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Multiple Lumbar Perineural Cysts Presented With Nonspecific Back Pain

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Bulent Kaya at Necmettin Erbakan Üniversitesi
Bulent Kaya
Erdal Kalkan at Necmettin Erbakan Üniversitesi
Erdal Kalkan
Mehmet Fatih Erdi at Necmettin Erbakan Üniversitesi
Mehmet Fatih Erdi
Fatih Keskin at Necmettin Erbakan Üniversitesi
Fatih Keskin
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Abstract and Figures

In this report we present a case of relatively rare multiple lumbar perineural cysts. Tarlov cysts, also known as perineural cysts are most often found in the sacral region. There are very few cases of multiple lumbar perineural cysts. A-50-year-old male patient admitted to our clinic with nonspecific back pain complaint. The neurological examination was within normal range. Magnetic resonance imaging showed multiple perineural cysts at lumbar region. The patient underwent medical treatment without any surgical intervention. The outcome of the medical treatment was satisfactory. Although it's very rare lumbar multiple perineural cysts can be seen without any neurological symptom and the treatment strategy of these cysts have some controversies.
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J.Neurol.Sci.[Turk]
418
Journal of Neurological Sciences [Turkish] 30:(2)# 36; 418-421, 2013
http://www.jns.dergisi.org/text.php3?id=669
Case Report
Multiple Lumbar Perineural Cysts Presented With Nonspecific Back Pain
Bulent KAYA, Erdal KALKAN, Fatih ERDİ, Fatih KESKİN, Yasar KARATAS
Necmettin Erbakan University, School of Medicine, Department of Neurosurgery, Konya,
Turkey
Summary
In this report we present a case of relatively rare multiple lumbar perineural cysts. Tarlov
cysts, also known as perineural cysts are most often found in the sacral region. There are very
few cases of multiple lumbar perineural cysts. A-50-year-old male patient admitted to our
clinic with nonspecific back pain complaint. The neurological examination was within normal
range. Magnetic resonance imaging showed multiple perineural cysts at lumbar region. The
patient underwent medical treatment without any surgical intervention. The outcome of the
medical treatment was satisfactory. Although it's very rare lumbar multiple perineural cysts
can be seen without any neurological symptom and the treatment strategy of these cysts have
some controversies.
Key words: Multiple, lumbar, perineural cyst
Nonspesifik Bel Ağrısı ile Başvuran Multipl Lomber Perinöral Kist Olgusu
Özet
Bu yazıda oldukça nadir görülen çoklu lomber perinöral kist olgusu sunulmuştur. Talov
kistleri olarak da bilinen perinöral kistler genellikle sakral bölge yerleşimlidirler. Çoklu
lomber perinöral kistler oldukça nadir görülürler. 50 yaşındaki erkek hasta nonspesifik bel
ağrısı şikayeti ile kliniğimize başvurdu.Nörolojik muayenesi normal sınırlarda idi. Manyetik
rezonans görüntülemede lomber bölgede multipl perinöral kist saptandı. Hastaya herhangi bir
cerrahi müdahale olmadan tıbbi tedavi uygulandı. Hasta medikal tedaviden oldukça yarar
gördü. Multipl lomber perinöral kistlerin nörolojik bulgu vermeden görülmeleri oldukça nadir
olmasına rağmen tedavi stratejileri konusunda tartışmalar devam etmektedir.
Anahtar Kelimeler: Multipl, lomber, perinöral kist
INTRODUCTION
Perineural cysts were firstly described by
Tarlov in 1938(7) as an incidental finding of
an autopsy study. They are uncommon
lesions of the nerve roots and most often
located in sacrum. The cyst cavity lay
between arachnoid and pia mater of the
involved root. These cysts are commonly
asymptomatic and are incidental findings
on imaging studies(1). But some
devastating results like as cauda equina
syndrome can be seen due to this lesions(5).
We report a case of multiple lumbar
perineural cysts presented with only
nonspecific back pain without any
neurological symptom. To our knowledge
this is the first report presented in the
literature.
CASE PRESENTATION
A-50-year-old male patient admitted to our
clinic with back pain lasting for one
month. The past medical history was
J.Neurol.Sci.[Turk]
419
normal. The pain was increasing while
walking and reducing with resting. The
neurological examination revealed no
abnormality. Lumbar magnetic resonance
imaging (MRI) revealed multiple lumbar
cysts with typical imaging characteristics
of perineural cysts. The cysts were uniform
hyperintense on T2-weighted images with
a thin rim of signal void around them. On
T1-weighted images, the cysts were
isointense with cerebrospinal fluid (Figure
1,2,3). Because the patient was
neurologically intact any surgical
intervention did not considered and the
patient underwent medical therapy with
non-steroid antiinflammatory and
myelorelaxant drugs. After 2 weeks the
patient's back pain complaint near totally
resolved.
