Neurosurg Focus 31 (6):E14, 2011

Tarlov : a controversial lesion of the sacral spine

Corrado Lucantoni, M.D.,1 Khoi D. Than, M.D.,2 Anthony C. Wang, M.D.,2 Juan M. Valdivia-Valdivia, M.D.,2 Cormac O. Maher, M.D.,2 Frank La Marca, M.D.,2 and Paul Park, M.D.2 1Institute of Neurosurgery, Università Cattolica del Sacro Cuore, Rome, Italy; and 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan

The primary aim of our study was to provide a comprehensive review of the clinical, imaging, and histopatho- logical features of Tarlov cysts (TCs) and to report operative and nonoperative management strategies in patients with sacral TCs. A literature review was performed to identify articles that reported surgical and nonsurgical management of TCs over the last 10 years. Tarlov cysts are often incidental lesions found in the spine and do not require surgical intervention in the great majority of cases. When TCs are symptomatic, the typical clinical presentation includes back pain, coccyx pain, low , bowel/bladder dysfunction, leg weakness, and sexual dysfunction. Tarlov cysts may be revealed by MR and CT imaging of the lumbosacral spine and must be meticulously differentiated from other overlapping spinal pathological entities. They are typically benign, asymptomatic lesions that can simply be monitored. To date, no consensus exists about the best surgical strategy to use when indicated. The authors report and discuss various surgical strategies including posterior decompression, wall resection, CT-guided needle as- piration with intralesional fibrin injection, and shunting. In operative patients, the rates of short-term and long-term improvement in clinical symptoms are not clear. Although neurological deficit frequently improves after surgical treatment of TC, pain is less likely to do so. (DOI: 10.3171/2011.9.FOCUS11221)

Key Words • Tarlov cyst • sacral perineural cyst • spine • incidental finding •

ue to the wide availability of imaging, inciden- ning surgical treatment. There is no consensus on the best tal lesions are increasingly found in patients treatment of symptomatic sacral cysts, although various undergoing neuroimaging studies. Tarlov cysts surgical strategies have been proposed. Dfrequently present as multiple cystic lesions of the nerve Our goal is to provide a review focusing on the more root sheath in the lower spine. The first report of a TC commonly located sacral TC. The definition of a TC, as was made by Tarlov32 in 1938 as an incidental finding at well as the clinical and operative management of this autopsy, and the lesion was subsequently classified as a small subset of symptomatic cysts, is analyzed. Type II meningeal cyst by Nabors et al.20 Tarlov cysts are typically located at the junction of the dorsal ganglion and the posterior nerve root and usually develop between Methods the endoneurium and perineurium of the nerve root.6 A thorough search of the PubMed database for Although the etiology is still unclear, microcommunica- English-language literature concerning sacral perineural tion with the subarachnoid space at the dural sleeve of cysts was conducted for the years 2000–2011. Studies the nerve root may function as a valve, allowing CSF in- were limited to this time period to emphasize the most flux and restricting CSF efflux, causing formation of the current data. Search terms used were Tarlov cyst(s), peri- cysts.20,21 neural cyst(s), and sacral nerve root cyst(s). The bibliog- We focus on a particular incidental lesion of the raphy of each article was reviewed for additional relevant lumbosacral spine: sacral perineural (Tarlov) cysts. Tar- articles. Each article was carefully analyzed and included lov cysts are rare lesions. According to the findings of in our study if details of treatment and outcome were previous studies, the lesions occur in about 1%–5% of reported. Pathogenesis, pathology, clinical presentation, patients.23,26 Depending on their location, size, and re- neuroimaging, treatment options, and surgical indications lationship to the nerve roots, a subset of cysts may be- were reviewed. In addition, case reports were included in come symptomatic and cause sensory disturbances, mo- this study to describe as many different treatment options tor deficits, or bowel/bladder dysfunction. This occurs in as possible. approximately 1% of patients.26 The clinical significance of this lesion must be meticulously assessed before plan- Results Abbreviation used in this paper: TC = Tarlov cyst. Twelve studies published in the last 10 years were

