurosurg 2022; 167:e978-e989. [PMID: 36058485 DOI: 10.1016/j.wneu.2022.08.125] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/25/2022] [Accepted: 08/26/2022] [Indexed: 02/05/2023]
Abstract
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.
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Affiliation(s)
- Qinguo Huang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Department of Neurosurgery, The Second Affiliated Hospital, Shantou University Medical College, Shantou, China
| | - Junjie Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Qiang Zhou
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hong Li
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xiaoyu Yang
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lin Peng
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Lei Chen
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Songtao Qi
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Glioma Center, Guangzhou, China
| | - Yuntao Lu
- Department of Neurosurgery, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Neurology Research Institution, Nanfang Hospital, Southern Medical University, Guangzhou, China; Nanfang Glioma Center, Guangzhou, China.
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Ma Q, Xie J, Yang C, Wu C, Zhang J, Yin X, Si Y, Liu Y, Yang J, Sun J. Multiple dimensions of radiographic reconstruction for the optimal operative strategy of sacral meningeal cysts. Eur Spine J 2022; 31:3146-3158. [PMID: 35947195 DOI: 10.1007/s00586-022-07337-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 07/04/2022] [Accepted: 07/21/2022] [Indexed: 06/15/2023]
Abstract
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.
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Affiliation(s)
- Qianquan Ma
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Jingcheng Xie
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Chenlong Yang
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Chao Wu
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Jia Zhang
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Xiaoliang Yin
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Yu Si
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Ying Liu
- Department of Radiology, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Jun Yang
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China
| | - Jianjun Sun
- Department of Neurosurgery, Peking University Third Hospital, Peking University, Beijing, 100191, China.
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Feigenbaum F, Parks SE, Chapple KM. Prospective Validation of a Quality-of-Life Measure for Women Undergoing Surgical Intervention for Symptomatic Sacral Tarlov Cysts: The Tarlov Cyst Quality of Life Scale. World Neurosurg 2022; 165:e276-81. [PMID: 35700862 DOI: 10.1016/j.wneu.2022.06.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 06/05/2022] [Accepted: 06/06/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The use of health-related quality-of-life scales has expanded into most areas of medicine. Established quality-of-life scales are used in several areas of neurosurgery, but none have been validated for use in patients with symptomatic Tarlov cysts. The majority of symptomatic Tarlov cysts are found in the sacral spinal canal of women. We, therefore, validated a site-specific quality-of-life measure for women with symptomatic sacral nerve root compression caused by Tarlov cysts. METHODS Women undergoing surgical treatment for sacral Tarlov cysts at a single institution between 2017 and 2020 were enrolled in this prospective validation study. Participants were administered a 13-item version of the survey along with other validated quality-of-life measures preoperatively and at 3 months postoperatively. Psychometric analyses were performed to validate the measure. RESULTS One hundred twelve patients met inclusion criteria and completed surveys preoperatively and at 3 months postoperatively. Patients' mean scale scores decreased significantly preoperatively to postoperatively, reflecting good discriminability (P < 0.001). Interitem correlations suggested 2 items were correlated at >0.80, which were dropped to create an 11-item scale. The internal consistency of the 11-item scale was 0.822. Concurrent validity was established by correlating scale scores with the Oswestry Disability Index (P < 0.001) and the physical function (P < 0.001) and pain (P < 0.001) subscales of the Short-Form 36 Survey. CONCLUSIONS We prospectively validated a site-specific, health-related quality-of-life survey for women with symptomatic sacral Tarlov cysts. This measure will be useful in future studies to inform clinicians and researchers about the progression of Tarlov cysts and patient response to surgical treatment.
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Sugawara T, Higashiyama N, Tamura S, Endo T, Shimizu H. Novel wrapping surgery for symptomatic sacral perineural cysts. J Neurosurg Spine 2021:1-8. [PMID: 34598157 DOI: 10.3171/2021.5.spine21179] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Taku Sugawara
- 1Department of Spinal Surgery, Akita Cerebrospinal and Cardiovascular Center
| | - Naoki Higashiyama
- 1Department of Spinal Surgery, Akita Cerebrospinal and Cardiovascular Center
| | - Shinya Tamura
- 2Department of Neurosurgery, Akita City Hospitall; and
| | - Takuro Endo
- 1Department of Spinal Surgery, Akita Cerebrospinal and Cardiovascular Center
| | - Hiroaki Shimizu
- 3Department of Neurosurgery, Akita University Hospital, Akita, Japan
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Galarza M, Chaban G, Gazzeri R, de la Rosa P, Montoya CG, Laut MM, Sosa F. Functional recovery following resection of large Tarlov cyst malformation: a multicentre longitudinal cohort study. Acta Neurochir (Wien) 2021; 163:2769-76. [PMID: 33761006 DOI: 10.1007/s00701-021-04817-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 03/16/2021] [Indexed: 10/21/2022]
Abstract
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.
