Tarlov Cyst Causing Sacral Insufficiency Fracture

2017 ◽  
Vol 13 (3) ◽  
pp. E4-E7 ◽  
Author(s):  
Ross C. Puffer ◽  
Marcus J. Gates ◽  
William Copeland ◽  
William E. Krauss ◽  
Jeremy Fogelson
Keyword(s):  
Bone Erosion ◽  
Insufficiency Fracture ◽  
Bowel Dysfunction ◽  
Insufficiency Fractures ◽  
Large Area ◽  
Nerve Roots ◽  
Posterior Aspect ◽  
Sacral Insufficiency Fracture ◽  
Tarlov Cyst ◽  
Tarlov Cysts

Abstract BACKGROUND AND IMPORTANCE: Tarlov cysts, also known as perineural cysts, have been described as meningeal dilations of the spinal nerve root sheath between the peri- and endoneurium at the dorsal root ganglion. Most often they are found in the sacrum involving the nerve roots. Normally asymptomatic, they have been reported to present with radiculopathy, paresthesias, and even urinary or bowel dysfunction. Sacral insufficiency has not been a well-documented presentation. CLINICAL PRESENTATION: The patient is a 38-year-old female who started to develop left low back pain and buttock pain that rapidly progressed into severe pain with some radiation down the posterior aspect of her left leg. There was no recent history of spine or pelvic trauma. These symptoms prompted her initial emergency department evaluation, and imaging demonstrated a large Tarlov cyst with an associated sacral insufficiency fracture. She was noted to have a normal neurological examination notable only for an antalgic gait. She was taken to surgery via a posterior approach and the cyst was identified eccentric to the left. The cyst was fenestrated and the nerve roots identified. Given her large area of bone erosion and insufficiency fractures, fixation of the sacroiliac joints was deemed necessary. Fusion was extended to the L5 vertebral body to buttress the fixation. She tolerated the procedure well and was discharged from the hospital on postoperative day 3. CONCLUSION: Tarlov cysts of the sacrum can lead to significant bone erosion and subsequent insufficiency fractures, requiring fenestration and in some cases, complex sacropelvic fixation.

scholarly journals Depressive symptomatology in a female patient with Tarlov cyst

2019 ◽  
Vol 7 ◽  
pp. 2050313X1984469
Author(s):  
Konstantinos Kontoangelos ◽  
Marina Economou ◽  
Vasiliki Katsi ◽  
Charalambos Papageorgiou
Keyword(s):  
Depressive Symptomatology ◽  
Sudden Onset ◽  
Spinal Nerve ◽  
Magnetic Resonance Imaging Scan ◽  
Cystic Dilatation ◽  
Nerve Roots ◽  
Tarlov Cyst ◽  
Tarlov Cysts ◽  
Lumbar Area ◽  
First Time

Introduction: The spinal perineurial cyst is a rare anomaly of the nervous system. It is also known as Tarlov cyst, since it was described for the first time by Isadore M. Tarlov. The pathology is defined as a cystic dilatation between the perineurium and endoneurium of spinal nerve roots, located at the level of the spinal ganglion and filled with cerebrospinal fluid but without communication with the perineurial subarachnoid space. Case report: We present the case of a 56-year-old female who reported sudden onset of symptoms of a depressive symptomatology accompanied with acute pain in the lumbar area. Lumbosacral magnetic resonance imaging scan revealed Tarlov cysts. Discussion: Radiological investigations in patients with depressive symptomatology may be substantial.

scholarly journals Balloon kyphoplasty for treatment of sacral insufficiency fractures

2005 ◽  
Vol 18 (3) ◽  
pp. 1-5 ◽  
Author(s):  
H. Gordon Deen ◽  
Eric W. Nottmeier
Keyword(s):  
Image Guidance ◽  
Elderly Women ◽  
Insufficiency Fracture ◽  
Balloon Kyphoplasty ◽  
Fracture Site ◽  
Intractable Pain ◽  
Insufficiency Fractures ◽  
Sacral Insufficiency Fracture ◽  
Analgesic Medication ◽  
Sacral Insufficiency Fractures

Sacral insufficiency fracture is a painful injury, for which no effective treatment currently exists. The objective of this study was to report on the clinical outcomes and technical aspects of balloon kyphoplasty, which was used in three patients with this injury. Three elderly women with intractable pain from sacral insufficiency fractures were treated with polymethyl methacrylate (PMMA) injections into the sacrum by using a modified balloon kyphoplasty procedure. The visual analog scale pain score improved by four points in each case. Functional status was improved and analgesic medication requirements were decreased in all three patients. There were no complications associated with the procedure. Because of the unique anatomy of the sacrum, it was difficult to monitor instrument placement and PMMA injection by using conventional fluoroscopy. BrainLAB image guidance was used in one case, and was helpful in guiding instrument placement and assuring accurate PMMA deposition at the fracture site. Balloon kyphoplasty may be a treatment alternative in selected patients with sacral insufficiency fractures. BrainLAB image guidance may offer some advantages over conventional fluoroscopy with regard to the monitoring of instrument placement and PMMA injection.

