Article
Microsurgical fenestration of symptomatic sacral perineural cysts at the level of the distal dural sleeve
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Authors
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Axel Neulen
- Department of Neurosurgery, Georg August University, Göttingen, Germany
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Sara M. Pilgram
- Department of Neurosurgery, Georg August University, Göttingen, Germany
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Veit Rohde
- Department of Neurosurgery, Georg August University, Göttingen, Germany
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Alf Giese
- Department of Neurosurgery, Georg August University, Göttingen, Germany
| Published: | September 16, 2010 |
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Outline
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Objective: Surgical management of symptomatic perineural cysts (Tarlov cysts) remains a matter of debate. Based on a pathomechanism which assumes a valve mechanism allowing CSF to enter the cyst through microcommunications at the distal dural sleeve of the nerve root, we propose a microsurgical approach for symptomatic sacral perineural cysts which aims at establishing a free communication between the intradural space and the perineural cyst. To our knowledge, the series presented here is one of the largest studied so far and the first examining such an approach which does not aim at resection of the cyst.
Methods: In 11 patients (9 female, 2 male) who presented with symptoms including sciatica, lumbosacral and perineal pain, and urinary dysfunction, sacral perineural cysts were detected by MRI, which excluded other pathologies. Myelography demonstrated a delayed filling of the cysts in all patients selected for surgery. Microsurgical approach: After sacral laminectomy and opening of the thecal sac, the nerve was followed into the cyst. Fibrous arachnoidal tissue obstructing the neck of the cyst was resected, establishing a communication between the cyst and the intradural space. The dura was then reconstructed. Where feasible, plication of the cyst was performed. Follow up was obtained from return visits to the hospital and from self-assessment scales.
Results: For 2 patients, who recently underwent surgery, the evaluation is standing out. Mean follow up for the other patients was 11 months. Other than CSF fistula in 1 patient, no adverse events and no new neurological deficits occurred. 3 patients did not profit from surgery, 2 of which had multiple cysts of which small or promptly filling cysts remained untreated. 6 patients improved. 1 of these patients suffered a relapse of pain after 2 months, reoperation of the cyst which again demonstrated delayed myelographic filling did not induce an improvement. 1 patient returned to work after 3 months, 8 patients returned to their daily activities between 2 weeks and 2 months postoperatively.
Conclusions: Generation of a free communication between the cyst and the thecal sac is an appropriate treatment for symptomatic sacral perineural cysts in which a valve mechanism can by demonstrated by mylography through delayed filling of the cyst.