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Kögl N, Thomé C, Gindlhuber K, Dazinger F, Gizewski E, Kiechl S, Petr O. Sacral fracture associated with a Tarlov cyst causing an anterior sacral CSF fistula and intraventricular fat emboli - a case report and review of the literature. Br J Neurosurg 2021:1-5. [PMID: 34397315 DOI: 10.1080/02688697.2021.1940848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 05/30/2021] [Accepted: 06/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Sacral fractures are rare and either associated with high-energy trauma or osteoporosis in most cases. A search of the current literature on sacral fractures and cerebrospinal fluid fistula identified only few cases. Pathological fractures are uncommon and exceedingly rare in case of Tarlov cysts. Sacral fractures can be missed in oligosymptomatic patients. However, severe complications may emerge as shown by this case report. METHODS We present the case of a pathological sacral fracture at the level S2/3 following a low-impact trauma, associated with a Tarlov cyst, which was complicated by an anterior CSF fistula and intraventricular fat emboli. RESULTS The patient was treated conservatively with strict bedrest and a CT-guided blood patch. Postponed mobilization was successful with decreasing orthostatic symptoms. Follow-up MRI and CT imaging showed a complete resolution of the ventral CSF fistula and ossification of the fracture. The intraventricular fat did not resolve, however, there was no radiological sign of hydrocephalus with excellent clinical outcome at 6-months follow-up. CONCLUSION Although exceedingly rare, sacral Tarlov cysts may be associated with pathological fractures of the sacrum. Relevant complications can emerge and need to be properly addressed.
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Affiliation(s)
- Nikolaus Kögl
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
| | - Karin Gindlhuber
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Florian Dazinger
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Elke Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, Innsbruck, Austria
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Hana T, Ogiwara H, Migita O, Nakabayashi K, Hata K, Morota N. Deleterious fibronectin type III-related gene variants may induce a spinal extradural arachnoid cyst: an exome sequencing study of identical twin cases. Childs Nerv Syst 2021; 37:2329-34. [PMID: 33772355 DOI: 10.1007/s00381-021-05137-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/03/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Despite numerous studies, the etiology of spinal extradural arachnoid cyst (SEDAC), a lesion associated with neurological symptoms, remains unknown. In this genomic twin study, we investigated the genetic etiology of SEDACs. METHODS The subjects were identical twins who developed notably similar SEDACs at the same vertebral level. Accordingly, we performed whole-exome sequencing analyses of genomic material from the twins and their parents using a next-generation sequencer. Additionally, we determined their detailed family history and analyzed the family pedigree. RESULTS The pedigree analysis suggested the potential presence of SEDACs in certain family members, indicating a genetic disease. Sequenced data were analyzed and filtered using a purpose-built algorithm, leading to the identification of 155 novel single-nucleotide polymorphisms (SNPs), of which 118 encoded missense or nonsense variants. A functional analysis of the proteins encoded by these SNP alleles revealed strong enrichment for the fibronectin type III (FN3) protein domain (q = 0.00576). Specifically, the data indicated that a missense variant affecting the FN3 protein domain of fibronectin 1 (FN1, p.P969S) can be the causal mutation underlying the SEDACs. CONCLUSION The data suggest that deleterious mutations in fibronectin-related genes may cause SEDACs. In particular, it was suspected that a variant of FN1 may be the cause of the SEDACs in the twin cases studied herein. Detailed studies with a larger number of cases are needed.
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Sun P, Xu W, Ye Y, Zhong F, Wan X, Li Y. Neglected Tarlov cysts: a case of a Tarlov cyst with spermatorrhea. Eur J Med Res 2021; 26:44. [PMID: 33964972 PMCID: PMC8106831 DOI: 10.1186/s40001-021-00514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
Background Tarlov cysts are a commonly misdiagnosed condition, which can present with many rare symptoms. We report a case of a Tarlov cyst with spermatorrhea and review the pertinent literature. Case presentation A 42-year-old male patient had a history of spermatorrhea for > 10 years, but was incorrectly diagnosed as the patient and the doctors consistently mistook the symptoms for a genitourinary disease. Magnetic resonance imaging showed that two cysts in the sacral canal. The diagnosis was Tarlov cyst. We performed surgery to remove the cyst and the symptoms of spermatorrhea disappeared after the operation. Conclusions This case demonstrates that orthopedics and urologists should improve their understanding of Tarlov cysts to avoid misdiagnosis and mistreatment.
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Affiliation(s)
- Pan Sun
- Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, 350122, Fujian, People's Republic of China
| | - Wangbing Xu
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Yongxiang Ye
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Faming Zhong
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Xuan Wan
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Yong Li
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China.
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Yoshioka F, Shimokawa S, Masuoka J, Inoue K, Ogata A, Abe T. Elimination of the check-valve mechanism of the sacral Tarlov cyst using a rotation flap technique in a pediatric patient: technical note. Childs Nerv Syst 2021; 37:1741-5. [PMID: 33404709 DOI: 10.1007/s00381-020-05029-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 12/22/2020] [Indexed: 10/22/2022]
Abstract
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.
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Yoshikawa T, Katsumori T, Hisano M, Yasumura T, Sasakura Y. Transcatheter arterial embolization for a symptomatic Tarlov cyst with hemorrhage due to an underlying arteriovenous fistula. Radiol Case Rep 2021; 16:1284-1287. [PMID: 33854665 PMCID: PMC8027132 DOI: 10.1016/j.radcr.2021.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 11/25/2022] Open
Abstract
Symptomatic sacral perineural cysts (Tarlov cysts) accompanied by intra-cyst hemorrhage are rare. The treatment strategies have not been established. We report a 57-year-old woman with severe back pain due to a Tarlov cyst accompanying intracyst hemorrhage. Computed tomography angiography revealed an arteriovenous fistula (AVF) at the area surrounding the cyst. The patient underwent transcatheter arterial embolization for the AVF. Thereafter, the hematoma and cyst decreased in size, and clinical symptoms markedly improved with no additional surgery. Transcatheter arterial embolization may be an effective alternative to surgery for Tarlov cysts with vascular disease, including AVF.
