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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tarlov cysts &#40;TC&#41; are cystic formations located between the perineurium and the endoneurium of the dorsal branch of a sacral root at the level of the dorsal root ganglion&#46; Prevalence ranges from 1 to 9&#37; of the general population&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#8211;3</span></a> being more frequent in women&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;4</span></a> Most of them are asymptomatic but&#44; due to their relationship with the sacral roots&#44; they have also been related to a variety of symptoms ranging from radicular pain and paresthesias&#44; to sacrococcygeal pain&#44; radicular&#44; perineal&#44; urogenital pain or bladder or ejaculation disorders&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The diagnosis and treatment of TC is controversial and different techniques has been proposed for the management&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">A case of a patient with urogenital and radicular pain secondary to a sacral Tarlov cyst who underwent surgery is presented&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0020" class="elsevierStylePara elsevierViewall">This is a 21-year-old female patient with a 6-year history of groin pain radiating to the genital region and anus&#44; on the right side&#44; with neuralgic discharges related to Valsalva maneuvers&#46; He also reported more diffuse pain referred to the sacral and coccygeal region as well as in the right leg on the posterior side up to the knee&#46; The pain improved with rest and worsened with sitting and exercise&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Om examination there were not loss of strength or sensivity in lower limbs or perineal region&#44; and reflexes were normal&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">MRI showed a TC of around 18 mms at the level of right S2&#46; Nerve roots were located in the anterior margin of the cyst and apparently displaced &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A neurophysiological study was conducted&#44; showing an active sacral radiculopathy with spontaneous activity of denervation at the right anal hemisphincter&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">The patient underwent surgery through a right sacral hemilaminectomy with intraoperative neurophysiological control&#44; exposing the cyst&#44; which did not have a completely free communication with the thecal sac&#46; The sacral roots were located on the anteromedial side of the cyst&#46; The cyst was opened and the communication with the thecal sac was sealed with a small piece of Tachosil&#174;&#46; Another layer of Tachosil&#174; was placed covering the laminectomy and a titanium mesh was placed over the laminectomy &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41; to reinforce closure and to restore the anatomy&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">The postoperative course was uneventful and urogenital symptoms disappeared after surgery&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">Control MRI 6 months after surgery showed the resolution of the cyst &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">After surgery she improved from the urogenital pain&#44; and the neuralgic discharges dissappeared&#46; Improvement continued one year after surgery&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">TC were described in 1938 after an anatomic study about cauda equina in 30 cadavers&#46; In his description&#44; the cysts were located in the perineural space&#44; at the junction of the posterior root and the ganglion and contain roots either on their wall or inside&#46; They communicated with the subarachnoid space but not freely&#44; so that they had late filling on a myelogram&#46; Tarlov differentiated them from meningeal diverticula&#44; which originate distal to the ganglion&#44; did not contain roots&#44; and had extensive communication with the subarachnoid space&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">5</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">A recent meta-analysis of 13&#44;266 patients estimates the prevalence of TC in 4&#46;27&#37;&#44; being more frequent in women and being symptomatic in around 16&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> 22&#37; of TC will become symptomatic over time<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> and it is thought that the cause of the onset of symptoms is due to a valvular mechanism in the neck of the cyst that would lead to a pressure increase in the cyst and growth&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">3&#44;5&#44;7&#44;8</span></a> This would explain that the prevalence of TC increases with age&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The most frequent location is sacral&#44; especially S2&#44;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a> and it usually affects S2&#8211;S4 roots&#46; Due to its location&#44; sensitive roots use to be more affected than motor roots&#46; The symptoms that have been related to TC are lumbosacral&#44; radicular&#44; perineal and urogenital pain&#44; coccydynia&#44; urinary dysfunction &#40;voiding urgency and increased urinary frequency&#41; and intestinal dysfunction&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#8211;4&#44;7&#8211;11</span></a> Urodynamic disorders are frequent&#44;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;3&#44;7&#44;8&#44;11</span></a> being the sensation of early bladder filling the most common&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">2&#44;11</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">The diagnosis is mainly clinical&#44; but a well-directed anamnesis is necessary to establish it&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> In MRI it is sometimes possible to identify the roots in the cyst wall&#44; as in the case presented&#46; Contrast-enhanced myelography or myelo-CT can identify late cyst filling that would point to a valvular mechanism&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;3</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">Neurophysiological studies should be aimed at studying the sacral roots<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a> and usually show alterations in the Hoffmann reflex&#44; the anus-anal reflex and a delay in F waves&#46;<a class="elsevierStyleCrossRefs" href="#bib0135"><span class="elsevierStyleSup">11&#44;12</span></a> They should include a study of the sural nerve as well as the gastrocnemius and the intrinsic foot muscles innervated by tibialis&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">12</span></a></p><p id="par0085" class="elsevierStylePara elsevierViewall">Symptoms are frequently related to posture &#40;up to 74&#37;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">6</span></a>&#41;&#44; improving in the supine position&#44; and worsening when sitting as well as with Valsalva maneuvers&#46;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">1&#44;4&#44;7&#44;13</span></a> These phenomena are present in the reported case</p><p id="par0090" class="elsevierStylePara elsevierViewall">Some authors propose CSF drainage as a diagnostic