Figure 1: Sagittal T1-weighted MRI showed multiple cystic lesions into the spinal canal.
Figure 2: Sagittal T2-weighted MRI showed uniform hyperintense multiple cystic lesions compatible with Tarlov
cysts.
J.Neurol.Sci.[Turk]
420
DISCUSSION
The cystic lesions ‘perineural cyst' in the
sacral nerve root was firstly described by
Tarlov(7). Tarlov found that theses cysts
were located in the perineurial space,
between the endoneurium and perineurium
at the junction of the posterior nerve root
and its ganglion(6,7).
Nabors et al.(4) classified these cysts into
three types : extradural meningeal cysts
without spinal nerve root fibers (Type I);
spinal extradural meningeal cysts with
spinal nerve root fibers (Type II, Tarlov
cyst); and spinal intradural meningeal cysts
(Type III). Developmental or congenital
origin, arachnoidal proliferation, trauma
and inflammation were previously indicted
as etiological factors of these cysts(2,6). In
reported case there was no past history of
trauma, meningitis or previous surgery.
During the fetal period, the dura mater was
missing when it was developed. The
subarachnoid membrane was escaped(3).
Probably, this might be responsible for the
formation of these cysts. Ideal surgical
treatment of perineural cysts still have
some controversies and difficulties.
Successful surgical treatment of these cysts
is mainly dependent on appropriate patient
selection. The reported case was a
neurologically intact patient with moderate
back pain. Because of this we prefer to
follow-up the patient with medical
treatment. The back pain complaint of the
patient near totally resolved after two
weeks lasting medical treatment.
Perineural cysts generally arise proximal to
the sacral neural foramina. Our case
documents an unusual and hitherto
unreported pattern of multiple lumbar
perineural cysts.
Correspondence to:
Yasar Karatas
E-mail: yasarkrts@gmail.com
Received by: 29 March 2013
Revised by: 10 April 2013
Accepted: 11 April 2013
The Online Journal of Neurological
Sciences (Turkish) 1984-2012
This e-journal is run by Ege University
Faculty of Medicine,
Dept. of Neurological Surgery, Bornova,
Izmir-35100TR
Figure 3: Axial T2-weighted MRI showed uniform hyperintense cystic lesion which compressed the spinal cord from
left side at L3 vertebral level.
J.Neurol.Sci.[Turk]
421
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World Wide Web service.
Comments and feedback:
E-mail: editor@jns.dergisi.org
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Journal of Neurological Sciences (Turkish)
Abbr: J. Neurol. Sci.[Turk]
ISSNe 1302-1664
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ResearchGate has not been able to resolve any citations for this publication.
Two Cases of Symptomatic Perineural Cysts (Tarlov Cysts) in One Family : A Case Report
Article
Full-text available
  • Oct 2008
Symptomatic sacral perineural cysts are uncommon. Several hypotheses have been proposed to explain the etiologies of perineural cysts, but the accurate etiologies remain unclear. We experienced two cases of symptomatic sacral perineural cysts (Tarlov cysts) in one family, who presented with perianal paresthesia. Both of them were operated and postoperatively their symptoms were disappeared immediately. We experienced the excellent treatment outcome with the surgical management of symptomatic perineural cysts in the sacral region. We assume that the theory of congenital origin including a familial tendency is the most plausible of the hypotheses that have been proposed.
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Spinal multiple extradural arachnoid cysts: Became symptomatic in an elderly age; A case report
Article
  • Jan 2012
Spinal extradural arachnoid cyst is a rare disease that includes approximately 1% of all primary spinal lesions. Spinal arachnoid cysts most frequently occur in thoracic region as a solitary mass. However, multiple extradural arachnoid cysts are extremely rare pathologies and only 8 cases have been reported in the literature before. In this report we described a case of 66 year old woman who had multiple spinal extradural arachnoid cysts presented with paraparesis and became symptomatic in an elderly age.
