上海新華醫(yī)院神經(jīng)外科 腰骶神經(jīng)中心 編譯原文：Sciatic neuralgia associated with a perineural (Tarlov) cyst作者：Peter C. Emary, John A. TaylorChiropractic Department, D’Youville College, Buffalo, NY（美國(guó) 紐約州）編譯：沈霖 楊敏 審校：鄭學(xué)勝Case PresentationA 56-year-old man presented with a 2-year history of severe and progressing left-sided low back and leg pain, described as “sharp” and “pinching” when either walking or arching his lower back. The pain severity was rated as a nine out of 10, and his overall Bournemouth Questionnaire1 score totalled 39 out of a possible 70, where zero equals no disability and 70 equals complete disability. The low back and leg symptoms were most intense in the evening. Flexing his left leg at the knee joint and or taking non-steroidal anti-inflammatory medication (Ibuprofen, Advil) provided relief. On physical examination, the Straight Leg Raise test (at approximately 30° of hip flexion), the Hibb’s test, and the Yeoman’s test each elicited pain and parasthesia down the patient’s left leg; the Double Leg Raise, seated Kemp’s, and Nachlas’ tests were negative. Lower limb neurological examination (including motor, reflex, sensory, and vibratory testing) was normal.一位56歲的男性患者，有2年嚴(yán)重的左腰部和腿部疼痛的病史，主要表現(xiàn)為行走或彎曲下背部時(shí)疼痛。疼痛的嚴(yán)重程度被評(píng)為9/10，Bournemouth問(wèn)卷總得分為39分，滿分為70分，其中0分表示無(wú)殘疾，70分表示完全殘疾。腰部和腿部癥狀在夜間最為嚴(yán)重。彎曲左膝部或服用非甾體抗炎藥（布洛芬，Advil）可以緩解疼痛。體檢時(shí)，直腿抬高試驗(yàn)（髖關(guān)節(jié)屈曲約30°）、Hibb試驗(yàn)和Yeoman試驗(yàn)均引起患者左腿疼痛和麻木；雙腿抬高試驗(yàn)、坐姿Kemp試驗(yàn)和Nachlas試驗(yàn)均為陰性。下肢神經(jīng)檢查（包括運(yùn)動(dòng)、反射、感覺(jué)和振動(dòng)測(cè)試）正常。Lumbar spine magnetic resonance imaging (MRI) had been performed at a hospital one month earlier. In the attending radiologist’s report, there was a left-sided perineural/arachnoid cyst (measuring 1.1 cm) noted at the L4-5 level in addition to degenerative changes at L4-5 and L5-S1. However, no clinical correlation or recommendation for further investigations or treatment was given. Copies of the patient’s MR images were subsequently obtained and these clearly revealed that the perineural cyst was displacing the left L4 nerve root and had resulted in posterior vertebral body scalloping and enlargement of the left L4-5 neural foramen (Figures 1 and 2). Based on these findings, the patient was diagnosed with sciatic neuralgia resulting from a left-sided L4-5 perineural cyst.一個(gè)月前，患者在一家醫(yī)院做了腰椎磁共振成像。