Neurosurg Focus / Volume 31 / December 2011 1

Unauthenticated | Downloaded 09/27/21 09:59 AM UTC C. Lucantoni et al. identified, each reporting treatment of more than 1- pa years of age old versus 1.3% in people greater than 50 tient with a TC. After review of these 12 articles, 1 other years of age.23 relevant study was identified and included in the analysis. From these studies, a combined total of 251 patients were Definition, Anatomy, Pathophysiology, and treated for symptomatic TCs. Data related to these series After the first report by Tarlov32 in 1938 as an inci- (> 2 patients/series) are summarized in Table 1. Table 2 dental finding at autopsy, several authors described dif- summarizes the 11 single case reports of TC treatment to ferent types of spinal cysts. Spinal meningeal cysts have provide further insight into the surgical management of been recently classified by Nabors et al.20 into 3 different these lesions. types: Type I (extradural meningeal cysts without spinal nerve root fibers); Type II (extradural meningeal cysts Discussion with spinal nerve root fibers [that is, TCs]); and Type III (spinal intradural meningeal cysts). In the practice of medicine, it is common to discover Regardless of the classification system, the definition an incidental lesion, which is an asymptomatic lesion of a TC is histopathological, because it requires the pres- found while examining the patient for reasons unrelated ence of spinal nerve root fibers in the wall of the cyst or in to the incidentally found lesion. In many hospitals, the its cavity. Tarlov cysts are defined as CSF-filled saccular introduction of the picture archiving and communication lesions located in the extradural space of the sacral spinal system has led to an increasing number of incidental le- canal and are formed within the nerve root sheath at the sion discoveries.34 Patients now undergo MR imaging of . Cyst walls are composed of peri- the lumbar spine for various symptoms including back neurium and neural tissue. The cysts show membranous pain, , and neurological dysfunction. These MR tissue walls, with peripheral nerve fibers and ganglionic imaging studies of the lumbosacral spine often result in cells embedded into connective tissue.6,21 Voyadzis et al.33 the discovery of benign lesions. The most common in- found nerve fibers in the walls of the cysts in 75% of their cidental lumbosacral lesions are vertebral hemangiomas, cases. perineural cysts, fibrolipomas, synovial cysts, and sacral Cysts created by the dilated sheaths usually have meningoceles.23 microconnections to the subarachnoid space. However, One recent report indicates an 8.4% rate of incidental when pulsatile and hydrodynamic forces of CSF, through findings on lumbar spine MR imaging for suspected disc a ball-valve mechanism, cause these perineural cysts to herniation or lumbar stenosis.23 The prevalence of differ- fill and expand in size, they can begin to compress neigh- ent incidental findings in the lumbosacral spine seems to boring nerve fibers, resulting in neurological symptoms.18 vary significantly for age and sex. Some authors describe The ball-valve theory has been previously postulated as a 1%–5% incidence of TCs (Table 3).23,26,33 The incidence the reason why some large TCs cause symptoms that does not significantly differ between sexes but is more progress, whereas others cause only mild symptoms. prevalent in younger people: 4.0% in people less than 50 The so-called un-valved cysts (that is, those in which

TABLE 1: Literature review of series in which patient were surgically treated for TCs*

No. of Follow-Up % w/ Symptom Authors & Year Patients (mos) Surgical Technique Improvement Complications Caspar et al., 2003 15 6–108 SL + CR 87 none Guo et al., 2007 11 3–156 SL + CR + CI + FG + MP + Gelfoam 82 CSF leak, bladder dysfunction Kunz et al., 1999 8 24–96 NA 38 NA Langdown et al., 2005 3 6–12 SL + CR + MP 100 CSF leak, cauda syndrome by MP displace- ment Lee et al., 2004 2 6 1) CT-NA; 2) SL + CR + NL + CI 100 none Mummaneni et al., 2000 8 1–73 SL + CF + CI 88 none Murphy et al., 2011 122 NA 1) CT-NA & FI; 2) SL + CF + FP 1) 65†; 2) 63 transient urticaria Neulen et al., 2011 13 2.5–20 SL + CF + CR 54‡ CSF leak Park et al., 2008 2 NA SL + CR + FG + Gelfoam 100 none Sajko et al., 2009 3 NA CF + FG 100 none Tanaka et al., 2006 12 6–52 SL + CR + CI 71 prostatitis, PF bleeding Voyadzis et al., 2001 10 3–136 SL + CR + NL + FG + Gelfoam 70 Zhang et al., 2007 31 10–28 CT-NA & FI 80 fever,

* CF = cyst fenestration; CI = cyst imbrication; CR = cyst resection; CT-NA & FI = CT-guided needle aspiration and fibrin injection; FG = fibrin glue; FP = fat packing; MP = muscle patch; NA = not available; NL = (cyst) neck ligation; PF = posterior fossa; SL = sacral laminectomy. † In 23% of improved patients, symptoms returned on average 7.3 months following the initial procedure. ‡ Includes 1 patient with initial improvement and pain relapse 2 months after surgery.

