Surgical indications for Tarlov cyst. Case presentation.

Abstract

Introduction: Tarlov cysts, also known as perineural cysts, are defined as extradural spinal meningeal cysts containing nerve root fibers, filled with cerebrospinal fluid (CSF) and located between the layers of the perineurium and endoneurium near the dorsal root ganglion. They are frequently located in the S1-S5 region of the spinal canal. Only 1-15.6% are symptomatic. Symptomatic cases manifest as lumbar or radicular pain according to the affected dermatome, which may or may not be accompanied by motor weakness. Rarely, cysts can manifest as cauda equina syndrome or myelopathy if located above the conus medullaris. The literature reports few cases treated surgically using different approaches, and there needs to be a consensus on the best treatment for these symptomatic cysts.

Case Report: A 59-year-old woman with Sjogren's syndrome and irritable bowel syndrome presented with a 2-year history of progressively worsening sacral pain. She had undergone outpatient medical treatment and anti-inflammatory physiotherapy without improvement. In the past two months, the pain has become incapacitating, radiating to the right lower limb with paresthesia and hypoesthesia in the S1 distribution, along with claudication, difficulty urinating, and chronic constipation. Imaging studies revealed an intradural space-occupying lesion from S1 to S4 with a cystic appearance. The patient underwent surgery in the sacral region to treat the Tarlov cysts, which included incision, exposure, access to the cysts, removal of the bony roof, identification and opening of the cysts, filling and closure, and a leak test.

Conclusion: Surgical treatment of Tarlov cysts demonstrates promising results in symptom relief and functional improvement in selected patients with severe symptoms that do not respond to conservative management. However, the inherent risks, potential complications, and possible recurrences must be carefully evaluated by the medical team and discussed with the patient before making a surgical decision.