Microsurgical Fenestration and Paraspinal Muscle Pedicle Flaps for the Treatment of Symptomatic Sacral Tarlov Cysts

OBJECTIVE: Sacral Tarlov cysts are rare causes of sciatic and sacrococcygeal pain and neurologic deficits. Although several microsurgical treatments have been described, the optimal treatment has yet to be determined. We describe our initial experience with symptomatic lesions combining 1) cyst fenestration and imbrication and 2) filling the epidural space using vascularized paraspinous muscle flaps rotated into the cystic cavity. METHODS: We retrospectively reviewed all consecutive cases of symptomatic giant sacral Tarlov cysts treated with microsurgery at our institution between 2003 and 2011. The main outcome measure was self-reported symptom relief. Postoperative imaging, surgical complications, and subsequent treatments were also recorded. RESULTS: Thirty-five patients were treated. Mean age was 52 years. All patients presented with a chief complaint of sacral-perineal pain. The mean cyst size was 3.6 cm (largest diameter). Follow-up beyond the initial hospital stay was available in 86% (median 8 months). Ninety-three percent reported improvement in pain at some point during the postoperative course but 50% of those developed recurrent pain symptoms. Postoperative imaging was available in 69% of the patients in whom 92% showed complete obliteration (25%) or reduction in cyst size (67%). CONCLUSIONS: The combination of microsurgical cyst fenestration and the use of vascularized muscle pedicle flaps to fill the cystic cavity and the epidural space results in obliteration or reduction in size of the majority of cysts and is associated with initial improvement in pain in most patients. However, delayed recurrence of pain was common with this technique.