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Symptomatic Tarlov Cyst: a Case Report and Surgical Management

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Symptomatic Tarlov Cyst: a Case Report and Surgical Management CASE REPORT Indonesian Journal of Neurosurgery (IJN) 2020, Volume 3, Number 3: 115-118 P-ISSN.2089-1180, E-ISSN.2302-2914 Symptomatic Tarlov Cyst: A Case Report and Surgical Management Sabri Ibrahim1, Victorio1* ABSTRACT Introduction: Perineural (Tarlov) cysts are meningeal dilatations and bladder incontinence. Initially, she had been evaluated by her of the posterior spinal nerve root sheath that most often affect physician, and magnetic resonance imaging (MRI) was ordered. She sacral roots and can cause a progressive painful radiculopathy. had received physical therapy with little benefit and was referred Tarlov described a case of symptomatic perineural cyst and for physiatrists assessment. recommended its removal. Conclusion: Review of the patient’s original MRI scan showed the Case Presentation: A 30-year-old female physician presented presence of perineural (Tarlov) cysts within the sacral canal at the with a chief complaint of bilateral posterior thigh pain and low level of S1-S2, with compression of the adjacent nerve root. Tarlov back pain, which began insidiously approximately 6 months before cysts can be a rare cause of lumbosacral radiculopathy and should her initial examination. She had a one-month history of bowel be considered in the differential diagnosis of radicular leg pain. Keywords: Arachnoid cysts; Case report; Radiculopathy; Tarlov cysts Cite This Article: Ibrahim, S., Victorio. 2020. Symptomatic Tarlov Cyst: A Case Report and Surgical Management. Indonesian Journal of Neurosurgery 3(3): 115-118. DOI: 10.15562/ijn.v3i3.83 1Division of Neurospine, Periveral INTRODUCTION: usually diagnosed on MRI, which reveals the lesion nerve and Pain Faculty of Medicine arising from the sacral nerve root close to the dorsal University of Sumatera Utara, Perineural (Tarlov) cysts are meningeal dilatations Medan, Indonesia root ganglion Tarlov advised extensive surgery with of the posterior spinal nerve root sheath that most sacral laminectomy and excision of the cyst along often affect sacral roots and can cause a progressive with the nerve root.6 Paulsen reported CT-guided painful radiculopathy. The cyst can enlarge via a percutaneous aspiration of these perineural cysts net inflow of cerebrospinal fluid, eventually causing for the relief of sciatica. Recently, microsurgical symptoms by distorting, compressing, or stretching excision of the cyst has been advocated, combined adjacent nerve roots. Tarlov cysts were first described with duroplasty or plication of the cyst wall.12-13 by Tarlov in 1938, after he identified 5 cysts in 30 1 We report a case of a symptomatic Tarlov cyst adult patients at autopsy. Tarlov described a case presenting as bilateral posterior thigh pain and low of symptomatic perineural cyst and recommended back pain, to increase the awareness of this rare its removal. Since then, a few cases have been entity in the neurosurgical community. reported in the literature.2-4 In later writings, he described symptomatic cases of perineurial cysts PATIENT AND OBSERVATION that were successfully treated surgically with sacral laminectomy and cyst excision.5,6 Over the years, A 30-year-old woman presented with a 6-month * Corresponding to: others have reported cases of Tarlov cysts causing history of progressive, intractable pain of the Victorio; Division of Neurospine, 7 8-10 Periveral nerve and Pain Faculty of coccygodynia, sacral pain, sacral radiculopathies bilateral posterior thigh and low back pain and 11 Medicine University of Sumatera and sacral insufficiency fractures. numbness. Pain was aggravated on walking. At the Utara, Medan, Indonesia; The prevalence of Tarlov cysts has been time, he was becoming increasingly incapacitated, [email protected] estimated to be 1 to 4.6% among the general adult although he was still able to work. She rated his pain population.2-8 70% of the cysts are asymptomatic, as 8 of 10 possible points on a visual analogue scale. 17% have an additive effect on other pathological Pain was rapidly relieved in the recumbent position. entities, and only 13% are symptomatic.5 She had a one-month history of bowel and bladder The patient may present with low back pain, incontinence. The pain was not associated with Received: 2019-09-27 sciatica, coccydynia or cauda equina syndrome. specific time, posture and it used to get relieved by Accepted: 2020-10-17 Because of severe myelopathy, the patients non-steroidal anti-inflammatory drugs (NSAID). Published: 2020-12-01 sometimes suffer sleep disorder.6 The cysts are For the last three months, the intensity and duration PublishedOpen access: by DiscoverSyshttps://ina-jns.org/ | IJN 2020; 3(3): 115-118 | doi: 10.15562/ijn.v3i3.83 115 CASE REPORT of pain had increased, which was now unrelieved Sensory examination showed diminished sensory by taking NSAIDs. The pain had progressed to the perception to pinprick on the soles of his feet and lower back and bilateral upper thigh up to the ankle. in S1 