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Klepinowski T, Orbik W, Sagan L. Global incidence of spinal perineural Tarlov's cysts and their morphological characteristics: a meta-analysis of 13,266 subjects. Surg Radiol Anat 2021; 43:855-863. [PMID: 33452905 PMCID: PMC8164596 DOI: 10.1007/s00276-020-02644-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and symptoms. Purpose of this meta-analysis is to deliver global incidence and characteristics (location, size, and shape) of TCs. METHODS Following PRISMA checklist, all major databases were searched by two authors for radiologic studies reporting incidence and morphologic features (location, size, and shape) of TCs. Anatomical Quality Assessment tool was applied for risk of bias evaluation. Meta-analysis of random-effects model was employed. Subgroup analysis for regional distribution, gender, sacral levels, age, correspondence with symptoms, and persistent genital arousal disorder (PGAD) were planned ahead. RESULTS 22 radiologic studies of level 3 evidence involving 13,266 subjects were included. Global pooled prevalence of TCs was 4.18% (95% CI 2.47-6.30). Mean pooled sagittal diameter was 11.86 mm (95% CI 10.78-12.93). Sacral cysts strongly prevailed over the other segments. Of the sacral, S2 level was the most common (46.7% [95% CI 29.4-60.5]). Geographically, the highest incidence was found in Europe (6.07% [95% CI 1.49-13.00]), followed by North America (3.82% [95% CI 0.49-9.44]), and Asia (3.33% [95% CI 1.52-5.75]). TCs were more common in women than in men (5.84% vs 3.03%, p < 0.001, test of homogeneity, χ2). Subjects with PGAD had incidence of 37.87% (95% CI 2.45-81.75). TCs in pediatric population are rare-0.53% (95% CI 0.02-1.51). 15.59% of TCs corresponded with symptoms. CONCLUSIONS Spinal perineural (Tarlov) cysts are found in a minority of population. S2 level of the sacral bone is affected most frequently. There is female predominance. Correspondence with symptoms is seen in less than one-fifth of TCs. Studies with stronger evidence level are needed to corroborate the results. The purported high incidence in PGAD requires confirmation in case-control studies for the risk-ratio calculation.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland.
| | - Wojciech Orbik
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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Kain K, Jain N, O' Brien K. Findings of subarachnoid fat after trauma to a tarlov cyst. Radiol Case Rep 2020; 16:258-261. [PMID: 33299505 PMCID: PMC7708659 DOI: 10.1016/j.radcr.2020.10.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Kevin Kain
- College of Osteopathic Medicine, Kansas City University, 2901 St. Johns Blvd, Joplin, MO
| | - Nitin Jain
- Department of Interventional Radiology, Ascension Macomb-Oakland Hospital. 11800 Twelve Mile Rd, Warren, MI
| | - Kevin O' Brien
- Department of Radiology, Ascension Macomb-Oakland Hospital. 11800 Twelve Mile Rd, Warren, MI
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Kim S, Lee HJ, Park JH, Kim T, Nam K. Tarlov Cysts Misdiagnosed as Adnexal Masses in Pelvic Sonography: A Literature Review. Front Med (Lausanne) 2020; 7:577301. [PMID: 33425933 PMCID: PMC7793900 DOI: 10.3389/fmed.2020.577301] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 11/13/2020] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Shengshu Kim
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si, South Korea
| | - Ho Jun Lee
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si, South Korea
| | - Joong Hyun Park
- Department of Neurology, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul-si, South Korea
| | - Taeyeon Kim
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si, South Korea
| | - Kiyeun Nam
- Department of Physical Medicine and Rehabilitation, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang-si, South Korea
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Nishimura Y, Hara M, Awaya T, Ando R, Eguchi K, Nagashima Y, Wakabayashi T, Ginsberg HJ. Possible Double Crush Syndrome Caused by Iatrogenic Acquired Lumbosacral Epidermoid Tumor and Concomitant Sacral Tarlov Cyst. NMC Case Rep J 2020; 7:195-199. [PMID: 33062568 PMCID: PMC7538451 DOI: 10.2176/nmccrj.cr.2019-0236] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 03/04/2020] [Indexed: 11/24/2022] Open
Abstract
We describe a rare case of 42-year-old female who had possible double crush syndrome caused by iatrogenic spinal epidermoid tumor (ET) associated with lumbar puncture as well as concomitant sacral Tarlov cyst in close proximity. She presented with progressive left-sided perianal pain. She had a history of a Caesarean section with lumbar spinal anesthesia. Magnetic resonance imaging (MRI) demonstrated a relatively small intradural extramedullary solid lesion at L5/S1 level and cystic lesion at S2 level. We considered there were two different lesions, such as a tumor and Tarlov cyst; however, we could not rule out the possibility of a single lesion with two different components. Furthermore, there was a distinct compression at more than one locations along the course of the left S2 nerve root and we suspected possible double crush syndrome. We conducted tumor removal and the lesion turned out to be two different pathologies, such as an ET and Tarlov cyst. Both lesions were intraopertively pinching the left S2 nerve root at different sites as expected. The tumor was successfully removed and the cyst wall was imbricated and sutured. We need to take the possibility of ET into consideration if the patient underwent invasive spinal procedure previously. We also have to pay attention to the possibility of double crush syndrome if the nerve root possibly holding the responsibility for symptoms is compressed at two or more sites. This is the first report of possible double crush syndrome caused by acquired spinal tumor and congenital Tarlov cyst.