在放射科醫(yī)生的報(bào)告中，除了L4-5和L5-S1的退行性改變外，還有一個(gè)左側(cè)的神經(jīng)根囊腫（長(zhǎng)1.1厘米）。然而，當(dāng)時(shí)并沒(méi)有認(rèn)為其與患者癥狀有臨床相關(guān)性或進(jìn)一步調(diào)查或治療的建議。隨后我們獲得了患者的磁共振圖像，這些圖像清楚地顯示神經(jīng)根囊腫卡壓了左側(cè)L4神經(jīng)根，并導(dǎo)致椎體后部扇形改變及左側(cè)L4-5神經(jīng)孔擴(kuò)大（圖1和圖2）。根據(jù)這些發(fā)現(xiàn)，病人被診斷為坐骨神經(jīng)痛，并考慮是由左側(cè)L4-5神經(jīng)根囊腫引起。The patient in this case was referred back to his primary care physician with a recommendation for neurosurgical consultation. A conservative approach was taken, however, and after four months the patient’s sciatic symptoms spontaneously resolved. Because a second MRI was not obtained, it is possible that the patient’s imaging findings were coincidental to his clinical symptoms. Regardless, his improvements were still maintained at follow-up (via telephone) one year later.在神經(jīng)外科醫(yī)生的建議下，這個(gè)病例中的病人被轉(zhuǎn)回他的初級(jí)保健醫(yī)生那里?；颊卟扇×吮Ｊ刂委煹姆椒?，四個(gè)月后病人的坐骨神經(jīng)的癥狀自然消失了。一年后通過(guò)電話隨訪，患者癥狀改善仍然非常明顯。專家點(diǎn)評(píng)：鄭學(xué)勝主任醫(yī)師認(rèn)為，臨床上腰段的神經(jīng)根囊腫發(fā)病率相對(duì)骶管囊腫要低很多，且很多患者并沒(méi)有明顯的臨床癥狀。本例患者雖然通過(guò)保守治療癥狀得到了緩解。但對(duì)于癥狀保守治療無(wú)法緩解的患者，應(yīng)該積極進(jìn)行外科治療。我中心今年也遇到一例相似的患者，下面與大家分享一下?；颊撸行?，44歲，因“右側(cè)臀部、腿部疼痛不適2年余”入院?；颊呓?jīng)長(zhǎng)時(shí)間的保守治療后無(wú)效，癥狀進(jìn)行性加重，行走約500米左右就因?yàn)橛蚁轮弁葱枰菹ⅲ朐呵盁o(wú)法正常行走，疼痛難忍。入院體格檢查提示右側(cè)直腿抬高試驗(yàn)陽(yáng)性?；颊呓?jīng)長(zhǎng)時(shí)間的藥物保守治療無(wú)效，在影像學(xué)檢查排除了其他可能的原因后，我們最后診斷考慮為腰5骶1神經(jīng)根囊腫引起的坐骨神經(jīng)痛，最后與患者充分溝通后，我們給予患者行神經(jīng)根囊腫封堵術(shù)治療。治療后，患者疼痛癥狀隨即明顯好轉(zhuǎn)，目前已恢復(fù)正常行走。 對(duì)于一些相對(duì)特殊罕見(jiàn)的神經(jīng)根囊腫的患者，需要明確囊腫所在節(jié)段和患者癥狀是否相對(duì)應(yīng)；重視體格檢查，充分完善影像學(xué)檢查后排除其他可能原因后，制定進(jìn)一步的治療方案。同時(shí)，對(duì)于不在骶管內(nèi)的腰骶神經(jīng)根囊腫，由于其發(fā)病機(jī)制與骶管囊腫基本是一致的，因此可以考慮直接針對(duì)病因治療，行神經(jīng)根漏口封堵術(shù)，同樣也能夠取得令人滿意的治療效果。

一、骶管囊腫的病人，可以懷孕嗎？懷孕會(huì)加重骶管囊腫嗎？ 鄭學(xué)勝：如果骶管囊腫已經(jīng)很大，或者癥狀很嚴(yán)重，或影響大小便功能了，應(yīng)該先做骶管囊腫手術(shù)之后再懷孕，因?yàn)閼言泻筒溉槭且粋€(gè)很長(zhǎng)的周期，有的骶管囊腫不宜久拖。相反，如果骶管囊腫較小，癥狀也不明顯，可以先懷孕。上海交通大學(xué)醫(yī)學(xué)院附屬新華醫(yī)院神經(jīng)外科鄭學(xué)勝二、骶管囊腫病人，選擇自然分娩還是選擇剖腹產(chǎn)？ 鄭學(xué)勝：我們沒(méi)有特別的要求，根據(jù)產(chǎn)科醫(yī)生的選擇即可。由于分娩的時(shí)間總歸是比較短的，在很有限的時(shí)間里，哪怕自然分娩時(shí)腹壓增高得更明顯，對(duì)骶管囊腫的影響是不大的。如果是骶管囊腫術(shù)后病人，由于漏口已經(jīng)嚴(yán)密封堵，也經(jīng)得起分娩的考驗(yàn)。三、骶管囊腫術(shù)后病人，可以做腰麻嗎？ 鄭學(xué)勝：骶管囊腫的手術(shù)切口很小，一般只有4—5厘米，切口最高一般不高于腰5水平，所以可以從更高一點(diǎn)的節(jié)段做腰麻。四、骶管囊腫會(huì)導(dǎo)致不孕嗎？ 鄭學(xué)勝：影響懷孕的因素主要是女性生殖系統(tǒng)和激素水平，與神經(jīng)功能關(guān)系不大。例如：著名體操運(yùn)動(dòng)員桑蘭由于頸髓完全性損傷導(dǎo)致高位截癱，大小便功能也喪失，但是在現(xiàn)代醫(yī)學(xué)的呵護(hù)下仍然成功地懷孕生育。這么多年的臨床上，我們從未見(jiàn)過(guò)骶管囊腫或骶管囊腫手術(shù)導(dǎo)致不孕的病例。