test&#44; being positive if symptoms relief is achieved&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Once the diagnosis is established&#44; different treatments have been proposed&#46; Some authors have published good results with a simple caudal epidural injection of steroids&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">8</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Percutaneous therapies have been proposed and are based on aspiration of the cyst and injection of fibrin in order to seal the communication with the subarachnoid space&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">9&#44;14</span></a> A comparative meta-analysis of surgical versus percutaneous treatment on 750 patients showed an overall improvement in 83&#46;5&#37; of patients regardless of the technique&#46; Comparing with surgical treatment&#44; percutaneous techniques showed fewer complications &#40;12&#46;47&#37; versus 21&#37;&#41; but greater radiological recurrence of the cyst &#40;20&#37; versus 8&#37;&#41; although clinical recurrence was similar &#40;21&#37; versus 20&#37;&#41;&#46; The limitation of this study is that the surgical techniques were not homogeneous&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Surgical treatment is based on the fenestration of the cyst and its imbrication&#44; closing the communication with the subarachnoid space&#46; It shows very favorable results in more than 80&#37; of cases&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">8&#44;9</span></a> The main disadvantage are complications&#44; among which CSF leak stands out&#46; To avoid them&#44; an exquisite surgical technique is essential&#46; In a systematic review of 283 patients&#44; 16&#46;9&#37; of complications were described with clinical improvement in 81&#37; of cases and radiological resolution in 79&#37;&#46; Improvement was achieved in motor deficits&#40;17&#46;8&#8211;5&#46;4&#37;&#41;&#44; sensory deficits &#40;47&#8211;14&#46;5&#37;&#41; and urinary&#47;bowel dysfunction &#40;40&#8211;14&#46;3&#37;&#41;&#46; The results were better in younger patients and if the symptoms had a shorter evolution time&#46;<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">9</span></a> A systematic review of the surgical treatment on 646 patients yielded better data with improvement in 83&#37; of the cases and 5&#46;4&#37; of complications&#44; being the fistula CSF the most frequent &#40;1&#46;7&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0130"><span class="elsevierStyleSup">10</span></a></p><p id="par0110" class="elsevierStylePara elsevierViewall">There are different surgical techniques reported&#46; Some authors recommend performing a laminoplasty to reconstruct the bone wall<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">15</span></a> and even endoscopic approaches has been used in a case of a sacral TC with radiculopathy&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">16</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The case presented is a clear example of a symptomatic Tarlov cyst with resolution of symptoms after surgical treatment&#46; We chose surgical treatment instead of percutaneous techniques due to the lack of experience with these techniques and the good results showed by surgery in literature&#46; It is important to know the symptoms associated with Tarlov cysts since neurosurgeons often disregard this pathology or do not identify it<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">11</span></a>&#44; depriving patients of a possible solution to their problem&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0120" class="elsevierStylePara elsevierViewall">TC are a quite common finding in MRI and some of them can be symptomatic&#46; It is important to know the symptoms related to them in order to set a correct diagnosis&#46; Neurophysiological studies can help in the management&#46; Surgical and percutaneous techniques are effective in the treatment of symptomatic TC&#46;</p></span></span>"
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            0 => "Tarlov cyst"
            1 => "Urogenital pain"
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            0 => "Quiste de Tarlov"
            1 => "Dolor urogenital"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tarlov cysts are a common finding in MRI&#46; Most of them are asymptomatic but in some cases can cause pain in urogenital region&#46; Diagnosis and treatment are controversial and most of the symptomatic cases are not well diagnosed and treated because of unawareness of neurosurgeons about them&#46; Treatment of symptomatic TC is effective and good results have been published with percutaneous and surgical techniques&#46; A case of a young woman with a symptomatic sacral cyst treated surgically successfully is presented and literature about it is reviewed&#46;</p></span>"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Los quistes de Talov son un hallazgo frecuente en resonancia magn&#233;tica&#46; La mayor&#237;a de ellos son asintom&#225;ticos&#44; pero en algunos casos pueden producir s&#237;ntomas dolorosos urogenitales&#46; El diagn&#243;stico y el tratamiento de los quistes de Tarlov es controvertido y la mayor&#237;a de los casos sintom&#225;ticos no son diagnosticados adecuadamente debido a que el neurocirujano no es capaz de identificar el cuadro cl&#237;nico&#46; El tratamiento de los quistes de Tarlov sintom&#225;ticos es efectivo y se han publicado buenos resultados tanto con t&#233;cnicas percut&#225;neas como quir&#250;rgicas&#46; Se presenta el caso de una mujer joven con quiste de Tarlov sintom&#225;tico intervenida quir&#250;rgicamente con resoluci&#243;n de la cl&#237;nica y se revisa la literatura publicada al respecto&#46;</p></span>"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Preoperative MRI&#46; &#40;A&#41; Sagital view showing a sacral Tarlov cyst&#46; &#40;B&#41; Axial view where it is possible to identify the nerve roots in the anterior wall of the cyst &#40;arrows&#41;&#46;</p>"
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        "etiqueta" => "Fig&#46; 2"
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Surgical steps&#46; &#40;A&#41; Cyst view after laminectomy&#46; &#40;B&#41; Roots in the anterior wall &#40;arrow&#41;&#46; &#40;C&#41; Cyst opening&#46; &#40;D&#41; Closure of the communication with the dural sac with a small piece of Tachosil&#174;&#46; &#40;E&#41; Final view of the nerve root&#46; &#40;F&#41; Titanium mesh over the laminectomy&#46;</p>"
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Postperative MRI showing the resolution of the sacral Tarlov cyst&#46; Titanium mesh is visible &#40;arrows&#41;&#44; restoring the sacral anatomy&#46;</p>"
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Más opciones de artículo
Case Report
Symptomatic sacral Tarlov cyst: Case report and review of literature
Quiste de Tarlov sacro sintomatico: presentacion de un caso y revision de la literatura
Angel Horcajadas Almansaa,
Autor para correspondencia
angel.horcajadas@gmail.com

Corresponding author.
, Ana M. Jorques Infantea, Ana M. Román Cutillasa, Luis Guzmán Álvarezb
a Neurocirugía, Hospital Vithas Granada, Spain
b Radiología, Hospital Vithas Granada, Spain

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