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Affiliation(s)
- Yusuke Nishimura
- Department of Neurosurgery, Nagoya University, Nagoya, Aichi, Japan
| | - Masahito Hara
- Department of Neurosurgery, Nagoya University, Nagoya, Aichi, Japan
| | - Takayuki Awaya
- Department of Neurosurgery, Nagoya University, Nagoya, Aichi, Japan
| | - Ryo Ando
- Department of Neurosurgery, Nagoya University, Nagoya, Aichi, Japan
| | - Kaoru Eguchi
- Department of Neurosurgery, Nagoya University, Nagoya, Aichi, Japan
| | | | | | - Howard J Ginsberg
- Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Fernández-Cuadros ME, Martín-Martín LM, Albaladejo-Florín MJ, Álava-Rabasa S, Pérez-Moro OS. [ Tarlov cyst and faecal incontinence: A case report and literature review]. Rehabilitacion (Madr) 2020; 54:215-220. [PMID: 32441263 DOI: 10.1016/j.rh.2019.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 07/30/2019] [Indexed: 06/11/2023]
Abstract
Tarlov, or perineural cysts, are lesions of the nerve root usually located at the sacral level of the spine. Their cause is unclear. These cysts are generally identified as an incidental finding and are usually asymptomatic. Symptomatic cysts are infrequent, with symptoms usually consisting of pain, radiculopathy and, less frequently, bladder, bowel and sexual dysfunction. We report the case of a 70-year-old woman with Tarlov cyst, provoking faecal incontinence, and review the aetiology, pathophysiology and management of this particular case.
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Affiliation(s)
- M E Fernández-Cuadros
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España.
| | - L M Martín-Martín
- Servicio de Neurofisiología, Hospital Universitario Santa Cristina, Madrid, España
| | - M J Albaladejo-Florín
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - S Álava-Rabasa
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
| | - O S Pérez-Moro
- Servicio de Rehabilitación y Medicina Física, Hospital Universitario Santa Cristina, Madrid, España
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Sahin E, Lee SH, Eun SS. CT-guided percutaneous aspiration of Tarlov cyst: a case report of 2-year follow up. AME Case Rep 2020; 4:11. [PMID: 32420534 DOI: 10.21037/acr.2020.04.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 03/06/2020] [Indexed: 11/06/2022]
Abstract
Tarlov cysts are a rare pathology characterized by sac formations at the nerve root in the sacrum. Although many options have been proposed, there is still no consensus regarding the optimal treatment strategy. The authors report a case involving a 43-year woman with a sacral perineural cyst causing buttock pain and anus discomfort for 4 years. The patient successfully underwent computed tomography (CT)-guided aspiration. She currently has no symptoms, and 2-year follow-up magnetic resonance imaging revealed a decrease in cyst size. CT-guided aspiration is a safe and effective treatment option, and leads to improvement in cyst-related symptoms with minimal risk.
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Affiliation(s)
- Ertugrul Sahin
- Department of Orthopedic Surgery, Spine Health Wooridul Hospital, Seoul, Korea
| | - Sang-Ho Lee
- Department of Neurosurgery, Spine Health Wooridul Hospital, Seoul, Korea
| | - Sang Soo Eun
- Department of Orthopedic Surgery, Spine Health Wooridul Hospital, Seoul, Korea
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El-Yahchouchi CA, Willard FH, Kaufmann TJ, Wald JT, Diehn FE, Geske JR, Maus TP. Synovial Cysts Confounding Access to the Dorsal S1 Neural Foramen in Transforaminal Epidural Steroid Injections. Pain Med 2020; 21:570-575. [PMID: 32142149 DOI: 10.1093/pm/pnz298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVES The S1 dorsal foramen is the route for 30% of lumbar transforaminal epidural injections; it is therefore important to identify structures impeding S1 foraminal access. The study objective was to characterize the imaging findings, prevalence, and anatomic origin of synovial cysts presenting within the S1 neural foramen. METHODS A case series (N = 14) established imaging characteristics of S1 synovial cysts. Imaging studies of 400 patients undergoing epidural injections were reviewed for lesions compromising S1 foraminal access. Cadaveric dissections defined the relationship of the inferior recess of the L5-S1 facet to the S1 dorsal foramen. RESULTS Elderly patients (mean age = 76) exhibited S1 synovial cysts. Synovial cysts were typically 1-2 cm in diameter, hyperintense on sagittal T2 weighted magnetic resonance images (MRIs), fluid-density on computed tomography, and dorsal to the S1 spinal nerve. Sixty percent of cysts exhibited complex MRI signal characteristics (thick wall, internal structure). Tarlov cysts, in contrast, were larger, lobular, and exhibited pure fluid intensity. Lesions impeded access to the S1 dorsal foramina in 5% of reviewed imaging studies (16 Tarlov cysts, three synovial cysts, one conjoint S1-S2 nerve root). The multifidus muscle was interposed between the L5-S1 facet inferior recess and the S1 dorsal foramen on dissection specimens; severe atrophy of the ipsilateral multifidus was noted on imaging in 17/18 synovial cysts. CONCLUSIONS The S1 neural foramina should be inspected on sagittal MRI, when available, for confounding lesions before performing S1 epidural injections. Tarlov cysts are more common than synovial cysts; the latter are seen in elderly patients with severe multifidus atrophy.
