Surgical treatment of sacral perineural cyst--case report

A 67-year-old man presented with persistent penis and scrotum pain due to S-2 and S-3 radiculopathy caused by a sacral perineural cyst. The cyst was treated with microsurgical partial cyst removal and cyst wall imbrication, together with closure of the point through which cerebrospinal fluid (CSF) flowed from the subarachnoid space into the cyst cavity. His pain resolved without recurrence of the cyst or complications. Symptomatic perineural cysts are quite rare. Surgical closure of the point through which CSF flows from the subarachnoid space into the cyst cavity is the most important intervention for symptomatic perineural cysts. If the source of CSF leakage cannot be detected, placement of a cyst-subarachnoid shunt should be considered in addition to partial cyst removal and cyst wall imbrication.     

症状性骶管内囊肿的诊断与治疗

目的：探讨症状性骶管内蛛网膜囊肿的诊断与治疗方法.方法：对12例以骶管内神经受压表现为主,如腰骶部疼痛、下肢痛、会阴部疼痛,鞍区麻木不适,大小便障碍,下肢无力患者,行MRI检查.结合临床症状、体征及MRI表现明确诊断为症状性骶管内囊肿后行手术治疗.手术均在显微镜下操作.对未见明显交通孔的7例中5例行囊壁大部切除后残存囊壁修补缝扎,2例因硬脊膜缺如,无法修补而行囊肿部分切除旷置;5例有交通孔的患者中,2例囊肿大部切除后用肌肉填塞交通孔,2例因交通孔处理困难未作特殊处理,1例囊肿大部切除后,切开交通孔处硬脊膜以扩大交通孔至脑脊液通畅流出,消除交通孔的单向阀门作用.严密缝合切口,术后采取头低臀高俯卧位.结果：骶管内囊肿在MRI上表现为骶管内单发或多发类圆形或椭圆形的软组织影,呈长T1、长T2表现,信号与脑脊液相同.术后2例出现少量皮下积液,加压包扎2～3个月后自行吸收,无1例脑脊液漏.随访3个月～4年6个月,平均18.3个月,症状完全缓解8例,部分缓解3例,1例3个月后症状复发,MRI检查示囊肿较术前轻微扩大,未再次手术.结论：MRI检查是正确诊断骶管内蛛网膜囊肿的有力手段,伴有临床症状、体征者应考虑手术治疗.对囊肿的处理以囊肿大部切除为主,严密缝合切口各层及术后合理体位可以有效防止并发症的发生.     

Clinical characteristics and surgical outcomes of spinal intramedullary ependymal cysts

Object

Intramedullary ependymal cysts are exceedingly rare lesions, and have been previously reported in the literature as case reports. The aim of this study was to discuss the clinical presentation and the outcomes of microsurgery for these benign lesions.

Methods

The authors retrospectively reviewed the records of ten patients who underwent microsurgery for intramedullary ependymal cysts. All patients had preoperative and postoperative magnetic resonance imaging. The surgical treatment included gross total resection and biopsy plus a cyst-subarachnoid shunt. The diagnosis of intramedullary ependymal cysts was based on radiological and pathological criteria. All patients were followed up, with a mean duration of 47.6 months.

Results

Intramedullary ependymal cysts were hypointense on T1-weighted images and hyperintense on T2-weighted images. Contrast-enhanced T1-weighted images showed no enhancement. Gross total resection was achieved in one case. Biopsy of the cyst wall plus cyst-subarachnoid shunt placement was achieved in nine cases. Long-term neurological function was improved in eight patients. No recurrence was observed on magnetic resonance imaging.

Conclusions

Ependymal cysts should be considered in the differential diagnosis of intramedullary cysts. For symptomatic patients, early surgery should be performed before neurological deficits deteriorate. Complete decompression and cyst-subarachnoid shunt placement is the optimal treatment and the outcome may be favorable.     

Surgical evaluation and management of symptomatic lumbosacral meningeal cysts

Sacral meningeal cysts are a fairly common finding in the workup of sciatica. In most instances, a cyst causes no symptoms. Occasionally, a symptomatic sacral cyst may present with chronic low back pain (radiculopathy), sensory loss in sacral dermatomes, perineal pain, or bowel or bladder dysfunction. Compared with computed tomography, magnetic resonance imaging shows meningeal cysts more often and allows better localization of sacral cysts. In this article, we present clinical guidelines that may be used to distinguish symptomatic cysts from asymptomatic cysts. We conclude that surgical treatment of a symptomatic cyst may include laminectomy with fenestration and imbrication of the cyst--or percutaneous treatment methods. Surgery for sacral meningeal cysts can lead to successful improvement of pain and function in activities of daily living in more than 80% of cases.     

