Surgical Treatment of Symptomatic Sacral Cysts
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This document reports on 3 cases of symptomatic sacral cysts treated with surgical excision and discusses sacral cysts and their treatment options. Sacral cysts are uncommon lesions that can cause low back pain and neurological symptoms. Diagnosis involves imaging like CT myelography or MRI. Surgical intervention includes excision for well-encapsulated cysts to preserve nerve roots or pressure balance procedures for large or multi-lobulated cysts where complete excision is impossible and nerve roots may need sacrificing. Percutaneous procedures are no longer recommended due to high failure and complication rates.
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Surgical Treatment of Symptomatic 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 彰基骨科
- 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 彰基骨科
- 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 • 彰基骨科
- 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 彰基骨科
- 9. Surgical Method • Posterior approach • Laminectomy • Cyst excision • Remnant wall oversewn 彰基骨科
- 10. RESULT • Recover well • No neurological compromise • No recurrence Origin Type Case 1 S2 I Case 2 S2 II Case 3 S1 I 彰基骨科
- 11. RESULT -- Specimen & Pathology -- 彰基骨科
- 12. RESULT -- Specimen & Pathology -- 彰基骨科
- 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 彰基骨科
- 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 彰基骨科
- 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 彰基骨科
- 17. Diagnosis • Plain roentgenography • Myelograms • CT • CT myelogram • MRI 彰基骨科
- 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 彰基骨科
- 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 彰基骨科
- 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 彰基骨科
- 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 彰基骨科