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Affiliation(s)
| | - Frank H Willard
- Department of Anatomy, University of New England, College of Osteopathic Medicine, Biddeford, Maine
| | | | | | | | - Jennifer R Geske
- Division of Biomedical Statistics and Informatics, Department of Health Sciences Research, Mayo Clinic, Rochester, Minnesota, USA
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Kikuchi M, Takai K, Isoo A, Taniguchi M. Myelographic CT, A Check-Valve Mechanism, and Microsurgical Treatment of Sacral Perineural Tarlov Cysts. World Neurosurg 2020; 136:e322-e327. [PMID: 31931233 DOI: 10.1016/j.wneu.2019.12.163] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 12/27/2019] [Accepted: 12/27/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE There is currently no consensus regarding surgical indications for symptomatic sacral perineural cysts. METHODS Nine patients with symptomatic sacral perineural cysts underwent microsurgery. All patients fulfilled the following criteria: (1) cyst sizes larger than 15 mm; (2) cysts show the "delayed inflow" and/or "delayed outflow" of contrast on myelographic computed tomography (CT), and (3) neurological symptoms correlate with the primary cyst. RESULTS On myelographic CT, all primary cysts showed the "delayed inflow" of contrast; the average cyst/thecal sac Hounsfield units (HU) ratio was 0.17. In 7 patients, the primary cyst showed "delayed outflow"; the average cyst/thecal sac HU ratio increased to 3.12 on images obtained 24 hours after contrast injection. Regarding the modified Rankin Scale, 67% of patients reported that their overall symptoms improved to normal activities after surgery. The most improved symptom was coccydynia (75% improvement, P = 0.017), followed by leg radiation pain (67% improvement, P = 0.027) and buttock pain (50% improvement, P = 0.068). Bowel/bladder dysfunction improved in 100% of patients, but newly developed in 1 patient (P = 0.32). Perineal pain only decreased in 33% (P = 0.41). CONCLUSIONS To the best of our knowledge, this is the first study to have performed a quantitative analysis of the dynamics of cerebrospinal fluid in sacral perineural cysts using myelographic CT. Sixty-seven percent of patients benefited from surgery; however, our criteria may not be a necessary and sufficient condition for patient selection because 33% did not respond to surgery despite the successful elimination of the check-valve.
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Affiliation(s)
- Miyu Kikuchi
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Keisuke Takai
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan.
| | - Ayako Isoo
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
| | - Makoto Taniguchi
- Department of Neurosurgery, Tokyo Metropolitan Neurological Hospital, Tokyo, Japan
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Hasoon J, Berger AA, Urits I, Orhurhu V, Viswanath O, Aner M. Spinal cord stimulation for the treatment of chronic pelvic pain after Tarlov cyst surgery in a 66-year-old woman: A case report. Case Rep Womens Health 2020; 25:e00171. [PMID: 31956516 PMCID: PMC6962650 DOI: 10.1016/j.crwh.2020.e00171] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 12/30/2019] [Accepted: 01/03/2020] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Jamal Hasoon
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Amnon A. Berger
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Ivan Urits
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Vwaire Orhurhu
- Massachusetts General Hospital, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
| | - Omar Viswanath
- Valley Anesthesiology and Pain Consultants – Envision Physician Services, Phoenix, AZ, United States of America
- University of Arizona College of Medicine – Phoenix, Department of Anesthesiology, Phoenix, AZ, United States of America
- Creighton University School of Medicine, Department of Anesthesiology, Omaha, NE, United States of America
| | - Musa Aner
- Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America
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Lim VM, Khanna R, Kalinkin O, Castellanos ME, Hibner M. Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia. Am J Obstet Gynecol 2020; 222:70.e1-70.e6. [PMID: 31319080 DOI: 10.1016/j.ajog.2019.07.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/09/2019] [Accepted: 07/11/2019] [Indexed: 11/19/2022]
Abstract
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.
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Affiliation(s)
- Victoria M Lim
- Department of Anesthesiology, Mayo Clinic Arizona, Phoenix, Arizona.
| | - Rohit Khanna
- Department of Radiology, Saint Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Olga Kalinkin
- Department of Radiology, Saint Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Mario E Castellanos
- Division of Pelvic Pain and Surgery, Saint Joseph's Hospital and Medical Center, Phoenix, Arizona
| | - Michael Hibner
- Division of Pelvic Pain and Surgery, Saint Joseph's Hospital and Medical Center, Phoenix, Arizona
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Abstract
Perrault syndrome is a rare autosomal recessive disorder that affects both males and females. The syndrome causes deafness in males, however females display gonadal dysgenesis along with sensorineural hearing loss. Herein, we present a 27-year-old female patient who is deaf and mute along with primary amenorrhea. Hormonal assays revealed hypergonadotropic hypogonadism and the karyotype was 46 XX. Pelvic ultrasound described a hypoplastic uterus and streak ovaries. MRI of the spine showed degenerative discs and Tarlov cysts. Whole exome sequencing identified a LARS2 mutation and the patient was diagnosed with Perrault syndrome type four (PRLTS4).