Operative treatment of symptomatic nerve root cysts]

AIM OF THE STUDY: Nerve root cysts are often asymptomatic and show a predilective manifestation for the lumbo-sacral spine. Depending on their size and the anatomic relationship to the nerve roots they may cause symptoms such as pain or even neurological deficits. From the therapeutical point of view, different moldalities of intervention are controversially discussed because the clinical importance of this entity is still unclear. There are curative as well as symptomatic therapeutic options. The curative therapy includes surgical excision of the cyst and duraplasty whereas the symptomatic therapy is limited to drainage of the cyst. The purpose of this study was to evaluate the role of surgical excision of the cyst with duraplasty using microsurgical techniques. METHOD: This study included 13 patients who suffered from pain and neurological deficits with myelographically and MRI proven sacral nerve root cysts. All patients underwent surgery for cyst excision plus duraplasty. RESULTS: Clinical symptoms such as pain and sensory deficits significantly improved in all patients postoperatively. 85 % of the patients showed a full recovery from the previously existing radicular pain and motoric as well as sensory deficits. All patients reported a significant improvement of their preoperative loss in muscle strength. CONCLUSION: Surgical excision combined with duraplasty using microsurgical techniques has proven to be the method of choice in the treatment of symptomatic sacral nerve root cysts.     

Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases

BACKGROUND: The widespread use of magnetic resonance imaging (MRI), now the first line investigation for back and leg pain, reveals cystic sacral lesions more often than myelography did in the past. There is agreement that symptomatic perineurial sacral cysts should be treated surgically. However, it is still debated whether the preference should be given to the curative option, consisting of excision of the cyst with duraplasty, or to drainage of the cyst to relieve symptoms. In this retrospective study the efficacy of microsurgical cyst resection with duraplasty is evaluated. METHODS: In 15 patients presenting with pain and neurologic deficits, myelography and/or MRI detected sacral cysts. The clinical features suggested that the space-occupying lesions caused the disturbances. Microsurgical excision of the cyst along with duraplasty or plication of the cyst wall was performed in all the cases. Postoperative care included bed rest and CSF drainage for several days. RESULTS: In 13 out of 15 patients the preoperative radicular pain disappeared after surgery. The 2 patients with motor deficits and the 6 patients with bladder dysfunction recovered completely. In all except 1 of the 10 patients complaining of sensory disturbances a significant improvement was achieved. No complications were observed. CONCLUSION: Microsurgical excision of the cyst combined with duraplasty or plication of the cyst wall is an effective and safe treatment of symptomatic sacral cysts and, in the view of the authors, the method of choice.     

Diagnosis and surgical strategy for sacral meningeal cysts with check-valve mechanism: technical note

Objective

There is agreement that symptomatic sacral meningeal cysts with a check-valve mechanism and/or large cysts representing space-occupying lesions should be treated surgically. This study investigated factors indicating a need for surgical intervention and surgical techniques for sacral meningeal cysts with a check-valve mechanism.

Methods

In ten patients presenting with sciatica and neurological deficits, myelography, computed tomography (CT) myelography, and magnetic resonance imaging (MR imaging) detected sacral meningeal cysts with a check-valve mechanism. One patient had two primary cysts. Ten cysts were type 2 and one cyst was type 1. Nine of the ten patients had not undergone previous surgery, while the remaining case involved recurrent cyst. For the seven patients with normal (i.e., not huge or recurrent) type 2 cysts and no previous surgery (eight cysts), suture after collapse of the cyst wall was performed. For the recurrent type 2 cyst, duraplasty and suture with collapse of the cyst wall were performed to eliminate the check-valve mechanism. For the remaining type 2 cyst, a primary root was sacrificed because of the huge size of the cyst. For the type 1 cyst, the neck of the cyst was ligated.

Results

In all cases, chief complaints disappeared immediately postoperatively and no deterioration of clinical symptoms has been seen after a mean follow-up of 27 months.

Conclusions

The presence or absence of a check-valve mechanism is very important in determining the need for surgical intervention for sacral meningeal cysts.     

