Microsurgical treatment of symptomatic sacral tarlov cysts

OBJECTIVE: Providing relief of symptomatic radiculopathy resulting from sac ral perineural cysts has proven difficult. Our goal was to improve the trea tment of these cysts with microsurgical cyst fenestration and imbrication, while minimizing functional damage to neural tissues. METHODS: We retrospectively reviewed the records for eight adult patients w ith large (2-3-cm) sacral perineural cysts who were treated at the Universi ty of California, San Francisco, between October 1992 and April 1999. All p atients presented with radicular pain that was refractory to medical treatm ent. Three patients also reported urinary incontinence. We performed sacral laminectomies with microsurgical cyst fenestration and cyst imbrication fo r all patients, using intraoperative electromyography to minimize damage to the sacral nerve roots. For seven patients, we reinforced the closures wit h epidural fat or muscle grafts and fibrin glue application. For five patie nts with cysts that communicated with the subarachnoid space in computed to mographic myelograms, we placed lumbar drains for cerebrospinal fluid diver sion for several days postoperatively. We assessed outcomes, using telephon e questionnaires and periodic postoperative physical examinations, 3 to 73 months after surgery. RESULTS: After surgery, radicular pain improved markedly for four patients and moderately for three patients; one patient with initial improvement exp erienced pain recurrence 9 months later. Bladder control improved markedly for two of the three patients with bladder dysfunction. There were no cereb rospinal fluid leaks and no new postoperative neurological deficits. CONCLUSION: Microsurgical cyst fenestration and imbrication are effective t reatments for long-term relief of refractory painful radiculopathy and urin ary incontinence associated with large sacral perineural cysts.