Recent article from China June 2012
Symptomatic Sacral Perineural Cysts.China. Pdf.pdf
Symptomatic Sacral Perineural Cysts.China. Pdf.pdf
Jianqiang Xu1, Yongdong Sun1, Xin Huang1, Wenzhong Luan2*
1 Department of Neurosurgery, General Hospital of Fengfeng Group, Handan, China, 2 Department of Neurosurgery, Peking University People’s Hospital, Beijing, China
1 Department of Neurosurgery, General Hospital of Fengfeng Group, Handan, China, 2 Department of Neurosurgery, Peking University People’s Hospital, Beijing, China
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Abstract
Background: There has been no consensus on the optimal treatment of symptomatic sacral perineural cysts. Most previous reports concerning the management methods were either sporadic case reports or a series of limited cases. This study is to further optimize the management for patients with symptomatic sacral perineural cysts by analyzing the outcomes of a cohort of patients who were treated with different strategies. Methods and Findings: We reviewed the outcomes of 15 patients with symptomatic sacral perineural cysts who were managed by three different modalities from 1998 through 2010. Six patients underwent microsurgical cyst fenestration and cyst wall imbrication. Seven patients underwent a modified surgical procedure, during which the cerebrospinal fluid leak aperture was located and repaired. Two patients were treated with medication and physical therapy. Outcomes of the patients were assessed by following up (13 months to 10 years). All of the six patients treated with microsurgical cyst fenestration and cyst wall imbrication experienced complete or substantial relief of their preoperative symptoms. However, the symptoms of one patient reappeared eight months after the operation. Another patient experienced a postoperative cerebrospinal fluid leakage. Six of the seven patients treated with the modified surgical operation experienced complete or substantial resolution of their preoperative symptoms, with only one patient who experienced temporary worsening of his preoperative urine incontinence, which disappeared gradually one month later. No new postoperative neurological deficits, no cerebrospinal fluid leaks and no recurrence were observed in the seven patients. The symptoms of the two patients treated with conservative measures aggravated with time. Conclusions: Microsurgical operation should be a treatment consideration in patients with symptomatic sacral perineural cysts. Furthermore, the surgical procedure with partial cyst removal and aperture repair for prevention of cerebrospinal fluid leakage seemed to be more simple and effective. |
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Citation: Xu J, Sun Y, Huang X, Luan W (2012) Management of Symptomatic Sacral Perineural Cysts. PLoS ONE 7(6): e39958. doi:10.1371/journal.pone.0039958
Editor: Isaac Yang, University of California Los Angeles, United States of America Received January 9, 2012; Accepted May 29, 2012; Published June 29, 2012 Copyright: ß 2012 Xu et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The authors have no support or funding to report. Competing Interests: The authors have declared that no competing interests exist. * E-mail: wzh_luan@163.com |
Introduction
Sacral perineural cysts, which were also termed Tarlov cysts, are collections of cerebrospinal fluid (CSF) between the endoneurium and perineurium of the nerve root sheath near the dorsal root ganglion [1]. These lesions are quite common as an incidental finding on magnetic resonance imaging (MRI), and most of them are asymptomatic [2]. In a series of 500 consecutive MRI scans of the lumbosacral spine, Paulsen et al [3] recorded an incidence of 4.6%, of which 20% were symptomatic. Approximately 1% of sacral perineural cysts become large and cause symptoms related to local compression [3], which should be treated.
There has been no consensus on the optimal treatment of symptomatic sacral perineural cysts since it was first described by Tarlov in 1938 [4]. Many methods have been applied to treat these symptomatic lesions, with variable results. Lumbar CSF drainage, lumboperitoneal shunt, and cyst subarachnoid shunt were not effective as a therapy for symptomatic Tarlov cysts [2], [5], [6]. CT-guided percutaneous aspiration of the cyst with infusion of fibrin glue yielded mixed results, and this method was associated with a high rate of aseptic meningitis [3], [7], [8]. Favorable results have been obtained with microsurgical cyst fenestration and imbrication in several reports [2], [4], [9],
Sacral perineural cysts, which were also termed Tarlov cysts, are collections of cerebrospinal fluid (CSF) between the endoneurium and perineurium of the nerve root sheath near the dorsal root ganglion [1]. These lesions are quite common as an incidental finding on magnetic resonance imaging (MRI), and most of them are asymptomatic [2]. In a series of 500 consecutive MRI scans of the lumbosacral spine, Paulsen et al [3] recorded an incidence of 4.6%, of which 20% were symptomatic. Approximately 1% of sacral perineural cysts become large and cause symptoms related to local compression [3], which should be treated.
There has been no consensus on the optimal treatment of symptomatic sacral perineural cysts since it was first described by Tarlov in 1938 [4]. Many methods have been applied to treat these symptomatic lesions, with variable results. Lumbar CSF drainage, lumboperitoneal shunt, and cyst subarachnoid shunt were not effective as a therapy for symptomatic Tarlov cysts [2], [5], [6]. CT-guided percutaneous aspiration of the cyst with infusion of fibrin glue yielded mixed results, and this method was associated with a high rate of aseptic meningitis [3], [7], [8]. Favorable results have been obtained with microsurgical cyst fenestration and imbrication in several reports [2], [4], [9],
[10].However, there remains some difficulties such as postoper-
ative CSF leakage and the cyst recurrence [2–9].
Most previous reports concerning the management methods were either sporadic case reports or series of limited cases [2], [4], [5], [10–14]. We therefore retrospectively reviewed 15 cases of sacral perineural cysts treated with different methods.
Methods
Between 1998 and 2010, 15 patients (nine men, six women) ranging from 23 to 60 years of age (mean, 37.8 yr) with symptomatic sacral perineural cysts were treated at General Hospital of Fengfeng Group (Table 1),whose follow-up is more than one year. The main symptoms and neurological deficits included low back pain or sacrococcygodynia (n = 12), sacral radiculopathy (n = 7), numbness (n = 6), sensory disturbance of the sacral dermatome (n = 9), claudication (n = 4), and bowel and bladder dysfunction (n = 6). Written informed consent was obtained from each patient. The study was approved by the Medical Ethical Committee of Peking University.
The diagnoses of sacral perineural cysts were confirmed for all patients by magnetic resonance imaging (MRI) studies. Besides the cysts, MRI also demonstrated additional pathological features in
Most previous reports concerning the management methods were either sporadic case reports or series of limited cases [2], [4], [5], [10–14]. We therefore retrospectively reviewed 15 cases of sacral perineural cysts treated with different methods.
Methods
Between 1998 and 2010, 15 patients (nine men, six women) ranging from 23 to 60 years of age (mean, 37.8 yr) with symptomatic sacral perineural cysts were treated at General Hospital of Fengfeng Group (Table 1),whose follow-up is more than one year. The main symptoms and neurological deficits included low back pain or sacrococcygodynia (n = 12), sacral radiculopathy (n = 7), numbness (n = 6), sensory disturbance of the sacral dermatome (n = 9), claudication (n = 4), and bowel and bladder dysfunction (n = 6). Written informed consent was obtained from each patient. The study was approved by the Medical Ethical Committee of Peking University.
The diagnoses of sacral perineural cysts were confirmed for all patients by magnetic resonance imaging (MRI) studies. Besides the cysts, MRI also demonstrated additional pathological features in
PLoS ONE | www.plosone.org 1
June 2012 | Volume 7 | Issue 6 | e39958
Management of Symptomatic Sacral Perineurial Cysts