骶管囊肿文献导读：显微外科手术治疗骶管囊肿：病例讨论和文献回顾

原文：Microsurgical treatment of sacral perineural (Tarlov) cysts: case series and review of the literature

作者：John F. Burke, MD, PhD, Jayesh P. Thawani, MD, Ian Berger, BS, Nikhil R. Nayak, MD, James H. Stephen, MD, Tunde Farkas, MD, Hovik John Aschyan, BA, John Pierce, MS, Suhail Kanchwala, MD, Donlin M. Long, MD, PhD, and William C. Welch, MD （美国 宾夕法尼亚）

编译： 杨敏 沈霖        审校：郑学胜

Tarlov cysts (TCs) occur most commonly on extradural components of the sacral and coccygeal nerve roots. These lesions are often found incidentally, with an estimated prevalence of 4%–9%. Given the low estimated rates of symptomatic TC and the fact that symptoms can overlap with other common causes of low-back pain, optimal management of this entity is a matter of ongoing debate. Here, the authors investigate the effects of surgical intervention on symptomatic TCs and aim to solidify the surgical criteria for this disease process.

Tarlov囊肿（TCs）最常见于骶尾部神经根的硬膜外病变。这些病变通常是偶然发现的，患病率约为4%-9%。考虑到症状性骶管囊肿的患病率较低，而且症状可能与其他常见的腰部疼痛病因重叠，因此，对该疾病的最佳治疗是一个持续争论的问题。本文作者调查了外科干预治疗症状性骶管囊肿的预后，目的是建立这一疾病过程的外科治疗标准。

Twenty-three adults (4 males, 19 females) who had been symptomatic for a mean of 47.4 months were treated with laminectomy, microsurgical exposure and/or imbrication, and paraspinous muscle flap closure. Eighteen patients (78.3%) had undergone prior interventions without sustained improvement. Thirteen patients (56.5%) underwent lumbar drainage for an average of 8.7 days following surgery. The mean follow-up was 14.4 months. Univariate analyses demonstrated that an advanced age (p = 0.045), the number of noted perineural cysts on preoperative imaging (p = 0.02), and the duration of preoperative symptoms (p = 0.03) were associated with a poor postoperative outcome. Although 47.8% of the patients were able to return to normal activities, 93.8% of those surveyed reported that they would undergo the operation again if given the choice.

23名成人（4名男性，19名女性）平均47.4个月出现症状，接受椎板切除术、显微手术暴露后折叠缝合术，以及棘旁肌瓣闭合术。18例患者（78.3%）术前曾接受过早期干预治疗，但没有持续改善。13例（56.5%）术后平均8.7d行腰椎引流术。平均随访14.4个月。单因素分析显示高龄（p=0.045）、术前影像学上发现的神经周囊肿数量（p=0.02）和术前症状持续时间（p=0.03）与术后不良预后相关。虽然47.8%的患者能够恢复正常活动，但93.8%的受访患者表示，如果再次选择，他们还是会选择接受手术。

Diagnosis and Surgical Intervention

All patients underwent imaging studies demonstrating TC. Magnetic resonance imaging of the lumbar spine delineated 1 or many cystic masses consistent with a diagnosis of TC (Fig. 1). Computed tomography scanning was also performed to reveal any possible bony erosion adjacent to the TC.