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Perineural cysts of the spinal nerve roots
Article
  • Jan 1938
During the course of dissection of the filum terminale at autopsy in about 30 adults 5 cases of cysts (neither parasitic nor dermoid) on the extradural portions of the posterior sacral or coccygeal nerve roots were encountered. Since but 2 reports of similar cysts have come to my attention, this experience seems worth recording, particularly since it was possible to determine the site of origin of the cysts in these cases. Marburg¹ described 4 cases of cysts of the spinal ganglia. The cysts were solitary in 3 cases and multiple in the fourth. Hinrichs² recorded a case in which 3 cysts occurred on the posterior thoracic and lumbar roots, in the region of junction of the root and the ganglion. The subjects were between 61 and 77 years of age and presented no symptoms referable to the cysts. Marburg concluded that it was likely that the cysts followed
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Congenital Cysts of the Spinal Membranes and Roots
Article
  • Mar 1963
One case of leptomeningeal cyst, three cases of spinal extradural cysts and ten cases of perineural cysts, two of which were operated on, are reported. The literature pertaining to these diseases is reviewed and the possibilities of a correct radiological diagnosis are discussed.
View
Updated assessment and current classification of spinal meningeal cyst
Article
  • Apr 1988
  • J NEUROSURG
The classification of spinal meningeal cysts (MC's) in the literature is indistinct, confusing, and in certain categories histologically misleading. Based on a series of 22 cases, the authors propose a classification comprising three categories: spinal extradural MC's without spinal nerve root fibers (Type I); spinal extradural MC's with spinal nerve root fibers (Type II); and spinal intradural MC's (Type III). Although water-soluble myelography may disclose a filling defect for all three categories, computerized tomographic myelography (CTM) is essential to reveal communication between the cyst and the subarachnoid space. Communication demonstrated by CTM allows accurate diagnosis of a spinal MC and rules out other mass lesions. Magnetic resonance imaging appears useful as an initial study to identify an intraspinal cystic mass. Final characterization is based on operative inspection and histological examination for all three categories.
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Cauda equina syndrome caused by Tarlov's cysts--case report
Article
  • Jan 2002
Perineural Tarlov cysts located on lumbo-sacral roots can be a cause of cauda equina syndrome. 1) To draw attention to the fact that multiple Tarlov lumbo-sacral perineural cysts can produce serious movement disturbances. 2) To document the usefulness of the magnetic resonance imaging in noninvasive diagnosis of perineural cysts. A male patient, 80 years of age, suffered from progressive weakness of lower limbs, which caused an increasing drop of the feet. The disease began in August 2000, following a long journey by train. The patient additionally complained of urinary incontinence as result of sneezing, coughing or fast walking. The urologist did not find prostatic gland hypertrophy. An examination by the internist revealed atheromatous myocardiopathy in circulation failure stage. Magnetic resonance imaging showed multiple perineural cysts up to 15 mm in diameter on lumbo-sacral roots. This clinical picture, supported by the magnetic resonance imaging allowed to recognize cauda equina syndrome caused by Tarlov lumbo-sacral perineural cysts. This case is a reminder, that part of perineural cysts, particularly multiple, can be a cause of nerve roots injury, and their lumbo-sacral location can produce cauda equina syndrome. As reported by Zarski and Leo, Tarlov cysts were cause of 7.3% of pain syndrome cases 2 patients in the study group showed lower limb claudication. Magnetic resonance imaging of patients with back pain, performed by Paulsen, Call and Murtagh, revealed that Tarlov cysts occurred in 4.6% of patients, but only 1% had the symptoms connected with the presence of those cysts. In available Polish literature no report has been found referring to fixed cauda equina syndrome which was caused by multiple cysts revealed through the magnetic resonance imaging of spinal canal. Only Zarski and Leo, discussing the correlation between the clinical and radicographic picture, described transient cauda equina syndrome in two patients who, beside Tarlov cysts, were also found to have intervertebral lumbosacral disc herniation. Tarlov was the first to describe well documented cauda equina syndromes caused by cysts on the lumbo-sacral roots. It is necessary to emphasize the established role of magnetic resonance of spinal canal in the diagnosis of perineural cysts on the lumbo-sacral roots as well as other anatomical anomalies of cerebrospinal fluid spaces. Despite the fact that cauda equina syndrome in the case reported here was a serious complication of multiple Tarlov cysts in the lumbo-sacral region, a surgical treatment was not undertaken; in such cases this treatment should be the chosen procedure. Multiple perineural Tarlov cysts in lumbo-sacral region, without disc herniation or other cause of vertebral canal stenosis, can produce cauda equina syndrome.
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