Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature
- Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
- Department of Neurosurgery, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra State, Nigeria
Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390-8621, Japan
DOI:10.4103/sni.sni_238_18Copyright: © 2018 Surgical Neurology International This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.
How to cite this article: Sunday Patrick Nkwerem, Kiyoshi Ito, Shunsuke Ichinose, Tetsuyoshi Horiuchi, Kazuhiro Hongo. Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature. 04-Sep-2018;9:180
How to cite this URL: Sunday Patrick Nkwerem, Kiyoshi Ito, Shunsuke Ichinose, Tetsuyoshi Horiuchi, Kazuhiro Hongo. Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature. 04-Sep-2018;9:180. Available from: http://surgicalneurologyint.com/surgicalint-articles/8991/
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.
Keywords: Cyst resection, perineural cyst, recurrence, surgical treatment, Tarlov cyst
Tarlov cysts, first described by Tarlov in 1938, are perineural cysts often seen in the extradural segment involving the posterior sacral nerve roots.[
A 40-year-old male presented with a 3-year history of sensory changes involving the S2–S3 distribution in the right leg (e.g., hypoesthesia without motor weakness or dysuria). The lumbosacral MRI showed a noncontrast enhancing right-sided cystic mass at the S2–S3 level; it had the same intensity as CSF on both the T1- and T2-weighted images [
Lumbosacral magnetic resonance images. Sagittal (a and b), axial (c), and coronal (d) view of lumbosacral magnetic resonance imaging showing the cyst (red arrow) at the S2 vertebra. Preoperative magnetic resonance images showing a less-enhanced tumor (b). The contents of the cyst have the same intensity as the cerebrospinal fluid on both T2-weighted images
A laminoplastic laminotomy was performed at three levels using an ultrasonic bone curette. At surgery, the S3 nerve root was enveloped within cyst wall and the S2 nerve root was clearly compressed [Figure
Operative procedure and intraoperative findings. (a) Intraoperative photograph showing that the S2 nerve root (double arrowheads) was compressed by the cyst component (white asterisk). (b) Closer observation revealed that the cyst wall (white asterisk) contains the S3 nerve root (double arrows). (c and d) After excision of the cyst wall, the inlet of the cerebrospinal fluid (CSF) was confirmed around the nerve root (single arrow). The inlet from the subarachnoid space was found (single arrowhead) and the CSF was spontaneously flowing out from it (small triple arrows). A Valsalva maneuver clearly showed the CSF flow from the subarachnoid space to the perineural cyst. (e) After confirmation of the subarachnoid connection, it was sealed with adipose tissue (large arrow) and fibrin glue. (f) Finally, imbrication of the cyst wall was performed with nonpenetrating titanium clips. A repeated Valsalva maneuver showed no CSF leakage
Tarlov cysts are meningeal dilatations commonly found between the endoneurium and perineurium in the spinal nerve root sheaths at the S2 and S3 levels. They commonly communicate with the subarachnoid space. Some authors believe that these are a congenital lesions, whereas others consider them to be acquired.[
Symptomatic Tarlov cysts
Although they are typically asymptomatic, 1% may demonstrate growth and contribute to nerve root compression (e.g., sacral/perineal pain, sphincter dysfunction, radiculopathy, and rarely, infertility).[
Surgical options for symptomatic Tarlov cysts
Different surgical treatment options are available for symptomatic Tarlov Cysts [
Studies demonstrating surgical outcomes of Tarlov cysts
Seven studies (all case series) evaluated the surgical treatment outcomes for Tarlov Cysts.[
There are several surgical treatment options for treating symptomatic (e.g., 1%) Tarlov cysts. An optimal strategy appears to include direct cyst resection, imbrication, and fat graft packing of the communication between the dural sac to the cyst (e.g., occlude the ball-valve mechanism of refilling).
Financial support and sponsorship
Japan Society for the Promotion of Science (JSPS) provided financial support in the form of Grants-in Aid for Scientific Research: KAKENHI. This work was supported by JSPS KAKENHI grant no. JP15 K10356.
Conflicts of interest
There are no conflicts of interest.
The authors express their gratitude to our colleagues in the Department of Neurosurgery, Shinshu University School of Medicine, for their daily contributions to helping patients with Tarlov cysts.
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