2 Neurosurg Focus / Volume 31 / December 2011

Unauthenticated | Downloaded 09/27/21 09:59 AM UTC Tarlov cysts

TABLE 2: Case reports of surgically treated TCs

Symptoms Authors & Year Follow-Up (mos) Surgical Technique Improvement Complications Acosta et al., 2003 3 SL + CF + CR; FG + myofascial flap yes none Chaiyabud & Suwanpratheep, 2006 9 SL + CF yes none Hsu & Kuo, 2010 0.3 NL + FG + fat yes none Ishii et al., 2007 NA SL + NL + root section yes none Kayali et al., 2003 3 SL + CF + CI yes none Jain et al., 2002 NA SL + CR yes none Ju et al., 2009 6 cyst-subarachnoid shunt yes none Landers & Seex, 2002 6 CT-NA + SL + CI + FG yes meningocele Morio et al., 2001 24 cyst-subarachnoid shunt yes none Prashad et al., 2007 9 SL + CR + CF yes none Singh et al., 2009 12 SL + CR yes none

CSF can freely circulate in and out) are unlikely to cause Neuroimaging symptoms. On the other hand, lesions in which CSF ac- Magnetic resonance imaging is the gold-standard cumulates under gravitational pressure within the cyst in modality to detect sacral perineural cysts, to study their a valve-like way enlarge over time and can cause neural relationship with surrounding structures, and to plan sur- structure compression. The cysts are often multiple and gical treatment (when indicated). On MR imaging, the can erode surrounding sacral bone structures, causing cyst is a fluid-filled lesion showing a low signal on T1- irritation of the periosteal pain fibers21 and insufficiency 27 weighted images and high signal on T2-weighted images fractures. (that is, CSF signal) (Fig. 1). Scalloping of the sacral ver- Several hypotheses have been proposed to explain tebral body or posterior arches, caused by a slow increase the etiologies of perineural cysts in the sacral region. The in size of the cysts, can be seen on both MR and CT im- most important ones include of nerve root ages. Computed tomography scans can also be useful for cysts followed by inoculation of fluid, arachnoidal prolif- the treatment of the cysts by percutaneous aspiration, as eration along and around the sacral nerve root, breakage 15,19,26 of venous drainage in the perineurium and epineurium has been reported. Plain radiographs usually appear secondary to hemosiderin deposition after trauma, and normal, but they may reveal characteristic bone erosion developmental or congenital origin.6,18,33 Some authors of the or neural foramina. have reported a 40% rate of association with trauma.22 Myelography is a more invasive imaging modality The presence of nerve fibers, ganglionic cells, or signs that can have a role in detecting communication of the of old microhemorrhages in the form of hemosiderin has TC with the subarachnoid space. The communication be- been related to fact that TCs may be in different stages of tween the thecal sac and cysts functions as a valve. Thus, evolution.24,33 a delayed filling after intrathecal contrast administration Based on their observations of 2 surgically treated helps to determine the “valved cysts,” which are more cases of symptomatic sacral TCs in one family, Park et likely to produce symptoms. al.24 suggested that a genetic origin could be an important factor involved in the pathogenesis of TCs. Surgical Indications and Treatment Options Because TCs are often incidental, the finding can Clinical Presentation lead to 3 different diagnostic options: 1) another pathol- Most people with TCs are asymptomatic. The report- ogy is causing symptoms (that is, the TC is not related ed incidence of symptomatic TCs is approximately 1% to symptoms); 2) another pathology is probably causing or less (Table 3).14,23,26 The clinical presentation of symp- symptoms, but the TC could be a secondary cause of the tomatic cysts is nonspecific and similar to other disc or symptoms; or 3) the TC is the only pathological finding lumbar spine pathological entities. Symptoms that can be that can explain the symptoms. Obviously, this requires correlated to TCs include low-back pain, sacrococcygeal pain, perineal pain, sacral nerve root pain (sciatic pain), TABLE 3: Incidence of TCs in patients undergoing MR imaging leg weakness, neurogenic claudication, bowel and blad- for lumbosacral symptoms der dysfunction, and sexual dysfunction.1,6,35 The onset of symptoms can be sudden or gradual. Usually, patients report that their symptoms are exacerbated by coughing, No. of Incidence of Incidence of standing, and change of position. This can be explained Authors & Year Patients TC (%) Symptomatic TC (%) by the increase in CSF pressure, leading to an activation Paulsen et al., 1994 500 23 (4.6) 5 (1.0) of the aforementioned ball-valve mechanism. Symptom- Langdown et al., 2005 3535 54 (1.5 ) 7 (0.2) atic relief can usually be achieved by recumbent position- ing. Park et al., 2011 1268 27 (2.1) 0 (0)