scholarly journals Percutaneous Sacroplasty under Fluoroscopic Guidance Combined with Epidurogram for Sacral Insufficiency Fracture Resulting from Metastatic Tumor and Osteoporosis

2016 ◽  
Vol 3;19 (3;3) ◽  
pp. E473-E480 ◽  
Author(s):  
Hahck Soo Park
Keyword(s):  
Insufficiency Fracture ◽  
Structural Complexity ◽  
Metastatic Tumor ◽  
Mass Effect ◽  
Cement Leakage ◽  
Treatment Modalities ◽  
Fluoroscopic Guidance ◽  
Nerve Roots ◽  
Sacral Insufficiency Fracture ◽  
Chemical Irritants

Sacral insufficiency fracture resulting from a metastatic tumor or an osteoporotic fracture causes severe low back pain and radiating pain mass effect on neural foramen and chemical irritants. Percutaneous sacroplasty is one of the effective treatment modalities for sacral insufficiency fracture and its pain. Because of the structural complexity of the sacrum, obtaining an epidurogram of the S1 and S2 nerve roots before the start of the procedure can be helpful to avoid nerve injury. We present 2 successful cases of percutaneous sacroplasty performed under fluoroscopic guidance. A 65-year-old man with sacral metastasis from stomach cancer and a 52-year-old man with sacral insufficiency fracture were suffering from severe buttock pain and radiating pain. After epidurography of the S1 and S2 nerve roots with steroid and contrast dye, percutaneous sacroplasty with fluoroscopy on the S1 or S2 body and alae was performed on both patients. There was no cement leakage or any other major complications. Both patients experienced significant reduction in pain. Key words: Fluoroscopy-guided, sacral cementoplasty, sacral insufficiency fractures, sacral metastasis

Novel wrapping surgery for symptomatic sacral perineural cysts

2021 ◽  
pp. 1-8
Author(s):  
Taku Sugawara ◽  
Naoki Higashiyama ◽  
Shinya Tamura ◽  
Takuro Endo ◽  
Hiroaki Shimizu
Keyword(s):  
Rating Scale ◽  
Bowel Dysfunction ◽  
Numeric Rating Scale ◽  
Nerve Roots ◽  
Postoperative Mri ◽  
Spine Imaging ◽  
Tarlov Cysts ◽  
Radicular Symptoms ◽  
Bladder Bowel Dysfunction

OBJECTIVE Perineural cysts, also called Tarlov cysts, are dilatations of the nerve root sleeves commonly found in the sacrum. The majority of the cysts are asymptomatic and found incidentally on routine spine imaging. Symptomatic sacral perineural cysts (SPCs) that induce intractable low-back pain, radicular symptoms, and bladder/bowel dysfunction require surgery. However, the surgical strategy for symptomatic SPCs remains controversial. The authors hypothesized that the symptoms were caused by an irritation of the adjacent nerve roots caused by SPCs, and developed a wrapping surgery to treat these cysts. METHODS Seven patients with severe unilateral medial thigh pain and ipsilateral SPCs were included. Preoperative MRI showed that the cysts were severely compressing the adjacent nerve roots in all patients. After a partial laminectomy of the sacrum, the SPCs were punctured and CSF was aspirated to reduce their size, followed by dissection of the adjacent nerve roots from the SPCs. The SPCs were then wrapped with a Gore-Tex membrane to avoid reexpansion. RESULTS All 7 patients experienced substantial relief of their symptoms. The average numeric rating scale pain score was reduced from an average preoperative value of 7.9 to 0.6 postoperatively. Postoperative MRI showed that all cysts were reduced in size and the adjacent nerve roots were decompressed. Regrowth of the treated cysts or recurrence of the symptoms did not occur during the entire follow-up period, which ranged from 39 to 90 months. No complications were noted. CONCLUSIONS The authors’ new wrapping technique was effective in relieving radicular symptoms for patients with symptomatic SPCs. The results suggested that the symptoms stemmed from compression of the adjacent nerve roots caused by the SPCs, and not from the nerve roots in the cysts.

scholarly journals Sacral insufficiency fractures after lumbosacral arthrodesis: salvage lumbopelvic fixation and a proposed management algorithm

