Research On The Treatment Of Symptomatic Sacral Tarlov Cysts By Microsurgical Stuffing

BackgroundSacral Tarlov cysts(STc)is located in the sacral sacral nerve root which have a high incidence of about 1.5%-13.2%;However,most of the patients have no clinical manifestations and only a small part may suffer from sacrococcygeal,perineal pain or feeling discomfort,sciatica,lower limb sensation,motor dysfunction,urinary dysfunction,sexual dysfunction and so on,Which is seriously affect the patient’s life and work,even can develop to depression,due to oppression of the sacral nerve root.It has often mistakenly thought that it did not need treatment or misdiagnosed as other diseases such as lumbar disc herniation,lower back pain,sciatica,and so on.So,the key to dealing with this disease is timely diagnosis and effective treatment.With the development of medicine and the widespread use of nuclear magnetic resonance imaging,more and more symptomatic sacral Tarlov cysts can be diagnosed.In recent years,the research reports of STc gradually increased,the reported treatment of STc is diverse and it can be generally divided into three parts: conservative treatment,surgical treatment and minimally invasive interventional therapy.At present,which one is the best treatment is still controversial.Because of the difference in inclusion criteria of each study,surgical indications,sample size,evaluation criteria,follow-up time,it is hard to make an objective and impartial evaluation to the various treatments.Because there is no objective evaluation criteria for nerve dysfunction caused by cysts;and the shortage of scientific evaluation criteria for the choice of surgical approach and judgement of surgical indications;Additionally,it also lacks objective and uniform standards on the evaluation of therapeutic effects.So,it is necessary to have a summary,and put forward the appropriate treatment guidelines or expert consensus.ObjectiveIn this study,we used a microsurgical approach to treat the symptomatic sacral Tarlov cyst patients by filling with fibrin glue,autologous fat and gelfoam.And we used the "symptomatic sacral Tarlov cyst nerve dysfunction score(ESSTCND)" to evaluate the neurological dysfunction.The aim of this study is to give a objective evaluation on the efficacy of the microsurgical approach and the evaluation standards of neurologic deficits evaluation,to provide a reference for clinicians to choose the treatment.MethodsThe clinical data of 72 patients with symptomatic Sacral Tarlov cysts were analyzed retrospectively from June 2010 to June 2013.Among them,there were 23 males,49 females,37 single cyst,35 multiple cysts.The average age of the patients was 44.9 years old.The average age of the male group,the female group,the single group and the multiple group was 39.3,44.6,41.8 and 44.1 years respectively.The surgical technique is using autologous fat tissue,fibrin glue and gelfoam to fill the cyst cavity under microscope and procedure was monitored by intraoperative eletroneurophilogy.The neurological function deficits was assessed by the evaluation standards of Symptomatic Sacral Tarlov cysts neurologic deficits(ESSTCND),which was set by neurosurgery specialists of the First Affiliated Hospital of the Third Military Medical University.The Numerical assessment scale(NRS)was used to assess the degree of pain in patients.The improvement rate of neurological dysfunction was used as the evaluation criterion of therapeutic effect.The treatment results of "excellent" and "good" are defined as treatment effectively.Excellent: patients with neurological dysfunction improvement rate ≥ 60%;and patients with satisfactory results.Good: patients with neurological dysfunction improvement rate ≥ 25%;and patients with satisfactory results of treatment.Data in the same group and the other group were compared by t test or Wilcoxon rank sum test;treatment efficiency comparison was made by using Pearson χ2 test and different efficacy levels were compared using Mann-Whitney test.ResultsCysts were mainly located in S1-S3 vertebral plane,the average volume of 12.5ml.The average volume of the male group,female group,single group and multiple group was 14.7,10.4,13.2,12.3ml respectively.The median ESSTCND score of the preoperative,postoperative 2 weeks,postoperative 1 year and postoperative 3-6 years was 62.5(16.7),25.0(18.5),25.0(16.7),25.0(20.8)respectively.Among them,the male group was 62.5(12.5),25.0(12.5),25.0(25.0),25.0(30.1)respectively;the female group was 62.5(16.7),25.0(20.8),25.0(17.8),25.0(20.3)respectively;the single group was 62.5(20.9),25.0(25.0),25.0(19.8),25.0(20.8)respectively;the multiple group was 62.5(16.7),25.0(12.5),25.0(25.0),25.0(21.9)respectively.The median NRS scores of the preoperative,postoperative 2 weeks,postoperative 1 year and postoperative 3-6 years was 6(2),1(2),1(2)and 1(3),respectively;Among them,the male group was 6(2),1(2),1(2),1(3)respectively;the female group was 6(1.25),1(2),1(2),2(3)respectively;the single group was 5(3),1(2),1(2),1(3)respectively;the multiple group was 6(1),1(2),1(2),2(2.5)respectively.The effective rates of postoperative 2 weeks,postoperative 1 year and postoperative 3-6 years were 94.5%,90.3% and 73.4% respectively.Among them,the male group was 95.6%,91.3% and 75.0% respectively;the female group was 93.9% %,89.8% and 72.7% respectively;the single group was 91.9%,89.2% and 68.8% respectively.The multiple groups were 97.1%,91.4% and 78.1% respectively.The postoperative neurological function of each group was significantly higher than that before operation(all P<0.01).There was no significant difference of ESSTCND score between the postoperative 2 weeks,1 year and 3 to 6 years.The postoperative pain in each group was significantly relieved than that before operation(all P<0.01).The effective rate of postoperative 3-6 years lower than postoperative 2 weeks and 1 year(all P<0.01),there was no significant change between postoperative 2 weeks and 1 year.However,there was no obvious change in the efficacy of treatment in the male group over time.There were no significant differences in the different therapeutic grades between each group at postoperative 2 weeks,1 year and 3-6 years(all P>0.05).There was no significant difference between the male group with female group and single group with multiple group in the age,history,follow-up time,cyst volume,operation time,bleeding volume,incision length,NRS score before and after surgery,ESSTCND score before and after surgery and postoperative effective rates(all P>0.05).ConclusionStuffing the cyst and blocking its communication with the subarachnoid space is an effective means of treating symptomatic sacral canal Tarlov cyst.ESSTCND which we used in this study is an effective,simple,comprehensive and objective way to evaluate the treatment effect.The micosurgical procedure performed in this study is an easy,valid,safe,rapid and effective technique to treat STc and it also has other advantages such as less nerve and tissue structure damages,fewer complications,lower recurrence rate and so on.