distribution. She denied any prior history of The pain was aggravated by activity and prolonged trauma or back injury. There was sensory deficit over standing and was more bothersome in the evening. the perineum. Anal sphincter tone and constriction On physical examination, a grade of 4/5 strength were abnormal. Knee jerks were normal. Bilateral was demonstrated in All lower limbs. Heel and ankle jerk was grade+. toe walking and knee bends were well performed. Preoperative MR imaging demonstrated a large sacral cyst arising within the thecal sac at S-1- S2, of around 7 x 4 x 3 cm with expansion of the osseous sacral central canal and enlargement of S-1 and S-2 neural foramina causing the compression of all adjacent nerve roots. The cyst did not fill with contrast material and appeared to have no communication with the spinal subarachnoid space. X-ray of the lumbosacral spine did not reveal any abnormality DISCUSSION Tarlov Cysts are common and usually detected incidentally during magnetic resonance imaging of the lumbosacral spine. Tarlov cysts are rare causes of low back pain. They are more common in females. It is generally agreed that asymptomatic Tarlov cysts do not require treatment. When symptomatic, the potential surgery-related benefit and the specific surgical intervention remain controversial. Tarlov’s initial descriptions of perineurial cysts were primarily localised to the posterior sacral or coccygeal nerve roots, most often the second or third sacral roots. These cysts generally occur at the junction of the posterior root Figure 1. MRI Lumbosacral Magnetic Resonance and the dorsal ganglion and are located between Imaging showing a Tarlov cyst at S1- S2 the perineurium and endoneurium. They are filled with cerebrospinal fluid (CSF) and are static in size. The clinical presentation of Tarlov cysts is variable. The cysts may cause local and/or radicular pain. The dominant syndrome is preferable to the caudal nerve roots, either sciatica, sacral or buttocks pain, vaginal or penile paranesthaesia or sensory changes over the buttocks, perineal area and lower extremity. Depending on their location, size and relationship to the nerve roots, they may cause sensory disturbances or motor deficits to the point of bladder dysfunction. Tenderness on firm pressure over the sacrum may be present. Commonly, the symptomatology is intermittent at its onset and is most frequently exacerbated by standing, walking and coughing. Bed rest alleviates the discomfort.8 Microscopic features of the cyst were described by Tarlov. The early stage in cyst formation is that of a space between the arachnoid which covers the root or the perineurium and the outer layer of the pia cover of the root or the endoneurium. It usually begins in one portion of the circumference of the Figure 2. Axial MRI Revealing a Large Cyst in Sacral Area perineural space, with larger cysts compressing 116 Published by DiscoverSys | IJN 2020; 3(3): 115-118 | doi: 10.15562/ijn.v3i3.83 CASE REPORT spinal canal or of the sacral foramina.5 Myelography studies using oil-based (iophendylate) contrast resulted in delayed filling of the cyst. Current studies using water-soluble (metrizamide) contrast allow for a more rapid filling of the cyst.5,9,,10,12 Unenhanced CT scans may show sacral erosions, asymmetric epidural fat distribution, and cystic masses that are isodense with CSF.9-12 In the event that an MRI cannot be performed, a CT myelogram can be used. Treatment includes both conservative and surgical approaches. Conservative treatment generally consists of the appropriate use of pain medication, and a physical therapy program. Tarlov cysts are a documented cause of sacral radiculopathy and other radicular pain syndromes. They must be considered in the differential diagnosis of patients presenting with these clinical Figure 3. After Sacral laminectomy (S2) the thin transparent presentations and appropriately treated by cyst cyst wall membrane was eksposed excision. To relieve progressively incapacitating symptoms, surgery was recommended. In our case, after laminectomy of S2 in the prone position, a large cyst was identified at the S2 level of the cord. It was situated near the dorsal root ganglion of S2. It was aspirated and discovered to be filled with cerebrospinal fluid; the Valsalva manoeuvre was used for approval. No inflow of cerebrospinal fluid was evident during a repeat Valsalva manoeuvre. The posterolateral wall of the cyst was resected after electrical stimulation verified that no motor nerve fibres were present. Because nerve fibres are often present in the cyst wall, risks include neurological deficits, urinary disturbances, as well as infection, spinal headache, and CSF leakage. Fibrin glue was then applied to fill the cyst cavity, to prevent cyst recurrence or CSF leakage, Although the cyst wall specimen was sent to the laboratory for pathological examination, its volume was inadequate to determine whether nerve root fibres were present Postoperatively, the patient reported marked Figure 4. The Tarlov cyst was aspirated pain relief. At month 3, the patient regained bowel and bladder control.
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