Infantile arachnoid cyst compressing the sacral nerve root associated with spina bifida and lipoma--case report

A 2-year-old boy presented with a rare sacral arachnoid cyst manifesting as gait disturbance. Neuroimaging revealed an intradural cyst in the sacral nerve root sheath associated with spina bifida occulta and a lipoma at the same level. At surgery, the conus medullaris was situated at the L-1 level and not tethered. The highly pressurized arachnoid cyst had exposed the dural sheath of the left S-2 nerve root and compressed the adjacent nerves. An S-2 nerve root pierced through the cyst. There was no communication between the cyst and spinal arachnoid space. We thought the one-way valve mechanism had contributed to the cyst enlargement and the nerve compression. Radical resection of the cyst was not attempted. A cyst-subarachnoid shunt was placed to release the intracystic pressure. Postoperatively, his gait disturbance improved and no deterioration occurred during the 4-year follow up. Both tethered cord syndrome and sacral arachnoid cyst in the nerve root sheath should be considered in pediatric progressive gait disturbance. Cyst-subarachnoid shunt is an alternative method to cyst resection or fenestration to achieve neurological improvement.     

CT-guided percutaneous aspiration of Tarlov cyst as a useful diagnostic procedure prior to operative intervention

Summary Tarlov or perineural cysts are lesions of the nerve root most often found in the sacral region. Several authors recommend surgical treatment of symptomatic Tarlov cysts. However, successful surgical treatment is dependent on appropriate patient selection.In this article, we report three cases of a sacral perineural cyst, causing sciatic pain, and emphasize the usefulness of CT-guided percutaneous aspiration as an important diagnostic and prognostic procedure prior to definitive operative treatment.     

Neuroepithelial cyst of the lateral ventricle. Clinical features and treatment.

This report concerns eight patients with noncolloid neuroepithelial cyst of the lateral ventricle, including four surgical and four conservative cases. Of the surgical patients, two had headache, one had orbital pain, and one had seizures. In the conservative group there were no symptoms due to the cysts and no changes in computed tomography scan during follow-up for an average of 1.4 years. Magnetic resonance imaging was performed in five cases and showed a cyst with an intensity similar to cerebrospinal fluid, while a cyst membrane was also detected in three cases. Our findings suggest that (1) the majority of symptomatic neuroepithelial cysts in the lateral ventricle are located in the trigone; (2) the cause of symptoms suggestive of obstruction, such as headache, is an isolated ventricle that demonstrates dilatation of the inferior horn on computed tomography and magnetic resonance imaging; (3) the operative indication is obstructive symptoms; and (4) cyst-peritoneal shunt is an effective procedure.     

脊柱外科中脑脊液漏的防治

目的：探讨脊柱外科中较常见并发症脑脊液漏的防治措施。方法：通过回顾性的方法对1995年1月－2000年5月发生的21例脊柱手术后脑脊液漏患者的临床资料进行分析总结。结果：经过术中、术后仔细的处理,21例脑脊液漏患者除1例保守治疗无效于21d再次开放切口修补硬膜外,其余20例患者全部经保守治疗后于6－36d内治愈,无1例发生脑脊髓膜炎;36例腰椎手术脑脊液漏患者随访术后3月－2年内发现形成脑脊液囊肿。结论：通过术中对硬脊膜损伤及时修补或堵塞,术后采取正确的保守治疗措施,绝大多数脑脊液漏均可治愈,极少数保守治疗无效者需开放切口,重新修补硬膜。对晚期形成的交通性或有症状的脑脊液囊肿,可 采取手术切除。     

Abdominal pain secondary to a sacral perineural cyst.

BACKGROUND CONTEXT: Perineural cysts are commonly found in the sacral region and are incidently discovered on imaging studies performed for the evaluation of low back and/or leg pain. PURPOSE: To report on a patient presenting with abdominal pain secondary to a large sacral perineural cyst. STUDY DESIGN/SETTING: Case report. METHODS/PATIENT SAMPLE: A 47-year-old woman was referred to a specialized multidisciplinary spine center with complaints of left lower quadrant abdominal pain and left leg pain. Of significant note was the presence of constipation and urinary frequency over the preceding 8 months. Physical examination was normal. Magnetic resonance imaging of the lumbosacral spine revealed large perineural cysts eroding the sacrum and extending to the pelvis. The presence of abdominal symptoms prompted a neurosurgical consultation. However, after considering the possible risks associated with the surgical procedure, the patient opted to follow the nonsurgical route. RESULT AND CONCLUSIONS: Although commonly visualized, sacral perineural cysts are rarely symptomatic. When symptomatic, it may be secondary to its size and location. Presence of abdominal pain in a patient with back and/or leg pain should prompt the evaluation of the lumbosacral spine.     