Neurosurg Focus / Volume 31 / December 2011 3

Unauthenticated | Downloaded 09/27/21 09:59 AM UTC C. Lucantoni et al.

Symptomatic relief was obtained with oral steroids in a patient with a cervical (C-6) perineural cyst and in a pa- tient with an L-5 perineural cyst, also obtaining in the latter case shrinkage of the cyst after epidural steroid injections. Langdown et al.14 reported on 3 patients with symptomatic TCs who refused surgery and were able to tolerate their fluctuating symptoms. They did not describe the alternative treatment recommended to these patients, but in a median radiological follow-up of 3.3 years, no changes in cyst features were documented. Reports in the literature thus far on different surgical options for TC can be divided in 2 subgroups: 1) diver- sion of CSF flow (CT-guided percutaneous aspiration and modifications, lumboperitoneal shunt, or cystosubarach- noid shunt); or 2) direct microsurgical approach. The first reports on a percutaneous CT-guided sacral meningeal cyst aspiration described this technique as a potential treatment to alleviate symptoms,26 but compli- cations such as the tendency of the cysts to reaccumulate fluid and cause symptoms were noted. Subsequently, some authors suggested the use of percutaneous CT-guided fi- brin glue injections in sacral meningeal cysts, reporting no recurrence of the cyst after 6 months, but there were 3 (of 4) cases of postprocedural aseptic meningitis.25 In a more recent study of 31 patients treated with CT-guided percutaneous fibrin glue injections with or without previ- ous cyst aspiration, the authors described an 80% symp- tom improvement.35 There was statistically significant back and leg pain reduction and no recurrence of the treated cysts for during a mean follow-up of 23 months. Two cases of transitory aseptic meningitis were reported. Murphy et al.19 retrospectively described a larger series of 122 patients treated by CT-guided fibrin glue cyst in- jection. This group showed symptomatic improvement in Fig. 1. Sagittal T2-weighted MR image showing an example of a 65% of patients, 23% experienced symptom recurrence small TC at S-2. after 7 months. The authors recommended percutaneous CT-guided aspiration of the cyst and fibrin glue injection one to carefully evaluate the correlation between clinical as a first treatment option, reserving open surgery only and radiological findings. for patients not candidates for aspiration or for patients in In Option 1, the main goal is treatment of the primary whom this technique was unable to improve symptoms. cause. Some authors have reported cases related to Option Assuming that a slit-like communication exists be- 2, in which TCs can contribute to symptoms by virtue of tween the subarachnoid space and the cyst, functioning their anatomical location, but they cannot be considered as a valve, pressure waves can enhance enlargement of the primary cause because patients have other identified the cyst. Thus, surgical strategies have been proposed pathology. In those cases, surgical treatment of the as- with the aim of decreasing CSF pressure of the cephalad sociated problem (for example, disc prolapse or foraminal thecal sac. Lumboperitoneal shunt implant after a CSF stenosis) can lead to symptomatic improvement.5,14 lumbar drainage test has been proposed as a surgical op- If the first 2 options can be excluded and the TC is tion to lessen the hydrostatic pressure and dampen the considered the cause of patient’s symptoms, treatment CSF pressure waves, decreasing the pressure within the of the cyst is indicated. However, no consensus has been sacral nerve root cyst, as well as compression of the ad- reached on the ideal treatment modality. There are very jacent nerve root. Bartels and van Overbeeke2 reported little published data regarding the natural history of TCs. on 2 patients suffering from back/leg pain treated with a Moreover, none of the available studies report significant lumboperitoneal shunt. Symptom relief was achieved at numbers, and there seems to be no clearly defined criteria a median of 10 months after shunt insertion. This option for surgical or conservative management of symptomatic has been suggested for patients with multiple TCs, when TCs. it is difficult to determine which one is symptomatic. Its Conservative treatment, including medical thera- advantage is also that it avoids direct manipulation of the py (with analgesic and nonsteroidal antiinflammatory cyst by requiring a more technically demanding surgical medications) and physical therapy, is suggested as a first procedure; however, the risks of every shunt procedure, option. Mitra et al.16 described 2 cases of symptomatic such as malfunction or infection, are present.2 In 2 single perineural cysts treated with conservative management. case reports,10,17 the patients underwent placement of cys-