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MESH Headings
- Adult
- Amenorrhea/genetics
- Amino Acyl-tRNA Synthetases/genetics
- Deafness/genetics
- Female
- Gonadal Dysgenesis, 46,XX/diagnosis
- Gonadal Dysgenesis, 46,XX/genetics
- Gonadal Dysgenesis, 46,XX/physiopathology
- Hearing Loss, Sensorineural/diagnosis
- Hearing Loss, Sensorineural/genetics
- Hearing Loss, Sensorineural/physiopathology
- Humans
- Hypogonadism/genetics
- Infertility, Female/genetics
- Intervertebral Disc Degeneration/diagnostic imaging
- Intervertebral Disc Degeneration/genetics
- Magnetic Resonance Imaging
- Tarlov Cysts/diagnostic imaging
- Tarlov Cysts/genetics
- Ultrasonography
- Uterus/diagnostic imaging
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Affiliation(s)
- Dania Al-Jaroudi
- Department of Obstetrics and Gynecology, King Fahad Medical City, Riyadh, Saudi Arabia
- Reproductive Endocrine and Infertility Medicine Department, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saed Enabi
- Suliaman Al-Rajhi College, Al-Qasseem, Riyadh, Saudi Arabia
| | - Malak Sameer AlThagafi
- Saudi Diagnostic Lab Molecular Diagnostic, King Faisal Specialist Hospital International, Riyadh, Saudi Arabia
- Saudi Human Genome Lab at King Fahad Medical City (KFMC), National Genomics Center, Life Science and Environmental Institute, King Abdulaziz City for Science and Technology (KACST), Riyadh, Saudi Arabia
- Pathology Department, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Medani K, Lawandy S, Schrot R, Binongo JN, Kim KD, Panchal RR. Surgical management of symptomatic Tarlov cysts: cyst fenestration and nerve root imbrication-a single institutional experience. J Spine Surg 2019; 5:496-503. [PMID: 32043000 PMCID: PMC6989930 DOI: 10.21037/jss.2019.11.11] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 09/16/2019] [Indexed: 05/26/2023]
Abstract
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.
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Affiliation(s)
- Khalid Medani
- Department of Neurological Surgery, University of California Davis, Sacramento, CA, USA
| | - Shokry Lawandy
- Department of Neurological Surgery, University of California Davis, Sacramento, CA, USA
| | - Rudolph Schrot
- Department of Neurological Surgery, Sutter Medical Center Sacramento, Sacramento, CA, USA
- Touro University College of Osteopathic Medicine, Vallejo, CA, USA
| | - Jose N. Binongo
- Department of Biostatistics & Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kee D. Kim
- Department of Neurological Surgery, University of California Davis, Sacramento, CA, USA
| | - Ripul R. Panchal
- Department of Neurological Surgery, University of California Davis, Sacramento, CA, USA
- Touro University College of Osteopathic Medicine, Vallejo, CA, USA
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Haouas MY, Khoulali M, En-Nhaili Z, El-Johani H, Rghioui M, Srour R. [Surgical treatment of sacral Tarlov cysts: about 20 cases]. Pan Afr Med J 2019; 33:98. [PMID: 31489076 PMCID: PMC6711676 DOI: 10.11604/pamj.2019.33.98.10760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Accepted: 12/06/2016] [Indexed: 11/11/2022] Open
Abstract
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.
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Affiliation(s)
- Mohammed Yassine Haouas
- Université Hassan II, Faculté de Médecine et de Pharmacie, CHU Ibn Rochd, Service de Neurochirurgie, Casablanca, Maroc
| | - Mohamed Khoulali
- Université Mohamed I, Faculté de Médecine,CHU Mohamed VI, Service de Neurochirurgie, Oujda, Maroc
| | - Zinelabidine En-Nhaili
- Université Hassan II, Faculté de Médecine et de Pharmacie, CHU Ibn Rochd, Service de Neurochirurgie, Casablanca, Maroc
| | - Hani El-Johani
- Université de Strasbourg, Faculté de Médecine, CHU Haute-pierre, Neurochirurgie, Strasbourg, France
| | - Mounir Rghioui
- Université Hassan II, Faculté de Médecine et de Pharmacie, CHU Ibn Rochd, Service de Neurochirurgie, Casablanca, Maroc
| | - Robin Srour
- Hôpitaux Civils de Colmar, Hôpital Pasteur, Service de Neurochirurgie, Colmar, France
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Fletcher-Sandersjöö A, Mirza S, Burström G, Pedersen K, Kuntze Söderqvist Å, Grane P, Fagerlund M, Edström E, Elmi-Terander A. Management of perineural (Tarlov) cysts: a population-based cohort study and algorithm for the selection of surgical candidates. Acta Neurochir (Wien) 2019; 161:1909-1915. [PMID: 31270612 PMCID: PMC6704091 DOI: 10.1007/s00701-019-04000-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 06/25/2019] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Alexander Fletcher-Sandersjöö
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden.
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Sadia Mirza
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Gustav Burström
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Kyrre Pedersen
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Per Grane
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Michael Fagerlund
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erik Edström
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Adrian Elmi-Terander
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Abstract
CLINICAL ISSUE Spinal cysts can be classified as meningeal, not meningeal, and tumor-associated cysts. Due to the widespread availability of high-resolution computed tomography and magnet resonance imaging, spinal cysts can be detected with high sensitivity these days. Concerning the variety of potential cystic differential diagnoses, a precise classification is difficult and can often only be realized after surgical inspection or histological examination. PRACTICAL RECOMMENDATIONS Spinal cysts are generally incidental findings during a routine diagnostic workup and need no further therapy. Surgical treatment can be necessary if the spinal cyst reaches a certain size and causes neurological symptoms due to the compression of the spinal cord or the nerve root.
