骶管囊肿文献导读：症状性骶管囊肿的囊肿切除和折叠缝合手术：病例分析1例和文献回顾

原文：Case Report

Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature

作者：Sunday Patrick1 Nkwerem, Kiyoshi Ito , Shunsuke Ichinose , Tetsuyoshi Horiuchi , Kazuhiro Hongo2

1.Department of Neurosurgery, Shinshu University School of Medicine, Matsumoto 390‑8621, Japan日本,  2.Department of Neurosurgery, Nnamdi Azikiwe University，Teaching Hospital, Nnewi, Anambra State, Nigeria 尼日利亚

编译：杨敏、沈霖 校对：郑学胜

A 40-year-old male presented with a 3-year history of sensory changes involving the S2-S3 distribution in the right leg (e.g., hypoesthesia without motor weakness or dysuria). The lumbosacral MRI showed a noncontrast enhancing right‑sided cystic mass at the S2–S3 level; it had the same intensity as CSF on both the T1 and T2weighted images [Figure 1]. Coronal fat‑suppressed T2weighted images revealed the mass likely originatedfrom the right S3 nerve root and was additionallycompressing the right S2 nerve root [Figure 2]。

患者男性、40岁，感觉减退3年，主要为右腿的S2-S3骶神经根分布区域，无运动无力或排尿困难。腰骶部MRI显示S2–S3水平的右侧囊性肿块，其强度与T1和T2加权图像上与脑脊液强度相同[图1]。冠状位脂肪抑制T2加权图像显示囊肿可能起源于右侧S3神经根。

A laminoplastic laminotomy was performed at three levels using an ultrasonic bone curette. At surgery, the S3 nerve root was enveloped within cyst wall and the S2 nerve root was clearly compressed [Figure 3a and b]. Partial resection of the cyst wall and imbrication of residual tissue was performed [Figure 3c]. An inlet from the subarachnoid space was identified, and its obliteration was confirmed by a Valsalva maneuver [Figure 3d]. This subarachnoid connection was sealed with adipose tissue and fibrin glue [Figure 3e]. Plication of the cyst wall was performed with nonpenetrating titanium clips (Vascular Clip System; LeMaitre Vascular Inc., Burlington, MA) [Figure 3f]. No postoperative CSF leakage occurred, and spinal lumbar drainage was not warranted. The patient’s preoperative sensory disturbance resolved. The postoperative MRI showed a reduction in the cyst’s size [Figure 4a and b] and no residual compression of the S2 nerve root [Figure 4c]. Histopathological examination confirmed collagen connective tissue without nerve fibers, findings consistent with a Tarlov cyst [Figure 5]. The patient remained asymptomatic 6 months later, and the 6‑month postoperative sacral MRI demonstrated no cyst recurrence.

用超声骨刀切开椎板。术中发现，S3神经根被包裹在囊壁内，S2神经根明显受压[图3a和b]。对囊壁进行部分切除和残余组织叠置缝合[图3c]。确定了一个来自蛛网膜下腔的漏口，确认漏口处有活瓣效应[图3d]。这个连接蛛网膜下腔的漏口用脂肪组织封堵，并用纤维蛋白胶密封[图3e]。用非穿透性钛夹（血管夹系统；LeMaitre Vescular Inc.，Burlington，MA）对囊肿壁进行折叠[图3f]。术后未发生脑脊液漏，不需要放置腰椎管外引流。病人术前的感觉障碍完全缓解。术后MRI显示囊肿较术前减小[图4a和b]，S2神经根无压迫[图4c]。组织病理学检查证实无神经纤维的胶原结缔组织，与Tarlov囊肿一致[图5]。术后6个月病人仍无症状，术后6个月骶骨MRI显示囊肿无复发。

 

Tarlov cysts are meningeal dilatations commonly found between the endoneurium and perineurium in the spinal nerve root sheaths at the S2 and S3 levels. Theycommonly communicate with the subarachnoid space.

Tarlov囊肿是一种常见于脊髓神经根鞘内，神经内膜和神经束膜之间的脑膜扩张，多位于S2和S3水平。它们通常与蛛网膜下腔沟通。

 

 

Discussion

讨论

Symptomatic Tarlov cysts

Although they are typically asymptomatic, 1% may demonstrate growth and contribute to nerve root compression (e.g., sacral/perineal pain, sphincter dysfunction, radiculopathy, and rarely, infertility). Growth of these cysts and symptoms are typically attributed to the aball‑valve effect/net inflow of the CSF from the subarachnoid space, a finding that may be confirmed on myelograph (e.g., delayed filling). Clinically, Tarlov cysts symptoms may exacerbate in the standing position (e.g., stimulates CSF flow to the cyst); this was seen in the case presented.

