Abstract
BACKGROUND CONTEXT Surgical intervention for sacral perineural cysts remains controversial. Although the exact pathophysiology is unknown, it may include a direct communication between the cyst and thecal sac resulting in trapping of cerebrospinal fluid (CSF) due to a valve mechanism. In consequence, microsurgical treatment was directed towards a cohort of patients with large cysts treated with different strategies depending on their intraoperative findings. PURPOSE To evaluate outcome in Tarlov syst surgery comparing two different technques. STUDY DESIGN/SETTING Retrospective comparative multicentre European. PATIENT SAMPLE In 31 consecutive patients (22 female and 9 male). OUTCOME MEASURES Visual analogic scale preop and postop, spine MRI preop and postop, EMG preop and postop. METHODS In 31 cases 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. Depending on the cyst anatomy, 20 patients underwent cyst fenestration and wall imbrication while eleven patients underwent cyst fenestration and CSF communication was located and repaired. A total of 27 patients had intraoperative EMG monitoring. 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. RESULTS Patients were divided in algic and nonalgic symptom relief: while all patients improved their perineal pain and urinary dysfunction only eleven 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 that 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.
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