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Puffer RC, Gates MJ, Copeland W, Krauss WE, Fogelson J. Tarlov Cyst Causing Sacral Insufficiency Fracture. Oper Neurosurg (Hagerstown) 2019; 13:E4-E7. [PMID: 28521343 DOI: 10.1093/ons/opw025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Accepted: 11/10/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Tarlov cysts, also known as perineural cysts, have been described as meningeal dilations of the spinal nerve root sheath between the peri- and endoneurium at the dorsal root ganglion. Most often they are found in the sacrum involving the nerve roots. Normally asymptomatic, they have been reported to present with radiculopathy, paresthesias, and even urinary or bowel dysfunction. Sacral insufficiency has not been a well-documented presentation. CLINICAL PRESENTATION The patient is a 38-year-old female who started to develop left low back pain and buttock pain that rapidly progressed into severe pain with some radiation down the posterior aspect of her left leg. There was no recent history of spine or pelvic trauma. These symptoms prompted her initial emergency department evaluation, and imaging demonstrated a large Tarlov cyst with an associated sacral insufficiency fracture. She was noted to have a normal neurological examination notable only for an antalgic gait. She was taken to surgery via a posterior approach and the cyst was identified eccentric to the left. The cyst was fenestrated and the nerve roots identified. Given her large area of bone erosion and insufficiency fractures, fixation of the sacroiliac joints was deemed necessary. Fusion was extended to the L5 vertebral body to buttress the fixation. She tolerated the procedure well and was discharged from the hospital on postoperative day 3. CONCLUSION Tarlov cysts of the sacrum can lead to significant bone erosion and subsequent insufficiency fractures, requiring fenestration and in some cases, complex sacropelvic fixation.
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Kontoangelos K, Economou M, Katsi V, Papageorgiou C. Depressive symptomatology in a female patient with Tarlov cyst. SAGE Open Med Case Rep 2019; 7:2050313X19844693. [PMID: 31041104 PMCID: PMC6477756 DOI: 10.1177/2050313x19844693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Accepted: 03/27/2019] [Indexed: 12/26/2022] Open
Abstract
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.
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Affiliation(s)
- Konstantinos Kontoangelos
- 1st Department of Psychiatry, Eginition Hospital, Medical School, University of Athens, Athens, Greece.,University Mental Health Research Institute, Athens, Greece
| | - Marina Economou
- 1st Department of Psychiatry, Eginition Hospital, Medical School, University of Athens, Athens, Greece.,University Mental Health Research Institute, Athens, Greece
| | - Vasiliki Katsi
- 1st Department of Cardiology, Hippokration Hospital, Medical School, University of Athens, Athens, Greece
| | - Charalambos Papageorgiou
- 1st Department of Psychiatry, Eginition Hospital, Medical School, University of Athens, Athens, Greece.,University Mental Health Research Institute, Athens, Greece
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Mijalcic MR, Djurovic B, Cvrkota I, Jokovic M, Bascarevic V, Micovic M. Tarlov cyst-a rare lesion in children: case report. Childs Nerv Syst 2019; 35:701-705. [PMID: 30810854 DOI: 10.1007/s00381-019-04105-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Accepted: 02/22/2019] [Indexed: 11/26/2022]
Abstract
Perineural cysts, also known as Tarlov cysts, are benign lesions increasingly found in patients undergoing neuroimaging studies. These cysts can very rarely be identified in children and even then, they are not so likely to be responsible for some neurological deficit. It seems to be of scientific and clinical importance to present a pediatric case with Tarlov cyst. We report a case of a patient, a 7-year-old boy, previously treated for nocturnal enuresis (bedwetting), who later developed signs and symptoms of classic urinary incontinence. Magnetic resonance imaging (MRI) showed a relatively large extradural cyst at the level of S2. The cyst was approached by laminectomy of L5 to S2, excised, and completely removed from the belonging nerve root. The patient has established normal sphincter control without even a single episode of involuntary discharge of urine. A surgery is a powerful, safe, and efficacious option for treatment in pediatric patients with sacral Tarlov cysts.
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Affiliation(s)
- M R Mijalcic
- Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia.
| | - B Djurovic
- Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia
| | - I Cvrkota
- Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia
| | - M Jokovic
- Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia
| | - V Bascarevic
- Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia
| | - M Micovic
- Department of Pediatric Neurosurgery, Clinical Center of Serbia, Clinic of Neurosurgery, Belgrade, Serbia
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Yamagami K, Shono T, Iihara K. Multiple Sacral Perineurial Cysts Presented Symptoms Triggered by Nonaneurysmal Perimesencephalic Subarachnoid Hemorrhage. NMC Case Rep J 2019; 6:57-60. [PMID: 31016102 PMCID: PMC6476817 DOI: 10.2176/nmccrj.cr.2018-0242] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 12/03/2018] [Indexed: 11/20/2022] Open
Abstract
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.
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Affiliation(s)
- Keitaro Yamagami
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Fukuoka, Japan.,Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
| | - Tadahisa Shono
- Department of Neurosurgery, Harasanshin Hospital, Fukuoka, Fukuoka, Japan
| | - Koji Iihara
- Department of Neurosurgery, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Fukuoka, Japan
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Paterakis K, Brotis A, Bakopoulou M, Rountas C, Dardiotis E, Hadjigeorgiou GM, Fountas KN, Karantanas A. A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature. World Neurosurg 2019; 126:581-587. [PMID: 30880195 DOI: 10.1016/j.wneu.2019.02.222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 02/21/2019] [Accepted: 02/22/2019] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Konstantinos Paterakis
- Medical School, University of Thessaly, Thessaly, Greece; Department of Neurosurgery, University Hospital of Larissa, Thessaly, Greece.
