Neurosurg Focus
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Review Case Reports
Diagnosis and management of sacral Tarlov cysts. Case report and review of the literature.
Perineurial (Tarlov) cysts are meningeal dilations of the posterior spinal nerve root sheath that most often affect sacral roots and can cause a progressive painful radiculopathy. Tarlov cysts are most commonly diagnosed by lumbosacral magnetic resonance imaging and can often be demonstrated by computerized tomography myelography to communicate with the spinal subarachnoid space. The cyst can enlarge via a net inflow of cerebrospinal fluid, eventually causing symptoms by distorting, compressing, or stretching adjacent nerve roots. ⋯ When symptomatic, the potential surgery-related benefit and the specific surgical intervention remain controversial. The authors describe the clinical presentation, treatment, and results of surgical cyst fenestration, partial cyst wall resection, and myofascial flap repair and closure in a case of a symptomatic sacral Tarlov cyst. They review the medical literature, describe various theories on the origin and pathogenesis of Tarlov cysts, and assess alternative treatment strategies.
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Sacral chordomas are relatively rare, locally invasive, malignant neoplasms. Although metastasis is infrequent at presentation, the prognosis for patients with chordoma of the sacrum is reported to be poor and attributable in most cases to intralesional resection. ⋯ The technical challenges of such operations, and the functional costs for the patient (with respect to anorectal and urogenital dysfunction) are significantly increased when the tumor involves high sacral levels. The authors review the clinical presentation and natural history of sacral chordoma and discuss the current treatment techniques and outcomes.
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Primary tumors of the sacrum are rare. In adults, the most common sacral tumors are metastases. ⋯ Chordomas along as well as tumors such as chondrosarcomas, osteosarcomas, myxopapillary ependymomas, myelomas, and Ewing sarcomas are considered malignant. In this article the authors focus on benign sacral tumors.
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The surgical management of sacral tumors requires partial or total sacrectomy and spinopelvic reconstruction. These lesions present a great surgical challenge, because most spine surgeons are unfamiliar with the techniques required for these procedures. The authors describe a step-by-step operative technique and provide several illustrations. ⋯ Spinopelvic reconstruction is undertaken using a modified Galveston technique or double iliac screw fixation combined with posterior lumbar segmental fixation. These provide a long lever arm within the ilium to counteract the forces exerted by the lumbar spine. Understanding the nature of the disease as well as the biomechanics of the lumbosacral pelvic area and spinopelvic fixation will help surgeons select the appropriate treatment for sacral tumors.