Diagnosis and Management of Sacral Tarlov Cysts

Frank L. Acosta, Jr.; MD, Alfredo Quinones-Hinojosa, MD; Meic H. Schmidt, MD; Philip R. Weinstein, MD


Neurosurg Focus. 2003;15(2) 

In This Article

Case Report


This 47-year-old woman presented with a 1-year history of progressive, intractable sacrococcygeal pain and numbness as well as dysesthesias of both feet. At the time, she was becoming increasingly incapacitated, although she was still able to work as a flight attendant. She rated her pain as 6 of 10 possible points on a visual analog scale. Her symptoms were aggravated by standing, walking, lifting, and climbing stairs as well as by coughing. Pain was rapidly relieved by recumbency. She had a history of renal calculi. She had no bowel or bladder dysfunction, and sensation for urination and defecation was normal.


On physical examination, a grade of 5/5 strength was demonstrated throughout all muscle groups. Heel and toe walking and knee bends were well performed. Straight leg raising was negative. Jugular compression test induced sacrococcygeal paresthesias without pain. Sensory examination showed diminished sensory perception to pinprick on the soles of her feet and in the S1 2 distribution. There was no sensory deficit over the perineum. Anal sphincter tone and constriction were normal. Knee jerks were hyperreflexive with a Grade 4+ response bilaterally, and ankle jerks were Grade 2+ bilaterally. Lumbar flexion seemed to relieve the pain, whereas extension made it worse.

Preoperative MR imaging demonstrated a large sacral cyst arising within the thecal sac at S-2, with expansion of the osseous sacral central canal and enlargement of S-1 and S-2 neural foramina causing compression of all adjacent nerve roots. Postmyelography CT scanning revealed evidence of cauda equina compression. The cyst did not fill with contrast material and appeared to have no communication with the spinal subarachnoid space (Fig. 1).


To relieve progressively incapacitating symptoms, surgery was recommended. After sacral laminectomy, microsurgical cyst fenestration was performed with the assistance of intraoperative electromyographic monitoring. Muscle flap closure reinforcement was conducted as described previously.[16] Briefly, after exposure of the S2 S4 sacral nerve roots, a large meningeal cyst was identified arising from the S-2 nerve root. The thin transparent cyst wall membrane was widely fenestrated with a scalpel and microscissors. Clear fluid contents of the cyst drained spontaneously. The posterolateral wall of the cyst was resected after electrical stimulation verified that no motor nerve fibers were present. Anal sphincter electro-myography was activated by low intensity 0.4 mA electrical stimulation applied to the anterior and medial surfaces of the cyst wall. Although rapid high-volume drainage of CSF from the rostral subarachnoid space was not observed, some seepage did occur, indicating that micro-scopic communication was present.

Fibrin glue was then applied to fill the cyst cavity. To prevent cyst recurrence or CSF leakage, a sacral spinalis muscle flap was then rotated into the epidural space created by evacuation of the S2 S4 cyst. Cyst closure was also supported using a lumbar subarachnoid drain for postoperative CSF diversion (Fig. 2). Although the cyst wall specimen was sent to the laboratory for pathological examination, its volume was inadequate to determine whether nerve root fibers were present.

Postoperative Course

The patient's postoperative course was uneventful. The lumbar drain was removed on postoperative Day 3, and a CT myelography revealed a very small amount of contrast exiting from the thecal sac to surround the myocutaneous flap. There was only mild indentation of the posterior thecal sac (Fig. 3). She noted marked improvement in her pain symptoms prior to dis-charge home on Day 4 postoperatively. During the follow-up visit 5 weeks later, she reported that the burning in her feet had resolved; however, she experienced some intermittent residual sacral coccygeal and retrorectal pain, which was much less severe than it had been preoperatively. There were no focal sensory or motor deficits. Sub-sequent communication from the patient indicated that further resolution of residual pain occurred slowly over the ensuing 3 months.


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