症状性骶管囊肿

虽然骶管囊肿通常无症状，但其中1%可能表现为进行性生长并导致神经根压迫（例如骶尾部/会阴疼痛、括约肌功能障碍、神经根病，以及罕见的不孕症）。这些囊肿的生长和症状通常归因于蛛网膜下腔脑脊液漏口的活瓣效应，这一发现可在脊髓造影上得到证实（例如，延迟充盈）。临床上，骶管囊肿的症状在站立时可能加重（例如刺激脑脊液流向囊肿）；这在本病例中的到证实。

 

Surgical options for symptomatic Tarlov cysts

Different surgical treatment options are available for symptomatic Tarlov Cysts [Table 1].[3,7] Reducing the size of the cysts often relieves symptoms; this typically requires sealing the connection with the subarachnoid space (e.g., obliteration of the ball‑valve mechanism of filling). The aim is to reduce cyst volume and prevent further communication with the CSF pathways.

症状性骶管囊肿的手术选择

有症状的骶管囊肿有不同的外科治疗方案。减小囊肿的大小通常可以缓解症状；这通常需要封堵囊肿与蛛网膜下腔的漏口（例如，封堵活瓣机制）。目的是减少囊肿体积，防止与脑脊液的进一步沟通。

 

Studies demonstrating surgical outcomes of Tarlov cysts

Seven studies (all case series) evaluated the surgical treatment outcomes for Tarlov Cysts. Surgical alternatives included excision and fenestration utilizing different techniques (e.g., cystectomy, imbrication, clipping, obliteration of the CSF fistula, and combined approaches to abolish communication with the subarachnoid space between the dural sac and the cyst). Fibrin glue obliteration and cyst resection are also effective in achieving symptomatic improvement but may lead to postoperative complications such as meningitis. Potts et al. [10] reported good surgical results after cyst fenestration; however, over 70% of patients ultimately suffered a recurrence. All other studies reported comparatively low rates of recurrence.

Tarlov囊肿手术治疗效果的研究

7项研究（全部病例系列）评估了Tarlov囊肿的外科治疗效果。手术选择包括切除和开窗，使用不同的技术（如囊肿切除术，折叠，夹闭，脑脊液瘘封堵，以及联合方法来消除硬膜囊和囊肿之间与蛛网膜下腔的漏口）。纤维蛋白胶封堵术和囊肿切除术也能有效改善症状，但可能导致术后并发症，如脑膜炎。据报道囊肿开窗术后手术效果良好，但超过70%的患者最终复发。所有其他研究报告的复发率相对较低。

 

Conclusion

There are several surgical treatment options for treating symptomatic (e.g., 1%) Tarlov cysts. An optimal strategy appears to include direct cyst resection, imbrication, and fat graft packing of the communication between the dural sac to the cyst (e.g., occlude the all-valve mechanism of refilling).

结论

对于症状性骶管囊肿有几种外科治疗方法可供选择。最佳策略包括直接囊肿切除、折叠和脂肪填塞漏口。

 

 

专家点评：

1、  新华医院神经外科支持本文观点，一侧的较大囊肿可能压迫对侧神经根产生症状，站立时进水压增加会引起症状加重，手术可以有效缓解症状。

2、  新华医院神经外科支持本文观点，单纯的囊肿开窗和神经根袖折叠缝合，术后复发率高。骶管囊肿大多数都有漏口，有些甚至有活瓣，单一的囊壁塑形无法达到消除漏口、无法解决根源问题，囊肿复发可能极大。因此同意本文封堵漏口的手术方法，但是我中心认为用肌肉封堵漏口比脂肪封堵更牢靠，更不易复发。

3、  郑学胜主任认为，封堵漏口是减少囊肿复发的关键，在严密的漏口封堵基础上，进行神经根袖折叠缝合，重建一个紧致的神经根袖。但神经根袖重建不能代替漏口封堵，主辅不能混淆。

4、  显微镜下手术及全程电生理监测，可以有效减少术中神经损伤风险。目前我中心所有骶管囊肿手术100%显微镜下操作及手术全程神经电生理监测。