2020 ◽  
Vol 33 (2) ◽  
pp. 225-236 ◽  
Author(s):  
Thomas J. Buell ◽  
Ulas Yener ◽  
Tony R. Wang ◽  
Avery L. Buchholz ◽  
Chun-Po Yen ◽  
...  
Keyword(s):  
Insufficiency Fracture ◽  
Sacral Fracture ◽  
Leg Pain ◽  
Insufficiency Fractures ◽  
Lower Extremity Weakness ◽  
Sacral Insufficiency Fracture ◽  
Lumbopelvic Fixation ◽  
Iliac Screws ◽  
Sacral Insufficiency Fractures

OBJECTIVESacral insufficiency fracture after lumbosacral (LS) arthrodesis is an uncommon complication. The objective of this study was to report the authors’ operative experience managing this complication, review pertinent literature, and propose a treatment algorithm.METHODSThe authors analyzed consecutive adult patients treated at their institution from 2009 to 2018. Patients who underwent surgery for sacral insufficiency fractures after posterior instrumented LS arthrodesis were included. PubMed was queried to identify relevant articles detailing management of this complication.RESULTSNine patients with a minimum 6-month follow-up were included (mean age 73 ± 6 years, BMI 30 ± 6 kg/m2, 56% women, mean follow-up 35 months, range 8–96 months). Six patients had osteopenia/osteoporosis (mean dual energy x-ray absorptiometry hip T-score −1.6 ± 0.5) and 3 received treatment. Index LS arthrodesis was performed for spinal stenosis (n = 6), proximal junctional kyphosis (n = 2), degenerative scoliosis (n = 1), and high-grade spondylolisthesis (n = 1). Presenting symptoms of back/leg pain (n = 9) or lower extremity weakness (n = 3) most commonly occurred within 4 weeks of index LS arthrodesis, which prompted CT for fracture diagnosis at a mean of 6 weeks postoperatively. All sacral fractures were adjacent or involved S1 screws and traversed the spinal canal (Denis zone III). H-, U-, or T-type sacral fracture morphology was identified in 7 patients. Most fractures (n = 8) were Roy-Camille type II (anterior displacement with kyphosis). All patients underwent lumbopelvic fixation via a posterior-only approach; mean operative duration and blood loss were 3.3 hours and 850 ml, respectively. Bilateral dual iliac screws were utilized in 8 patients. Back/leg pain and weakness improved postoperatively. Mean sacral fracture anterolisthesis and kyphotic angulation improved (from 8 mm/11° to 4 mm/5°, respectively) and all fractures were healed on radiographic follow-up (mean duration 29 months, range 8–90 months). Two patients underwent revision for rod fractures at 1 and 2 years postoperatively. A literature review found 17 studies describing 87 cases; potential risk factors were osteoporosis, longer fusions, high pelvic incidence (PI), and postoperative PI-to–lumbar lordosis (LL) mismatch.CONCLUSIONSA high index of suspicion is needed to diagnose sacral insufficiency fracture after LS arthrodesis. A trial of conservative management is reasonable for select patients; potential surgical indications include refractory pain, neurological deficit, fracture nonunion with anterolisthesis or kyphotic angulation, L5–S1 pseudarthrosis, and spinopelvic malalignment. Lumbopelvic fixation with iliac screws may be effective salvage treatment to allow fracture healing and symptom improvement. High-risk patients may benefit from prophylactic lumbopelvic fixation at the time of index LS arthrodesis.

Diagnosis and management of sacral Tarlov cysts

2003 ◽  
Vol 15 (2) ◽  
pp. 1-7 ◽  
Author(s):  
Frank L. Acosta ◽  
Alfredo Quinones-Hinojosa ◽  
Meic H. Schmidt ◽  
Philip R. Weinstein
Keyword(s):  
Medical Literature ◽  
Clinical Presentation ◽  
Treatment Strategies ◽  
Spinal Nerve ◽  
Nerve Roots ◽  
Tarlov Cyst ◽  
Root Sheath ◽  
Spinal Subarachnoid Space ◽  
Tarlov Cysts ◽  
Flap Repair

Perineurial (Tarlov) cysts are meningeal dilations of the posterior spinal nerve root sheath that most often affect sacral roots and can cause a progressive painful radiculopathy. Tarlov cysts are most commonly diagnosed by lumbosacral magnetic resonance imaging and can often be demonstrated by computerized tomography myelography to communicate with the spinal subarachnoid space. The cyst can enlarge via a net inflow of cerebrospinal fluid, eventually causing symptoms by distorting, compressing, or stretching adjacent nerve roots. It is generally agreed that asymptomatic Tarlov cysts do not require treatment. When symptomatic, the potential surgery-related benefit and the specific surgical intervention remain controversial. The authors describe the clinical presentation, treatment, and results of surgical cyst fenestration, partial cyst wall resection, and myofascial flap repair and closure in a case of a symptomatic sacral Tarlov cyst. They review the medical literature, describe various theories on the origin and pathogenesis of Tarlov cysts, and assess alternative treatment strategies.