4 Neurosurg Focus / Volume 31 / December 2011

Unauthenticated | Downloaded 09/27/21 09:59 AM UTC Tarlov cysts tosubarachnoid shunts. These systems were implanted et al.21 suggested that a tendency to improve after surgery following a direct surgical approach, aiming to equal- was present in patients with single or multiple perineu- ize the pressure between the thecal sac and the cyst but ral cysts > 1 cm in diameter and with delayed contrast avoiding the risk of cyst wall resection and potential neu- filling on postmyelographic CT scanning. Patients who rological sequelae. The authors reported relief of symp- present with pain exacerbated by both postural changes toms without complication (Table 2). and Valsalva maneuvers are also likely to benefit most Although some authors have not described good from surgery.18 results in association with direct surgical treatment,12 To our knowledge, only 1 study has reported on the several authors have recommended it for selected symp- results of surgical treatment compared with conservative tomatic patients. Numerous strategies of direct surgical management. Kunz et al.12 did not observe significant dif- approaches have been proposed (Table 1). Simple poste- ferences in terms of symptomatic improvement between rior sacral bony decompression has low success rates and the 2 groups (total 16 patients). Due to unfavorable results can have serious complications, such as dural or nerve le- in terms of pain relief observed after surgical treatment, sions.3 Microsurgical excision3,6,18,21,33 consists of a sacral they recommended surgery only for those patients with a laminectomy or laminoplasty31 followed by microsurgical short history and with a neurological deficit.12 resection of the wall of the cyst(s). Care must be taken Unfortunately, all these recommendations are based in preserving nervous fibers of the parental nerve roots, on results obtained from a small number of patients and, which lie directly on the walls of the cyst.3,6 Procedures overall, from retrospective reviews. including cyst imbrication by suturing the walls of the cyst;31 neck ligation7,33 to close communication of the cyst with the subarachnoid space; and cyst fenestration allow- Conclusions ing free communication of the CSF between the thecal 21 Tarlov cysts are usually incidental findings on radio- sac and the cyst have been suggested as different tech- logical examination performed in the lumbosacral spine. 8 nical options. Some authors have proposed excising the A small percentage of these lesions may be symptomatic. cyst and sacrificing the parental root without significant Meticulous care should be taken to clearly define the pa- neurological deficit. tient’s symptoms and correlate them to radiological find- Absorbable gelatin sponge and/or fibrin glue and ings. What Tarlov stated in his seminal article more than muscle or fat patching can be used to fill the cyst cav- 70 years ago still seems to be true today: “The clinical ity and cover the dural defects. Neurological worsening significance of these cysts remains to be determined.”32 due to muscle patch displacement and subsequent cauda The results reported in the literature on the surgical equina syndrome14 has been reported. Leakage of CSF treatment of symptomatic cysts, which can now be per- has been a reported complication in 1 of 11 patients re- formed using different methods, have conflicting results, ported by Guo et al.,6 1 of 3 by Langdown et al.,14 and 1 can be technically demanding and not without significant of 13 by Neulen et al.21 Prolonged lumbar drainage is the complications, and often do not provide lasting benefit. suggested treatment for CSF leakage. Some authors have The best management option must be determined by the recommended routine postoperative lumbar drainage for size and location of the patient’s cyst, as well as the sur- 3–7 days to prevent CSF leakage,3,18 as well as the use of geon’s skillset. intraoperative electrophysiological monitoring to mini- 18 mize damage to the sacral nerve roots during excision. Acknowledgment Despite low rates of cyst recurrence (range 0%– 10%3,6,12,21), different rates of symptomatic improvement The authors thank Holly Wagner for providing editorial assis- have been reported in association with microsurgical tance with the preparation of this manuscript. treatment (Table 1), varying from 38% to 100%. These results should also be correlated to the patient’s preopera- Disclosure tive symptoms. Caspar et al.3 noted an improvement in 87% of patients complaining of radicular pain, 90% of The authors report no conflict of interest concerning the mate- patients with sensory disturbances, and 100% of patients rials or methods used in this study or the findings specified in this paper. No intra- or extramural funding was received to generate this with a motor deficit or bowel/bladder dysfunction. Neulen 21 study. et al. suggested that radicular symptoms are less likely Author contributions to the study and manuscript preparation to benefit from surgery, probably because of the perma- include the following. Conception and design: Park, Lucantoni, nent impairment of the nerve itself, resulting in chronic Valdivia, Maher, La Marca. Acquisition of data: Lucantoni, Than, pain due to deafferentation. Wang. Analysis and interpretation of data: Park, Lucantoni, Than, In statistical terms, the numbers in the present report Wang, Valdivia. Drafting the article: Lucantoni, Than, Wang. Criti- are too small to draw any definitive conclusions. How- cally revising the article: Park, Lucantoni, Than, Valdivia, Maher, La Marca. Reviewed submitted version of manuscript: all authors. ever, several authors have suggested some indications to Study supervision: Park, Maher, La Marca. identify the better responder to surgical treatment. Voy- adzis et al.33 observed that better results were achieved in patients with radicular symptoms or bladder/bowel dysfunction, and patient with cyst diameters exceeding References 1.5 cm. Surgical treatment of multiple cysts, especially 1. Acosta FL Jr, Quinones-Hinojosa A, Schmidt MH, Weinstein those larger than 1.5 cm, has been suggested.6,18 Neulen PR: Diagnosis and management of sacral Tarlov cysts. Case

