Cyst of Tarlov Cause of Refractory Lumbar Pain, Case Report.

Alberto Lázaro Carrillo Comas *¹, Leniel Laud Rodríguez ², Yarlenis Pérez Santiesteban ³

1, 2, 3. Department of Neurosurgery, University Hospital Faustino Pérez, Matanzas, Cuba.

Corresponding Author: Alberto Lázaro Carrillo Comas, Department of Neurosurgery, University Hospital Faustino Pérez, Matanzas, Cuba.

Copy Right: © 2022 Alberto Lázaro Carrillo Comas, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: November 28, 2022

Published Date: December 05, 2022

Abstract

The cysts of Tarlov (QT) they were reported for the first time toward 1938 when Isadore Tarlov once culminated 30 autopsies, they have only been reported less than 100 cases with clinical relevance. It affects between 4,6 and 9%, habitually they are asymptomatic, however they can originate symptoms that embrace from the pain radicular until disfunción of sphincters. They are several their treatment options; that they go from the conservative until different technical surgical.

Clinical cases: The case of a 65 year-old patient is presented with pain in lumbar region that is irradiated toward abdominal and pelvic region that received multiple treatments medical and several abdominal surgeries during a 10 year-old term, besides having valued by multiple specialties without improvement clinic, to the physical exam it verifies intense pain to the palpación of the thorny processes from L5 to S3, hipoestesia in region perineal, besides constipación, you confirms the diagnosis of Cyst of Tarlov for resonance sacred lumbo. Once confirmed the diagnosis, the strategy surgical centered exhibition of the cyst, the fenestration of the capsule, identification of the involved root and ostium, settles down as well as he/she closes of this last one, culminated with a closing multicapa to avoid the water-pipes of liquid cefalorraquídeo. In the postoperative one it is verified total relief of the pain and improvement of the constipación.

Conclusion: it is really valuable to incorporate it inside our main diagnostic options when valuing a patient with a square of compression radicular of lumbar and sacred localization.

Keyword: Tarlov cyst, Refractory Lumbar pain.

Introduction

The cysts of Tarlov (QT) or cysts perineurales were reported for the first time toward 1938 when Isadore M. Tarlov makes allusion once to the same one culminated 30 autopsies in the Neurological Institute of Montreal; from that description made by the neurosurgeon Tarlov this entity it takes their name in the scientific literature and only less than 100 cases with clinical relevance have been published (1-3). he/she is considered that at world level this illness affects between 4,6 and the population's adult 9% and being habitually is asymptomatic however, when they are presented at level foraminal or in the neural channel they can originate symptoms that embrace: pain radicular, parestesias and disfunción of sphincters. These are a relatively frequent discovery in the studies of magnetic nuclear resonance of the column lumbosacra (4-6). 

In the literature several treatment options are shown; those which they go from the initial that is always conservative by means of analgesic conventional and physiotherapy, until different variants of surgical treatment as they are it the: Laminectomía sacred descompresiva only, the resection of the cyst, the incision and drainage of the cyst with imbrication of the redundant root and the placement of a derivation lumboperitoneal (5-7). 

Presentation of the Case  

The case of a 65 year-old patient is presented with antecedents of presenting pain in lumbar region that is irradiated toward abdominal and pelvic region, that which caused reiterated consultations with different specialties like gastroenterólogos, gynecologists, urólogos and general surgeons being subjected in the 10 year-old term to multiple treatments medical and several abdominal surgeries, inside those which we find he/she is a divertículos surgery and roads biliares.  

Later to the multiple medical treatments and surgical procedures to those that it was subjected and the persistence of the lumbar painful square with pelvic irradiation, and like significant fact the increment of the pain with spending of the weeks, to the point of not allowing him to stroll, neither to remain given sitting their intensity and irradiation toward pelvis, and he/she appears difficulties to defecate. Due to all him previously outlined the patient decides to go to the neurosurgery consultation, where immediately you proceeds to examine and intense pain is verified to the palpación of the thorny processes from L5 to S3, hipoestesia in periné, bilateral reflective diminished aquileano.  

Subsequently for the clinical data gathered in the interrogation and the discoveries of the physical exam you proceeds to indicate studies imageneológicos, beginning with the On-line Axial Tomografía of Lumbo-sacred Column as it is shown in the Figure 1 where in the axial cut you can appreciate clearly he/she made in interior from the channel raquídeo to sacred level an image rounded hipodensa of very defined borders that you/they cause bony remodeling of the channel with marked weigh loss and erosion of the previous and later wall of the sacred one, that which is reaffirmed in the figure 2 where a TAC is shown in court sagital and you confirms the diágnostico with the study of magnetic resonance where you can appreciate image hiperintensa in T2 at sacred level (characteristic of the cyst of Tarlov).