骶管内蛛网膜囊肿的外科治疗

目的 :探讨骶管内蛛网膜囊肿的诊断及治疗方法。方法 :2 3例骶管内蛛网膜囊肿病人行椎板减压后 ,对囊肿的处理有 3种方法 :13例行囊肿大部分切除后 ,重新缝合残余的囊肿以包绕囊内神经根 ;8例囊肿大部分切除后用肌肉填塞交通孔 ;2例囊肿切开旷置。平均随访 3 0 2个月 ,观察疗效。并对其临床表现 ,手术中的病理特点 ,手术后的并发症 ,以及X线片 ,CT ,CTM ,MRI等影像学资料进行分析。结果 :MRI可清楚显示囊肿呈长T1及T2信号 ,信号强度与脑脊液一致。临床症状以骶管内神经受压表现为主 ,囊肿与硬膜囊一般有交通孔。囊肿切除后重新缝合包绕神经组与囊肿切除肌肉填塞组优良率并无统计学差异。术后并发症有皮肤糜烂和颅内感染。结论 :MRI是最好的影像学诊断方法 ;骶管内蛛网膜囊肿的发生是由于先天的硬膜缺隐所致。对囊肿的处理以囊肿切除 ,肌肉填塞封堵交通孔最为合理。术后不宜放引流及平卧。     

Sacral perineural cyst--report of a case

The presence of cysts within the sacral spinal canal, so-called sacral cysts, is described in literature. These include 'sacral perineural cyst', 'sacral extradural cyst', 'occult intrasacral meningocele' and 'anterior sacral meningocele'. Sacral perineural cyst in these cystic disorders was first described as an incidental autopsy finding by Tarlov in 1938. Since then, several reports have been made describing the sign and symptom, neurological findings, roentgenographic diagnosis and cause and origin of the sacral perineural cysts, although many problems are not yet solved satisfactorily. This cyst occurs on the extradural components of sacral or coccygeal nerve roots. Although most are asymptomatic, these occasionally cause low back pain, sciatic and sacrococcygeal pain, sensory and motor disturbance in the lower extremities, and urinary dysfunction, which symptoms are similar to those brought on by lumbar disc herniation. In 1948, Tarlov reported a case of sciatic pain due to a perineural cyst, the removal of which relieved the symptoms. Symptoms occur because adjacent nerve roots are impinged upon by the thin-walled, fluid-filled cysts, which are formed in a space between the endoneurium and the perineurium. Microscopically, the cyst walls consist of peripheral nerve fibers or ganglionic cells covered with meningeal epithelium. Communication of the cyst with subarachnoid cerebrospinal fluid may be poor, but myelogram and CT myelogram demonstrate the cysts filling with contrast media. With the advent of magnetic resonance imaging (MRI), imaging of the sacral perineural cysts has improved. Recently we had the opportunity to evaluate a patient in whom perineural cysts had caused considerable erosion of the sacrum.(ABSTRACT TRUNCATED AT 250 WORDS)     

骶管内蛛网膜囊肿的MRI表现及诊断价值

目的 探讨骶管内蛛网膜囊肿的MRI特点及其诊断价值.方法 28例骶管内蛛网膜囊肿经手术病理证实.其中其中男19例,女9例,年龄16～70岁,平均41.6岁.所有病例均行MR检查.结果 囊肿位于骶管内,呈卵圆形、不规则形、串珠形.囊肿境界清楚,囊壁薄,囊液信号与脑脊液信号相似,T1WI囊液呈低信号,T2WI囊液呈高信号,其中4例囊肿内可见细条状神经根影,6例增强扫描囊液、囊壁无强化.结论 MRI是最好的影像学诊断方法;骶管内蛛网膜囊肿的发生,主要是先天的硬膜缺陷所致.     

卵巢子宫内膜异位囊肿术后盆腔囊性包块分析

目的 探讨卵巢子宫内膜异位囊肿术后异位囊肿的复发和盆腔包裹积液发生的规律,以及合理有效的治疗方案.方法 比较两者发生的时间、手术范围,与年龄、服药、CA125的关系,以及影像学的特征.采用阴道超声引导下穿刺治疗,并就其囊液进行分析.结果 术后1～6月内,盆腔包裹积液发生率为41.7%（10/24）,没有发生卵巢子宫内膜异位囊肿复发,两者相比（P〈0.001）差异有统计学意义.术后18月以上出现的囊肿中,卵巢子宫内膜异位囊肿居多,发生率为40%（12/30）两者的发生率相比（P〈0.05）,差异有统计学意义.结论 子宫内膜异位症术后盆腔包裹积液出现一般早于卵巢子宫内膜异位囊肿的复发,且这种囊肿可以通过阴道超声进行介入治疗.     

