- Division of Neurosurgery, The Spine Clinic of Los Angeles, Good Samaritan Hospital, Los Angeles, CA 90017, USA
- Department of Orthopedic Surgery, First Affiliated Hospital of the People's Liberation Army General Hospital, Beijing 100048, China
Larry T. Khoo
Division of Neurosurgery, The Spine Clinic of Los Angeles, Good Samaritan Hospital, Los Angeles, CA 90017, USA
DOI:10.4103/2152-7806.85469Copyright: © 2011 Smith ZA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Smith ZA, Li Z, Raphael D, Khoo LT. Sacral laminoplasty and cystic fenestration in the treatment of symptomatic sacral perineural (Tarlov) cysts: Technical case report. Surg Neurol Int 27-Sep-2011;2:129
How to cite this URL: Smith ZA, Li Z, Raphael D, Khoo LT. Sacral laminoplasty and cystic fenestration in the treatment of symptomatic sacral perineural (Tarlov) cysts: Technical case report. Surg Neurol Int 27-Sep-2011;2:129. Available from: http://sni.wpengine.com/surgicalint_articles/sacral-laminoplasty-and-cystic-fenestration-in-the-treatment-of-symptomatic-sacral-perineural-tarlov-cysts-technical-case-report/
Background:Perineural cysts of the sacrum, or Tarlov cysts, are cerebrospinal fluid (CSF)-filled sacs that commonly occur at the intersection of the dorsal root ganglion and posterior nerve root in the lumbosacral spine. Although often asymptomatic, these cysts have the potential to produce significant symptoms, including pain, weakness, and/or bowel or bladder incontinence. We present a case in which the sacral roof is removed and reconstructed via plated laminoplasty and describe how this technique could be of potential use in maximizing outcomes.
Methods:We describe technical aspects of a sacral laminoplasty in conjunction with cyst fenestration for a symptomatic sacral perineural cyst in a 50-year-old female with severe sacral pain, lumbosacral radiculopathy, and progressive incontinence. This patient had magnetic resonance imaging (MRI) and computed tomography (CT)-myelographic evidence of a non-filling, 1.7 × 1.4 cm perineural cyst that was causing significant compression of the cauda equina and sacral nerve roots. This surgical technique was also employed in a total of 18 patients for symptomatic tarlov cysts with their radiographic and clinical results followed in a prospective fashion.
Results:Intraoperative images, drawings, and video are presented to demonstrate both the technical aspects of this technique and the regional anatomy. Postoperative MRI scan demonstrated complete removal of the Tarlov cyst. The patient's symptoms improved dramatically and she regained normal bladder function. There was no evidence of radiographic recurrence at 12 months. At an average 16 month followup interval 10/18 patients had significant relief with mild or no residual complaints, 3/18 reported relief but had persistent coccydynia around the surgical area, 2/18 had primary relief but developed new low back pain and/or lumbar radiculopathy, 2/18 remained at their preoperative level of symptoms, and 1/18 had relief of their preoperative leg pain but developed new pain and neurological deficits.
Conclusions:Sacral laminoplasty and microscopic cystic fenestration is a feasible approach in the operative treatment of this difficult, and often controversial, spinal pathology. This technique may be used further and studied in an attempt to minimize potential surgical morbidity, including CSF leaks, cyst recurrence, and sacral insufficiency fractures.
Keywords: Laminoplasty, perineural cyst, sacral, Tarlov cyst
Perineural cysts of the sacrum were first described during anatomic dissections by Tarlov in 1938.[
The patient is positioned prone on a standard operating room table with a Wilson frame. A midline incision, similar to that used in a lower lumbar laminectomy, is planned over the sacrum with the aid of multi-planar fluoroscopy. In general, the planned incision is approximately 5 cm in length. The skin and subcutaneous tissue is opened sharply on the midline and a careful subperiosteal dissection of the paravertebral musculature exposes the sacral roof. In many circumstances, the sacral lamina may be significantly eroded and a bluish hue from the underlying cyst can be seen through the sacral lamina. Care must be taken not to break through an eroded lamina and we suggest avoiding monopolar cautery over areas with notably thinned bone.
Following exposure of the sacral roof, attention is turned to development of bilateral bony laminar troughs for en bloc removal of the sacral roof overlying the cyst. Preoperative analysis and measurements of thin-cut CT scans allow for the planning of the width and length of drilling with the ultimate goal of creating a bony window that exposes the borders of the cyst and caudal portion of the thecal sac [
The primary aim of microsurgical dissection is to decompress the surrounding nerve roots and remove any persistent connection between the cyst and the cerebrospinal fluid (CSF) of the lumbar cistern. In all of our operative cases, we have found a discrete connection where CSF will intermittently fill the cyst in conjunction with each CSF pulsation. This is commonly associated with intradural arachnoid webs and membranes. These often are found at the connection between the cyst and the thecal sac and may work to block retrograde flow from the cyst. In our opinion, this observation may be suggestive of the hydrostatic “ball-valve” mechanism that is commonly noted by other reports.[
Following removal of the sacral lamina, the cyst wall is exposed [
Invariably, dissection reveals a discrete connection at the superior portion of the cyst. The cyst wall is dissected to expose this connection. A local fat graft and/or muscle graft is then obtained locally from below the subcutaneous opening and positioned within this communication [
A 50-year-old female presented with a history of longstanding severe coccydynia, groin numbness, left leg radiculopathy, and 3 of months of worsening bladder incontinence. On exam, she had signs of an S1 motor radiculopathy. MR imaging (MRI) of the lumbosacral spine demonstrated a 1.7 cm × 1.4 cm mass with a homogenously bright T2 signal [
Commonly severe bony erosion is found on the undersurface of the sacral roof as shown in (a). The lamina of a sacral roof are repositioned and secured with titanium mini-plates following cyst imbrication, closure, and placement of fibrin glue sealant. The lamina of a sacral roof are repositioned and secured with titanium mini-plates following cyst imbrication, closure, and placement of fibrin glue sealant (b)
A total of 18 patients have been treated with this technique for patients with symptomatic cysts of the sacrum that have progressive symptoms and have failed conservative management options. The initial clinical results in this patient cohort are reported. The presenting clinical characteristics of these patients are shown in
The purpose of this technical report is to describe and illustrate the technical aspects of our surgical approach. While multiple techniques have been previously reported, little consensus exists regarding the most effective surgical approach. Percutaneous treatments, including percutaneous fibrin glue therapy[
In this technical case report, we describe a previously unreported technique for the surgical management and surgical treatment of symptomatic sacral Tarlov cysts. We believe the replacement of the sacral roof may be beneficial for bolstering and supporting a dural closure. In 18 patients treated with this technique, only a single patient required revision surgery for a postoperative CSF leak. In this case, there was a large communication with the thecal sac, and enthusiastic resection of the cyst wall left a defect with attenuated walls that were difficult to close. Unlike some authors,[
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