上海新華醫(yī)院神經(jīng)外科 腰骶神經(jīng)中心編譯原文：Spinal cord stimulation for the treatment of chronic pelvic pain after Tarlov cyst surgery in a 66-year-old woman: A case report作者：Jamal Hasoon , Amnon A. Berger , Ivan Urits , Vwaire Orhurhu , Omar Viswanath, Musa Aner.Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America(美國(guó)，波士頓)編譯：沈霖 楊敏 審校：鄭學(xué)勝AbstractTarlov cysts are extradural meningeal cysts with collections of cerebrospinal fluid within the nerve sheath. These cysts are uncommon but tend to present more often in women. Symptomatic Tarlov cysts can lead to a variety of neurologic symptoms and painful conditions, including chronic pelvic pain. There is no consensus regarding the best treatment for symptomatic cysts. Surgical management has high rates of complication, including chronic pain, but better long-term results for symptom and cyst resolution. We describe a patient who developed worsening pelvic pain and lumbar radiculopathy after surgical management of her Tarlov cysts. Medication failed to relieve the pain, as did a variety of other procedures, before the patient ultimately received significant pain relief from high-frequency spinal cord stimulation. This case may provide guidance for physicians when managing patients suffering from symptomatic Tarlov cysts, or worsening pain symptoms after surgical management of these cysts.骶管囊腫是一種由于腦脊液在神經(jīng)鞘內(nèi)聚集引起的硬膜外囊腫。這類囊腫臨床上相對(duì)不常見(jiàn)的，但往往更常見(jiàn)于婦女。癥狀性骶管囊腫可導(dǎo)致多種神經(jīng)癥狀和疼痛狀況，包括慢性盆底疼痛。對(duì)于癥狀性囊腫的最佳治療，目前尚無(wú)共識(shí)。手術(shù)治療有相對(duì)較高的并發(fā)癥發(fā)生率，包括慢性疼痛，但對(duì)癥狀的緩解及囊腫的長(zhǎng)期治療效果更好。我們介紹一位在接受骶管囊腫手術(shù)治療后盆底疼痛進(jìn)行性加重以及出現(xiàn)腰椎神經(jīng)根病的患者。在藥物保守治療及其他治療方式無(wú)效的情況下，患者最終通過(guò)高頻脊髓刺激中獲得顯著的疼痛緩解。這個(gè)病例可以為臨床醫(yī)生在治療有癥狀的骶管囊腫或手術(shù)治療后疼痛癥狀進(jìn)一步加重的患者提供指導(dǎo)。Case DescriptionThe patient was a 66-year-old woman with a longstanding history of chronic pelvic pain secondary to multiple large Tarlov cysts affecting the S1-S4 nerve roots. She had attempted medication management with acetaminophen, NSAIDs, and neuropathic pain medications. She had also undergone a series of epidural steroid injections and a trial of superior hypogastric plexus blocks but obtain minimal relief with these. She ultimately had surgery for the removal of the Tarlov cysts as well as sacral lamina reconstruction (Fig. 1). However, the