骶管内蛛网膜囊肿的外科治疗

目的探讨骶管内蛛网膜囊肿的诊断及治疗方法。方法23例骶管内蛛网膜囊肿患者行椎板减压术后,分别对囊肿进行处理。13例行囊肿大部切除后,重新缝合残余部分以包绕囊内神经根;8例囊肿大部切除后用肌肉填塞交通孔;2例囊肿切开旷置。随访时间3个月～11年2个月,平均30.2个月,观察疗效,并对其临床表现,术中的病理特点,术后并发症,以及X线片、CT、CTM、MRI等影像学资料进行分析。结果MRI可清晰地显示囊肿呈长T1及T2信号,信号强度与脑脊液一致。临床症状以骶管内神经受压表现为主,囊肿与硬膜囊一般有交通孔。囊肿切除后重新缝合包绕神经组与囊肿切除肌肉填塞组优良率并无统计学差异。术后并发症有皮肤糜烂和颅内感染。结论骶管内蛛网膜囊肿的发生是由于先天性硬脊膜缺陷所致。对囊肿的处理以囊肿切除、肌肉填塞封堵交通孔最为合理。术后以不放引流条及忌平卧为宜。     

Endoscopic removal of cysticercal cysts within the fourth ventricle. Technical note.

There is no consensus as to the optimum management of patients who harbor cysticercal cysts within the fourth ventricle. Compared with the alternative treatment options of anthelmintic medication and/or cerebrospinal fluid shunt placement, the surgical removal of the cyst has the advantage of eliminating the inflammatory nidus and potentially obviating the need for a complication-prone shunt. Here, an endoscopic surgical approach is described and proposed as an alternative to the standard suboccipital craniectomy for removal of cysticercal cysts within the fourth ventricle. A retrospective analysis of five consecutive endoscopic cases was performed. Endoscopic removal of all cysts within the fourth ventricle was successful in each case. The mean length of operative time was short and blood loss was insignificant. The endoscopic procedure was safe and associated with minimal postoperative discomfort in most patients. In properly selected patients, the endoscopic removal of cysticercal cysts located within the fourth ventricle should be considered as the primary treatment for this condition.     

Endoscopic and endoscope-assisted neurosurgical treatment of suprasellar arachnoidal cysts (Mickey Mouse cysts).

Suprasellar arachnoid cysts represent less than 10% of all intracranial arachnoid cysts. Some of them may be quiescent throughout life, some may become symptomatic as they become enlarged and some disappear spontaneously. In this study we discuss the surgical strategies for endoscopic and endoscope-assisted treatment of suprasellar (Mickey Mouse) cysts and analyze the clinical results and experience collected over some years in our department upon doing these operations routinely. Between December 1996 and December 2003, 13 patients (7 female and 6 male patients), mean age 29 years, underwent endoscopic or endoscope-assisted procedures for suprasellar cysts at our department. The indication for surgical treatment was based on the neurological and radiological examination. The goal of surgical treatment was to normalize the cerebrospinal fluid flow and to establish a communication, permanently, between the cyst cavity and the intraventricular or/and subarachnoid space. Intraoperatively we observed in all patients no complications. Seven of 13 patients, who had received shunt systems in other hospitals before admission in our clinic, remained shunt-free postoperatively. Overall clinical improvement was achieved for a long period of between 6 and 74 months in 11 patients, one developed a psychomotor disturbance and another one, who had epilepsy before treatment, was unchanged postoperatively. Our data suggest that suprasellar cysts are well treated by endoscopic or endoscope-assisted procedures with good clinical outcome and low surgical morbidity.     

骶管内囊肿的诊断及其发生机制的探讨

目的：探讨骶管内蛛网膜囊肿的影像学特点发生机制。方法：观察24例手术证实的骶管内蛛网膜囊肿病人的X线片、CT、造影后CT、MRI等影像资料，分析其临床特点及术中的病理特点。结果：5例X线片显示骶骨侵蚀性改变，5例CT显示骶骨侵蚀性改变及骶管内囊肿，1例造影后CT囊肿内造影剂显影，22例MRI显示囊肿呈长T1及T2信号，信号强度与脑脊液一致。临床症状以骶管内神经受压表现为主，囊肿与硬膜囊一般有交通孔。交通孔为瓣膜样。结论：MRI是最好的影像学诊断方法；骶管内蛛网膜囊肿的发生是由于先天的硬膜缺陷所致；瓣膜样交通孔是病程进展的结果。