Neurosurg Focus / Volume 31 / December 2011 5

Unauthenticated | Downloaded 09/27/21 09:59 AM UTC C. Lucantoni et al.

report and review of the literature. Neurosurg Focus 15(2): 20. Nabors MW, Pait TG, Byrd EB, Karim NO, Davis DO, Ko- E15, 2003 brine AI, et al: Updated assessment and current classification 2. Bartels RH, van Overbeeke JJ: Lumbar of spinal meningeal cysts. J Neurosurg 68:366–377, 1988 drainage for symptomatic sacral nerve root cysts: an adjuvant 21. Neulen A, Kantelhardt SR, Pilgram-Pastor SM, Metz I, Rohde diagnostic procedure and/or alternative treatment? Technical V, Giese A: Microsurgical fenestration of perineural cysts to case report. Neurosurgery 40:861–865, 1997 the thecal sac at the level of the distal dural sleeve. Acta Neu- 3. Caspar W, Papavero L, Nabhan A, Loew C, Ahlhelm F: Mi- rochir (Wien) 153:1427–1434, 2011 crosurgical excision of symptomatic sacral perineurial cysts: a 22. Nishiura I, Koyama T, Handa J: Intrasacral perineurial cyst. study of 15 cases. Surg Neurol 59:101–106, 2003 Surg Neurol 23:265–269, 1985 4. Chaiyabud P, Suwanpratheep K: Symptomatic Tarlov cyst: re- 23. Park HJ, Jeon YH, Rho MH, Lee EJ, Park NH, Park SI, et port and review. J Med Assoc Thai 89:1047–1050, 2006 al: Incidental findings of the lumbar spine at MRI during 5. Dimitroulias AP, Stenner RC, Cavanagh PM, Madhavan P, herniated intervertebral disk disease evaluation. AJR Am J Webb PJ: Multiple bilateral sacral perineural cysts unusually R o ­e n t ­g e n o l 196:1151–1155, 2011 distal to the exit foramina. Br J Neurosurg 21:521–522, 2007 24. Park HJ, Kim IS, Lee SW, Son BC: Two cases of symptomatic 6. Guo D, Shu K, Chen R, Ke C, Zhu Y, Lei T: Microsurgical perineural cysts (tarlov cysts) in one family: a case report. J treat­ment of symptomatic sacral perineurial cysts. Neurosur- Korean Neurosurg Soc 44:174–177, 2008 gery 60:1059–1066, 2007 25. Patel MR, Louie W, Rachlin J: Percutaneous fibrin glue thera- 7. Hsu CH, Kuo MF: Unknown case/presacral mass: a presenta- py of meningeal cysts of the sacral spine. AJR Am J Roent- tion of a large Tarlov cyst. Spine (Phila Pa 1976) 35:1412– genol 168:367–370, 1997 1413, 2010 26. Paulsen RD, Call GA, Murtagh FR: Prevalence and percuta- 8. Ishii K, Yuzurihara M, Asamoto S, Doi H, Kubota M: A huge neous drainage of cysts of the sacral nerve root sheath (Tarlov presacral Tarlov cyst. Case report. J Neurosurg Spine 7:259– cysts). AJNR Am J Neuroradiol 15:293–299, 1994 263, 2007 27. Peh WC, Evans NS: Tarlov cysts—another cause of sacral in- 9. Jain SK, Chopra S, Bagaria H, Mathur PP: Sacral perineural sufficiency fractures? Clin Radiol 46:329–330, 1992 cyst presenting as chronic perineal pain: a case report. Neurol 28. Prashad B, Jain AK, Dhammi IK: Tarlov cyst: case report and India 50:514–515, 2002 review of literature. Indian J Orthop 41:401–403, 