130. Cold facts on surgical Tarlov cysts

Abstract

BACKGROUND CONTEXT Surgical intervention for sacral perineural cysts remains controversial. In consequence, microsurgical treatment was directed toward a cohort of patients with large cysts treated with different strategies depending on their intraoperative findings. PURPOSE To assess results in the largest group of surgically treated Tarlov cysts. STUDY DESIGN/SETTING Multicenter, retrospective, comparative study. PATIENT SAMPLE In 31 consecutive patients (22 female, 9 male), MRI revealed sacral perineural cysts of at least the size of the S1 vertebral body. All patients had previously received at least a year of conservative modalities. Symptoms at initial presentation included aggravated lumbosacral pain, pseudoradicular symptoms, perineal pain and urinary dysfunction. Mean follow-up was 23 ± 5 months. Imaging and clinical follow-up examinations were analyzed. OUTCOME MEASURES SF outcome measures. VAS. METHODS Depending on the cyst anatomy, 20 patients underwent cyst fenestration and wall imbrication while 11 patients underwent cyst fenestration and cerebrospinal fluid communication was located and repaired. Twenty-seven patients had intraoperative EMG monitoring. RESULTS Patients were divided in algic and nonalgic symptom relief: while all patients improved their perineal pain and urinary dysfunction only 11 patients reported lasting pain control following surgery. Two patients had previously cyst puncturing and embolization. Three patients underwent additional surgery: one early CSF fistula repair and two deferred refenestration with cerebrospinal fluid tamponade. One patient underwent later an L5-S1 arthrodesis. Three patients experienced internal CSF fistula and were treated conservatively. Successful fenestration and collapse of the cyst revealed by postoperative MRI was evident in 27 cases. Postoperative EMG showed improvement in 22 cases. CONCLUSIONS Direct surgical approach of sacral perineural cysts to the thecal sac is a feasible option in patients with fairly large symptomatic cysts. Partial cyst removal and closure repair for prevention of CSF communication appeared simple and equally effective. Intraoperative EMG monitoring was of particular help regarding cyst wall anatomy. Advice should be given to patients regarding expectations for pain improvement after surgery. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.