Insufficiency Fractures vs. Low-Energy Pelvic Ring Fractures – Epidemiological, Diagnostic and Therapeutic Characteristics of Fragility Fractures of the Pelvic Ring

2021 ◽  
Author(s):  
Manuel Sterneder ◽  
Patricia Lang ◽  
Hans-Joachim Riesner ◽  
Carsten Hackenbroch ◽  
Benedikt Friemert ◽  
...  
Keyword(s):  
Pelvic Ring ◽  
Diagnostic Testing ◽  
Insufficiency Fracture ◽  
Fragility Fractures ◽  
Relative Increase ◽  
Trauma Centre ◽  
Low Energy ◽  
Insufficiency Fractures ◽  
Type Iv ◽  
Pelvic Ring Fractures

Abstract Background Fragility fractures of the pelvis (FFP) encompass two fracture entities: fracture after low-energy trauma and insufficiency fracture without trauma. It is unclear whether the two subgroups differ in terms of diagnosis and therapy. The aim of this retrospective study was to evaluate insufficiency fractures with regard to defined parameters and to compare specific parameters with the fractures after low-energy trauma. Patients and Methods In the period from 2008 to 2017, 203 patients with FFP were recorded at our clinic (Level 1 Trauma Centre DGU, SAV approval). Of these, 25 had an insufficiency fracture and 178 had a pelvic ring fracture after low-energy trauma. Epidemiological, diagnostic and therapeutic parameters were examined. Results There was a relative increase in the insufficiency fracture within the FFP (2008 – 2009: 5.0% vs. 2015 – 2017: 17.8%). In these patients, osteoporosis tended to be more pronounced than in patients after low-energy trauma (t-value: − 3.66 vs. − 3.13). The diagnosis of insufficiency fractures showed increased use of MRI and DECT (60.9% vs. 26.0%) and a high proportion of type IV fractures after FFP (40.0% vs. 7.9%). In terms of therapy, surgical treatment of the insufficiency fracture was sought more often (68,2% vs. 52,1%), with a tendency towards increased use of combined osteosynthesis procedures (14.3% vs. 7.6%). Conclusion We were able to show that as the number of cases increases, the insufficiency fracture becomes more important within FFP. If these patients tend to have more pronounced osteoporosis, particular attention should be paid to the diagnosis and adequate therapy of the osteoporosis, especially in the case of an insufficiency fracture. In addition to the increased diagnostic testing using MRI and DECT to detect oedema and the increased surgical therapy for this type of fracture, it is also noteworthy that the insufficiency fracture can cause higher-grade fractures after FFP.

Pelvic pain from a giant presacral Tarlov cyst successfully obliterated using aneurysm clips in a patient with Marfan syndrome

2014 ◽  
Vol 21 (5) ◽  
pp. 833-836 ◽  
Author(s):  
Bonnie Wang ◽  
Seong-Jin Moon ◽  
William C. Olivero ◽  
Huan Wang
Keyword(s):  
Marfan Syndrome ◽  
Pelvic Pain ◽  
Surgical Care ◽  
Late Life ◽  
Genital Prolapse ◽  
Cardiovascular Complications ◽  
Tarlov Cyst ◽  
Tarlov Cysts ◽  
Bladder Symptoms ◽  
The Right

Patients with Marfan syndrome used to succumb early in life from cardiovascular complications. With the current rapid advance in medical and surgical care, such patients may now have near-normal longevities. Consequently, rare late-life complications are emerging in these patients and represent challenges to clinicians for their diagnoses and treatments. The authors report a rare case of pelvic pain and genital prolapse from a giant presacral Tarlov cyst in a 67-year-old patient with Marfan syndrome. This 67-year-old Caucasian female presented with progressively severe pelvic pain, intermittent explosive diarrhea, and dysuria. Physical and bimanual examination demonstrated genital prolapse and a nontender, cyst-like mass fixed in the midline. She underwent ultrasound, CT, and eventually MRI evaluations that led to the diagnosis of a giant (6.7 × 6.4 × 6.6 cm) Tarlov cyst originating from the right S-2 nerve root sleeve/sacral foramen with intrapelvic extension. She underwent S1–S2 and S2–S3 laminectomy with obliteration of the Tarlov cyst using aneurysm clips. Postoperatively, her pelvic pain and bowel symptoms resolved and the bladder symptoms improved. The 3-month follow-up CT of abdomen/pelvis demonstrated resolution of the cyst. The present case illustrates that clinicians caring for elderly patients with Marfan syndrome need to increasingly recognize such unusual late-life complications. Also, these large Tarlov cysts can be simply and effectively obliterated with aneurysm clips.

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