2007 10. Ju CI, Shin H, Kim SW, Kim HS: Sacral perineural cyst ac- 29. Sajko T, Kovać D, Kudelić N, Kovac L: Symptomatic sacral companying disc herniation. J Korean Neurosurg Soc 45: perineurial (Tarlov) cysts. Coll Antropol 33:1401–1403, 2009 185–187, 2009 30. Singh PK, Singh VK, Azam A, Gupta S: Tarlov cyst and infer- 11. Kayali H, Düz B, Gönül E: Symptomatic sacral Tarlov cyst: tility. J Med 32:191–197, 2009 case report. J Ankara Medical School 25:103–106, 2003 31. Tanaka M, Nakahara S, Ito Y, Nakanishi K, Sugimoto Y, Iku- 12. Kunz U, Mauer UM, Waldbaur H: Lumbosacral extradural ma H, et al: Surgical results of sacral perineural (Tarlov) cysts. arachnoid cysts: diagnostic and indication for surgery. Eur Acta Med Okayama 60:65–70, 2006 Spine J 8:218–222, 1999 32. Tarlov IM: Perineural cysts of the spinal nerve roots. Arch 13. Landers J, Seex K: Sacral perineural cysts: imaging and treat- Neurol Psychiatry 40:1067–1074, 1938 ment options. Br J Neurosurg 16:182–185, 2002 33. Voyadzis JM, Bhargava P, Henderson FC: Tarlov cysts: a study 14. Langdown AJ, Grundy JR, Birch NC: The clinical relevance of 10 cases with review of the literature. J Neurosurg 95 (1 of Tarlov cysts. J Spinal Disord Tech 18:29–33, 2005 Suppl):25–32, 2001 15. Lee JY, Impekoven P, Stenzel W, Löhr M, Ernestus RI, Klug 34. Wagner SC, Morrison WB, Carrino JA, Schweitzer ME, Noth- N: CT-guided percutaneous aspiration of Tarlov cyst as a use- nagel H: Picture archiving and communication system: effect ful diagnostic procedure prior to operative intervention. Acta on reporting of incidental findings. 225:500–505, Neurochir (Wien) 146:667–670, 2004 2002 16. Mitra R, Kirpalani D, Wedemeyer M: Conservative manage- 35. Zhang T, Li Z, Gong W, Sun B, Liu S, Zhang K, et al: Percu- ment of perineural cysts. Spine (Phila Pa 1976) 33:E565– taneous fibrin glue therapy for meningeal cysts of the sacral E568, 2008 spine with or without aspiration of the cerebrospinal fluid. J 17. Morio Y, Nanjo Y, Nagashima H, Minamizaki T, Teshima R: Neu­rosurg Spine 7:145–150, 2007 Sacral cyst managed with cyst-subarachnoid shunt: a techni- cal case report. Spine (Phila Pa 1976) 26:451–453, 2001 18. Mummaneni PV, Pitts LH, McCormack BM, Corroo JM, Manuscript submitted August 15, 2011. Weinstein PR: Microsurgical treatment of symptomatic sacral Accepted September 12, 2011. Tarlov cysts. Neurosurgery 47:74–79, 2000 Address correspondence to: Paul Park, M.D., Department of Neu- 19. Murphy KJ, Nussbaum DA, Schnupp S, Long D: Tarlov cysts: rosurgery, University of Michigan, 1500 East Medical Center Drive, an overlooked clinical problem. Semin Musculoskelet Ra- Room 3552, Taubman Center, Ann Arbor, Michigan 48109-5338. diol 15:163–167, 2011 email: [email protected].

6 Neurosurg Focus / Volume 31 / December 2011

Unauthenticated | Downloaded 09/27/21 09:59 AM UTC