Settling down the surgical strategy of exhibition of the cyst and their fenestration of their capsule, subsequently identification of the involved root and identification of the ostium that it exercises function of valve mechanism that causes the constant growth of the same one and consequently the progressive pain without relief for the compression that exercises on the other roots, once identified the ostium is sealed with muscle and finally achieved all the objectives, you proceeds to a closing multi layer with fascia and muscular planes avoiding the water-pipe I liquidate.

The patient had a complete relief of the lumbar pain, pelvic pain and like fact but outstanding she outlines disappearance completely of the abdominal nuisances, also in the later days to the intervention the patient could stroll without difficulty and improvement of the dysfunctions sphincters and rest of neurological manifestations. 

Discussion 

The cyst sacred perineural was defined by Tarlov in its original work of 1938 like a cystic dilation in the space preferable subaracnoideo at level of the sacred channel in the union of the dorsal root with the spinal ganglion specifically among the perineuro and the endoneuro caused by a communication with the space subaracnoideo. In their work Tarlov clarifies that the predilection for the sacred roots is not very established and he/she makes reference to 4 cases described by Marburg in 1902 and another described in 1932 by Hirnichs, in those which both mention cysts thoracic and lumbar perineurales. The work of Paulsen describes a prevalencia of 4.6% after analyzing 500 magnetic resonances of lumbar and sacred column. Same statistical data obtained Salt after analyzing 88 patients (5).

In their fisiopatology from their first description am established the mechanism valvular that allows the step of liquid cerebrospinal to the interior of the cyst through the ostium but it impedes their return, causing a cystic dilation for the increase of the hydrostatic pressure and they can acquire enormous size, some can until presenting calcifications in the interior (Calcification arachnoid) (9). This cystic dilation causes a compression of the adjacent nervous and/or bony structure what carries a sintomatología importante.5 it is Necessary to point out that Schreiber 15 reported from 1951 that the cysts can be formed during the spinal surgery due to laceration of the dura mater for the formation of a pseudomeningocele (1-8).

Tarlov in 1952 makes a clinical correlation with the discoveries in the autopsy, defining that the cysts sacred perineurales can present symptoms similar to the hernias of nucleus pulpy lumbosacral. The main premiere symptom is the low back pain form, lumbosciatica coccydynia, as well as abdominal pain and pain perineal that can increase with the changes postural or with the maneuvers of Valsalva, due to the increase of pressure intracystic and consequently increase of the compression of adjacent nervous structures, consequently would be explained that some cases with cysts of great size exist incontinence of sphincters, paresthesias or dysesthesias and paresis (8, 9).

They are multiple the studies that at the present time they can be used to arrive to a diagnosis, but the magnetic resonance of column lumbosacral is the diagnostic test of election, with a characteristic image not enhanced with the contrast although in the current moment there are not reliable approaches to distinguish symptomatic lesions of the asymptomatic ones. To value the communication between the cyst and the space subarachnoid and to study an eventual surgery it can be useful the IRM with study of cerebrospinal liquid (11). The simple x-rays can be useful to demonstrate bony remodeling although it is relegated given the biggest reliability toasts for the CT and the reconstructions 3D available at the present time (it Figures 1 and 2). 

The treatment of the Cyst of Tarlov is controversial in when that a consent doesn't exist in which the first treatment line is confirmed once its diagnosis, but if key points exist in those that all the investigations coincide and it is in defining if it also exists compression of nervous structures that are causing syntomatology in the moment of the diagnosis, if there is remodeling of the adjacent bony structures, this way to trace a behavior that can go from the conventional methods, where they are centered analgesic, medications guided to diminish the production of liquid cerebrospinal, steroids and medications antineurític for the  syntomatologyof neurological compression of structures. Followed by surgical procedures even inside those which consent it doesn't exist of with which surgical technique better results are obtained, but always having present that possible complications can appear during or after the procedure; for what the good result will be determined by a correct one  diagnostic (7-12).

Conclusions

The Cysts of Tarlov are not taken in bill like one of the main low back pain cause and lumbosciatica associated to abdominal pain and sphincter dysfunctions, inside the patients that go to neurosurgery consultation for this square, since some occasions can associate to other pathologies degenerative lumbosacral. For what is really valuable to incorporate it inside our main diagnostic options when valuing a patient with a square of compression root of lumbar and sacred localization.

References

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