Microsurgical excision of symptomatic sacral perineurial cyst with sacral recapping laminectomy : a case report in technical aspects

Abstract

Perineurial cysts (Tarlov cysts) are lesions of the nerve root that are often observed in the sacral area. There is debate about whether symptomatic perineurial cysts should be treated surgically. We presented three patients with symptomatic perineurial cyst who were treated surgically, and introduced sacral recapping laminectomy. Patients complained of low back pain and hypesthesia on lower extremities. We performed operations with sacral recapping technique for all three. The outcome measure was baseline visual analogue score and post operative follow up magnetic resonance images. All patients were completely relieved of symptoms after operation. Although not sufficient to address controversies, this small case series introduces successful use of a particular surgical technique to treat sacral perineural cyst, with resolution of most symptoms and no sequelae.

Keywords: Laminectomy; Tarlov cysts.

Fig. 1

Preoperative magnetic resonance (MR) T2-weighted image sagittal image (A) showing sacral cyst. Myelogram oblique view (B) and CT-myelogram (C) demonstrates that the cyst is divided into two segments and caused compression of adjacent nerve roots. Intraoperative photograph (D) shows that the large cyst below S1 nerve root is connected with small cyst through small stalk overlying S2 root. Photograph (E) after sacral recapping. Postoperative MR T2-weighted image sagittal image (F) obtained 6 months after surgery demonstrates complete excision of cyst.

Fig. 2

Preoperative magnetic resonance (MR) T2-weighted image sagittal image showing sacral cyst (A). CT-myelogram (B) demonstrates that the cyst caused compression of adjacent nerve roots. Postoperative MR T2-weighted image sagittal image (C) obtained 1 year after surgery demonstratsd complete excision of cyst. Intraoperative photograph (D) shows that the large cyst below S1 nerve root is connected with small cyst through small stalk overlying S2 root. Photograph (E) after sacral recapping.

Fig. 3

Preoperative magnetic resonance (MR) T2-weighted image sagittal image (A) showing sacral cyst. CT-myelogram (B) demonstrates the cyst was filled with contrast media. Intraoperative photograph (C) shows after sacral recapping with miniplates. Postoperative MR T2-weighted image sagittal image (D) obtained 4 months after surgery demonstrated complete excision of cyst.

Fig. 4

The chiseling point of sacral lamina is approximately 3 mm medial to dorsal sacral foramina. Oblique chiseling is helpful when closing (A). The sacral laminae cap is closed using heavy silk 1/0 suture or miniplates (B).