| | - Alexandros Brotis
- Department of Neurosurgery, University Hospital of Larissa, Thessaly, Greece
| | - Maria Bakopoulou
- Animus-Kyanous Stavros Private Clinic, Larissa, Thessaly, Greece
| | - Christos Rountas
- Department of Radiology, University Hospital of Larissa, Medical School, University of Thessaly, Thessaly, Greece
| | - Efthymios Dardiotis
- Department of Neurology University Hospital of Larissa, Medical School, University of Thessaly, Thessaly, Greece
| | - Georgios M Hadjigeorgiou
- Department of Neurology University Hospital of Larissa, Medical School, University of Thessaly, Thessaly, Greece
| | - Kostas N Fountas
- Medical School, University of Thessaly, Thessaly, Greece; Department of Neurosurgery, University Hospital of Larissa, Thessaly, Greece
| | - Apostolos Karantanas
- Department of Diagnostic Radiology, University Hospital of Heraklion, Medical School, University of Crete, Heraklion, Greece
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Karti DT, Karti O, Celebisoy N. A rare cause of Horner's syndrome: cervicothoracic spinal root cysts. Neurol Sci 2019; 40:1311-4. [PMID: 30790081 DOI: 10.1007/s10072-019-03773-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/15/2019] [Indexed: 10/27/2022]
Abstract
OBJECTION We herein report cervicothoracic spinal root cysts as a rare cause of Horner's syndrome. CASE REPORT A 62-year-old woman was admitted to our neuro-ophthalmology clinic complaining of drooping of her right upper eyelid. The history, physical examination, and laboratory tests were normal. The extraocular movements were full. The right eyelid was ptotic and the right pupil was smaller than the left. Right Horner's syndrome was diagnosed by the neuro-ophthalmologic examination and pharmacological tests. Cervical magnetic resonance imaging showed multiple spinal nerve root cysts between C7 and T1 segments of the spinal cord. CONCLUSION This report showed for the first time that cervicothoracic spinal root cysts could cause Horner's syndrome and should be kept in mind in performing neuroimaging studies.
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Sharma M, SirDeshpande P, Ugiliweneza B, Dietz N, Boakye M. A systematic comparative outcome analysis of surgical versus percutaneous techniques in the management of symptomatic sacral perineural (Tarlov) cysts: a meta-analysis. J Neurosurg Spine 2019; 30:1-12. [PMID: 30738394 DOI: 10.3171/2018.10.spine18952] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 10/11/2018] [Indexed: 01/15/2023]
Abstract
OBJECTIVESymptomatic 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.METHODSThe 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.RESULTSOverall 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).CONCLUSIONSThe 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.
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Abstract
We report an 8-month-old female infant with complaints of irritability and recent inability to sit in a stable position. On physical examination, a palpable mass in the left upper quadrant of her abdomen was evident. Sonography and magnetic resonance imaging showed a giant cyst, consisting of 2 communicating compartments: dorsal and ventrolateral. The dorsal part compressed the conus medullaris, and the ventrolateral part compressed the left kidney. Partial cyst wall resection and imbrication for the dorsal pouch were done, and diagnosis of Tarlov cyst was confirmed via the visualization of the endocystic nerve root during surgery. Familiarizing physicians with this unusual presentation of Tarlov cyst may help them in early recognition of this lesion, and subsequent surgery might be considered to prevent clinical sequela. To our knowledge, a lumbar Tarlov cyst presenting as a giant abdominal cyst in an infant has not been reported in the English-language literature.
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Affiliation(s)
- Mojtaba Dayyani
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Samira Zabihyan
- Department of Neurosurgery, Ghaem Teaching Hospital, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran; Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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Kozłowski P, Kalinowski P, Jankiewicz M, Kozłowska M, Bilski M, Budny A, Słabczyński P, Łukowski M, Szczypiór G, Burdan F. [Perineural cysts]. Pol Merkur Lekarski 2018; 45:201-204. [PMID: 30531671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Perineural cyst (Tarlov cyst) is a lesion in a form of fluid-filled sacks, usually located within the nerve root sheath at the posterior root of a spinal nerve, whose wall is formed by: endoneurium, peripheral nerve fibers and ganglion cells and areolar tissue. Depending on the studied population, the frequency of lesion occurence was estimated at 1.5- 13.2%, with its significant majority occuring in women. Cyst development may be the result of ischemia, hemorrhage, inflammation or trauma. Cysts are usually asymptomatic theefore they are likely to bo detected accidentally. However, in approximately 1/4 of the cases, the cyst puts so much pressure on the nerve and the neighbouring nerve roots that it becomes symptomatic (causes pain). The presence of clinical symptoms may be an indication for conservative treatment (i.e. analgesics, rehablitation, cyst puncture) or surgery (usually laminectomy).
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Affiliation(s)
- Piotr Kozłowski
- St Johns' Cancer Center in Lublin; Department of Human Anatomy, Medical University of Lublin
| | | | | | | | | | - Agnieszka Budny
- St Johns' Cancer Center in Lublin; Department of Human Anatomy, Medical University of Lublin
| | | | | | | | - Franciszek Burdan
- St Johns' Cancer Center in Lublin; Department of Human Anatomy, Medical University of Lublin
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Nkwerem SP, Ito K, Ichinose S, Horiuchi T, Hongo K. Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature. Surg Neurol Int 2018; 9:180. [PMID: 30221025 PMCID: PMC6130174 DOI: 10.4103/sni.sni_238_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 08/13/2018] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Sunday Patrick Nkwerem
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan.,Department of Neurosurgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
| | - Kiyoshi Ito
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Shunsuke Ichinose
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Tetsuyoshi Horiuchi
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
| | - Kazuhiro Hongo
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
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