Sacral cysts

1. Surgical Treatment of
Symptomatic Sacral Cyst ：
Three Cases Report and Literature
Review
JUI-KUO HUNG 洪瑞國 MD&MHA
Department of Orthopaedic Surgery
Changhua Christian Hospital

2. Introduction
-- Sacral Cyst --
• Collection of CSF
– Between the endoneurium and perineurium
• First described by Tarlov in 1938
• 4.6% among general population
– 4th
~ 5th
decade
• 20~25% is symptomatic
– Surgical treatment
– Variable modalities
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3. Introduction
-- Sacral Cyst --

4. Introduction
-- Sacral Cyst --
• Percutaneous aspiration
• Percutaneous fibrin glue therapy
• Simple bony decompression
• Cyst with or without root resection
• I&D with plication of cyst
• Pressure balance procedure
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5. CASE REPORT

6. CASE 1
-- 54 y/o Female --
• Low back pain
– Right sacral root signs
• Plain X-rays
– L4/5 slippage
• MRI
– Cystic lesion around S1
to S3
– T1 ： Low-Signal
– T2 ： High-Signal

7. CASE 2
-- 41 y/o Male --
• Low back pain
– Left L5/sacral root
signs
• Plain X-rays
– S1-S3 rarefaction
• MRI
– Cystic lesion around
L5 to S3
– T1 ： Low-Signal
– T2 ： High-Signal
•
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8. CASE 3
-- 36 y/o Male --
• Low back pain
– Left L5/Sacral root
signs
• Plain X-rays
– No significant finding
• MRI
– Cystic lesion around
S1 to S3
– T1 ： Low-Signal
– T2 ： High-Signal
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9. Surgical Method
• Posterior approach
• Laminectomy
• Cyst excision
• Remnant wall
oversewn
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10. RESULT
• Recover well
• No neurological compromise
• No recurrence
Origin Type
Case 1 S2 I
Case 2 S2 II
Case 3 S1 I
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11. RESULT
-- Specimen & Pathology --
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12. RESULT
-- Specimen & Pathology --
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13. DISCUSSION

14. Sacral Cyst
• First described by Tarlov in 1938
• 4.6% prevalence in general population
– 4th
to 5th
decade
– ♀ ＞♂
– 20% is symptomatic
• Compression S/S
• Low back pain, sensory impairment
• Bladder dysfunction, motor weakness, or
impotence
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15. Diverticula
-- Meninges, arachnoid, nerve root sheath --
Nabor’s classification
• Type I
– Extradural cyst, no
nerve root fibers
• Type II
– Extradural cyst, with
nerve root fibers
• Type III
– Intradural cyst
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16. Diverticula
-- Meninges, arachnoid, nerve root sheath
Goyal’s classification
I Perineural cysts
II Root sleeve dilatations
III Intradural and extradural arachnoid
cysts
IV Traumatic root cysts
V Extradural ganglion cysts
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17. Diagnosis
• Plain roentgenography
• Myelograms
• CT
• CT myelogram
• MRI
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18. Treatment
-- Variable Surgical Modality --
• Percutaneous aspiration
• Percutaneous fibrin glue therapy
• Simple bony decompression
• Cyst with or without root resection
• I&D with plication of cyst
• Pressure balance procedure
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19. Percutaneous Procedure
• Percutaneous fibrin glue therapy
• Percutaneous aspiration
• High failure rate
• High complication rate
– Hemorrhage
– Nerve root injury
Patel MR et al: Percutaneous fibrin glue therapy
of meningeal cysts of the sacral spine. AJR 1997
Paulsen et al: Prevalence and percutaneous drainage of cysts
of the sacral nerve root sheath. Am J Neuroradiol 1994
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20. Surgical Excision
• Cyst excision, fenestration and imbrication
• Variable results
– Recurrence of symptoms
– Surgical complication
• Poor patient selection
• Poor surgical technique
• Previous severe neurological compromise
• Unresectable or multi-lobulated cysts
Voyadzis JM et al: Tarlov cysts: A study of
10 cases. J Neurosurg 2001

21. Pressure Balance Procedure
Lumboperitoneal CSF Shunting
• External drainage
• Lumboperitoneal shunt
• Diagnostic tools
• Therapeutic options
• Posture headache
Bartels et al: Lumbar cerebrospinal fluid
drainage for symptomatic sacral nerve root
cysts. Neurosurgery, 1997

22. Pressure Balance Procedure
Cyst-Subarachnoid Shunting
• Microsurgical technique
• Artificial shunt
– Thecal sac and cyst
• No complication
– Shunt malfunction
– Infection
– Liquorrhea Morio et al: Sacral cyst managed with cyst-
subarachnoid shunt. Spine 2001

23. SUMMARY

24. Sacral cysts
• Uncommon but not rare lesions
• Variable symptoms and signs
• Differential diagnosis
– Sacral radiculopathy
– Sacral pain syndrome
• Diagnostic tools
– CT myelogram
– MRI
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25. Surgical Intervention
• Percutaneous procedure
– No longer used
• Surgical excision and cyst plication
– Well-encapsulated, easily dissected lesion
– Better to preserve nerve roots
• Pressure balance procedure
– Large, multi-lobulated cysts
– Complete excision is impossible
– Nerve root will be sacrified
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