所有患者都接受了显示囊肿的影像学检查。腰椎磁共振成像显示1个或多个囊性肿块，符合骶管囊肿的诊断（图1）。电脑断层扫描也显示出任何可能的骨侵蚀邻近的囊肿。

Given symptoms refractory to medication and/or prior intervention as well as radiological evidence of TC, patients were offered the option of surgery. Other causes of pain were ruled out before patients were presented with a surgical option. All patients elected to undergo microsurgical treatment performed by the study’s senior author. Surgery entails a lumbosacral incision, subperiosteal dissection, and an osteoplastic laminotomy that is performed over the level of the cyst. Incision and exposure are conducted using anatomical landmarks. Following incision into the cyst wall, a 4-0 Nurolon suture is placed lateral to the opening on either side to bring the dural edges inward and under the closure. Autologous muscle patches can be used to augment the dural closure and decrease the overall volume of the cyst. The resulting defect requires watertight tension-free closure. Sharp lateral dissection is used to free the paraspinous musculature. If necessary, the fascial insertion can be detached medially along the posterior iliac spine, taking care not to injure the superior cluneal nerves, the dorsal sacroiliac ligaments, or the iliolumbar ligament. The midline incision is closed in several layers, including deep and more superficial subcutaneous tissues as well the skin, by using a simple, running absorbable suture reinforced with nonabsorbable verticalmattress sutures. Patients with cysts larger than 2.5 cm in the largest dimension and/or a history of prior interventions have lumbar drains placed at the time of surgery. The lumbar drain is used in the event of large cysts, when a significant amount of dura mater is excised during excision of the cyst wall. Methods of the surgical approach are visually summarized in Fig. 2

对于药物或先前保守治疗无效的骶管囊肿患者，放射学明确有骶管囊肿，此类患者可以选择手术。术前因排除其他的疼痛原因。所有病人都选择接受显微外科治疗，由本研究的资深术者进行。手术包括腰骶部切口，骨膜下剥离，以及在囊肿上方进行的骨塑形椎板切开术。使用解剖标志进行切口和暴露。切开囊肿壁后，将4-0 Nurolon缝合线置于两侧开口的侧面，使硬脑膜边缘向内并位于闭合处。自体肌肉补片可以用来加强硬脑膜闭合，减少囊肿的总体积。由此产生的缺陷需要水密无张力闭合。侧切除术用于松解棘旁肌层。如有必要，可沿髂后棘内侧分离筋膜止点，注意不要损伤上臀神经、骶髂背韧带或髂腰韧带。中线切口分几层闭合，包括较深和更浅的皮下组织以及皮肤，方法是使用一种简单的可吸收缝线，并辅以不可吸收的垂直床垫缝合线。最大直径大于2.5厘米的囊肿和/或有既往手术史的患者在手术时放置了腰椎引流管。当囊肿壁切除时，大量硬脑膜被切除，腰椎引流用于治疗大囊肿。手术入路的方法如图2所示。

Conclusions

Although TCs were described more than 75 years ago, there is still no consensus on their origin or treatment. Most are benign, but about 1% are symptomatic and can be managed effectively with surgery. A few studies have been conducted on the surgical management of TCs, and much of this literature shows positive outcomes (Table 1). Here, we described a cohort of patients with symptomatic TCs that was successfully treated with surgery. Age, extent of disease, and duration of symptoms were related to outcome. The overall long-term outcome for this patient group was positive.

尽管骶管囊肿在75年前就被描述过了，但是对于它们的起源和治疗方法仍然没有达成共识。大多数是良性的，但约1%是有症状的，可以通过手术有效地处理。对骶管囊肿的外科治疗已经进行了一些研究，并且大部分文献显示了积极的结果（表1）。本文描述了一组成功通过手术治疗的症状性骶管囊肿患者。年龄、疾病程度和症状持续时间与预后相关。该患者组的总体长期预后是积极的。

总结：

1、  同意本文关于手术指针的观点。我们亦认为有症状的骶管囊肿患者，影像学明确诊断，在排除其他疾病后有明确手术指针。

2、  本文主要采取后椎板切开术+囊肿折叠缝合术+肌瓣囊肿闭合术。我们的观点是漏口封堵术是骶管囊肿手术中的关键，无论囊肿大小，都应行漏口封堵术，提高手术预后，减少术后复发。对于较大的骶管囊肿可以在漏口封堵的基础上行肌瓣囊肿内封堵+囊肿折叠缝合术。

3、  我们术中应用显微镜和神经电生理术中监测，这两项措施可以提高手术预后并有效减少术中神经损伤并发症。