1. Tariq Elemam Elshafey Awad
Surgical Excision Of Symptomatic Sacral Perineurial Tarlov Cyst: Case Series & Review Of The Literature by
Tariq Elemam Elshafey Awad
Assist. Prof. of Neurosurgery & Spine Surgery
Suez Canal University
29th Annual meeting of ESNS
Luxor – 23th March 2016

2. Sacral perineurial cyst or Tarlov cyst
A cystic lesion of the nerve root,
common in the sacrum.
Named after Tarlov (1938) during autopsy study of the filum terminal.
Incidental findings on (MRI) 1.5% - 4.6%
Most asymptomatic but
< 1% significant clinical symptoms
e.g. local or radicular pain,
sensory or motor deficits
and even bladder dysfunction.

3. Sacral perineurial cyst or Tarlov cyst
Surgical strategies
Equalization of the CSF pressure between the cephalad thecal sac & the cyst
e.g. cyst-arachnoid shunt &
the lumboperitoneal shunt .
Closure of the cyst-arachnoid communication sacrificing the parent root.
Percut. CT-guided aspiration
Microsurgical fenestration or excision.

4. PATIENTS AND METHODS
15 consecutive patients at SCU Hospital in the neurosurgery department between June 2002 & July 2015.
local & radicular pain VAS
Muscle strength & weakness MRC grading system
Economic (activity) and functional (pain) status were assessed and classified according to Prolo Scale
(MRI) L-S spine with Gadolinium evaluation of the spatial relationship between parent roots and cysts with unprecedented accuracy.
(CT) the erosion of the sacral bone caused by the cyst expansion

5. Surgical Technique Sacral incision , 5–7 cm
Subperiosteal dissection of the paravertebral Ms exposes the sacral roof.
Bony erosion by the cyst (paper –thin bone) + blue-grey cyst wall
Sacral laminotomy, usually at 2-levels, for en bloc removal of the roof .
Microsurg. (the potential + of sacral nerve root fibers running in or adjacent to the cyst).
The thin, transparent cyst wall is opened widely with microscissors
dissection of the internal portion of the cyst reveals a discrete connection between the cyst & SA space
closure with non-absorbable 6–0 monofilament suture + local fat graft & gelatin sponge

6. Surgical Technique
routine lumbar subarachnoid drain to prevent CSF leak

7. Results
15 patients (5 M & 10 F) with symptomatic sacral perineurial cysts
The mean age was 31 yrs ( yrs).
Preoperative symptoms 3 categories:
axial pain in the form of LBP (7), coccydenia (3), buttock pain (3) & perianal pain (1).
LL pain was either nonspecific with dysthesia (8), radiacular (3).
nocturnal enuresis (2).

8. Results Average cyst size 2.7 cm (range 1.5 - 4.5 cm).
A correlation between size of the cyst & severity of the radicular pain was observed
All complete or substantial resolution of the preop. local & radicular
In all of the 13 patients who complained of sensory disturbances, a significant improvement was achieved. (Figure 1)
The 2 patients presented with nocturnal enuresis showed dramatic improvement P.O. with sound bladder control + marked improvement in school achievement.

9. LBP, coccydenia, bilat. LL pains 1 y S2 S3 3 50 improving
Case No.
Age (yrs), Sex
Main Symptom
Duration of Symptoms
Location
cyst size (cm)
Follow Up (months)
Post. Op. Course 1
35, F
LBP, coccydenia, bilat. LL pains
1 y
S2 S3 3 50
improving 2
7, M
nocturnal enuresis
3 yrs
S1 S2
3.5 27
60, F
LBP , Rt LL pains
2 yrs S2 36 4
34, M
buttock pain , sciatica
1.5 Yrs
S1S2S3
4.5 12
CSF leak 5
22, M
LBP , Rt sciatica
6 Ms
S1S2
1.8 6
27, F
buttock pain, coccydenia
2.5 95 7
7, F
3 Yrs 77 8
30, F
Bilat. Leg dysthesia
4 Yrs S3
1.5 60 9
42, F
LBP , Lt LL pains
S2, S3 65
superficial wound infection 10
23, F
buttock pain , Rt sciatica 11
39, M
LBP, bilat. LL pains
110
44, F
bilat LL pains 81 13
27 , F
LBP, perianal pain bilat LL pain 44 14
21, M
LBP Rt LL pain 15
47 , F
coccydenia
2.4
160
Patient characteristics & clinical findings

10. Clinical outcomEs

11. Case Presentation 7 yrs/M child
C/O primary Enuresis (mainly nocturnal, occasionally diurnal)
Occasional diurnal passage of stool
No psychological troubles in the family
Med. ttt was started ( fluid restriction after sunset, Oxybutynin HCL, desmopressin acetate for 2 years with no response)
O/E motor and senory exam of both LL intact
Lab : urine analysis (no infection – sp. Gravity 1025), stool analysis (N), normal glucose serum level

12. Radiology

14. Post operative

15. Case No 11. 39 Yrs/ M LBP & bilat LL pain for 3 yrs
Case No Yrs/ M LBP & bilat LL pain for 3 yrs. A: Tarlov cyst opposite S2. B: 3 yrs P.O. C: intraoperative

16. Case No 13. 27 yrs/ F presented with LBP & perianal pain for 2 yrs. P
Case No yrs/ F presented with LBP & perianal pain for 2 yrs. P.O. MRI T1 and T2 showing Tarlov cyst opposite S1 and S2.

17. Meningeal diveerticulum versus Tarlov Cyst
A positive filling defect and large size more than 1.5 cm is indication for surgery

18. Summary of the articles discussing the outcomes of sacral Tarlov cysts
Author
Number of patients
Follow - Up
Improvement (%)
Mummaneni et al., 2000 (11) 8
1-73 ms
87.5 %
Voyadzis et al., 2001 (26) 10
3-136 ms
70%
Caspar et al., 2003 (3) 15
6-108 ms
86.7 %
Langdown et al. , (8) 3
6-12 ms
100 %
Tanaka et al., 2006 (22) 12
6-52 ms
83.3 %
Guo et al., 2007 (5) 11 ms
81.8 %
Park et al., 2008 (14) 2 NA
Sajko et al., 2009 (17)
Neulen et al., 2011 (12) 13
2.5 – 20 ms
61.5%
Smith et al., 2011 (18) 18
9-44 ms
55.6%
Cantore et al., (2) 19
9-300 ms
84.2 %
Present study
160
Total
129

19. CONCLUSION
Cyst excision is an effective and safe technique for symptomatic sacral perineural (Tarlov) cysts. Careful patient selection is vital to the management of this often difficult & controversial pathology.

20. Thanks