patient's surgery resulted in worsening of her chronic pelvic pain, and also produced new-onset back pain and lumbar radiculopathy down both legs. The patient reported constant debilitating back and pelvic pain with intermittent stabbing and burning pain in her legs. Her worsening symptoms were uncontrolled with continued medication management as well as a repeat series of epidural steroid injections.患者是一位66歲女性，長(zhǎng)期有慢性盆底疼痛病史，繼發(fā)于累及S1-S4神經(jīng)根的多發(fā)巨大骶管囊腫。她曾嘗試用對(duì)乙酰氨基酚、非甾體抗炎藥和神經(jīng)性疼痛藥物進(jìn)行藥物治療。她還接受了一系列硬膜外類固醇注射和上腹部下叢阻滯的試驗(yàn)，但這些都取得極少程度的緩解。她最終接受了骶管囊腫切除和骶骨板重建手術(shù)（圖1）。然而，手術(shù)后她的慢性骨盆疼痛惡化，也產(chǎn)生了新發(fā)的背痛和雙腿的腰神經(jīng)根病。病人存在持續(xù)的背部和骨盆疼痛伴隨間歇性刺傷和腿部灼痛。通過(guò)持續(xù)的藥物治療以及一系列重復(fù)的硬膜外類固醇注射，她的癥狀沒(méi)有得到控制。Given that the patient's worsening symptoms were unrelieved with both medication management and interventional pain procedures, we tried high-frequency spinal cord stimulation for her worsening pain and new-onset radiculopathy.考慮到患者癥狀在藥物治療和介入性疼痛治療中都沒(méi)有得到緩解，我們嘗試高頻脊髓刺激治療其疼痛惡化和新發(fā)神經(jīng)根病。The patient was counseled regarding the risks and benefits of the procedure and elected to proceed. A spinal cord stimulator lead was introduced into the epidural space and advanced to the superior endplate of T8. A second lead was placed at the superior endplate of T9 (Fig. 2). The patient presented for follow-up after the procedure and reported significant improvement in her symptoms. She noted that the use of SCS had resulted in a 90% improvement of her back pain, a 95% improvement in her pelvic pain, and N50% improvement in her radiculopathy. Additionally, she reported she was much more active and was able to decrease her medication use with the pain relief she obtained from spinal cord stimulation.告知病人相關(guān)風(fēng)險(xiǎn)和獲益后，患者選擇接受治療。治療過(guò)程中，將脊髓刺激器導(dǎo)線引入硬膜外腔，并推進(jìn)到胸8的上終板。第二根導(dǎo)線被放置在胸9的上終板上（圖2）。病人在手術(shù)后接受隨訪，并報(bào)告其癥狀有明顯改善。她注意到使用脊神經(jīng)電刺激后腰痛改善了90%，盆底疼痛改善了95%，神經(jīng)根病改善了50%。此外，她本人說(shuō)，她變得更加積極，同時(shí)能夠減少藥物的使用，并從脊髓電刺激中緩解了疼痛。DiscussionThere is no consensus on the optimal management of symptomatic Tarlov cysts. Percutaneous cyst drainage is a nonsurgical intervention has been used to treat this condition. This treatment is only temporary though, as cysts tend to gradually reform and symptoms recur. In addition to percutaneous drainage, one study has demonstrated that cyst aspiration with the placement of fibrin glue can prevent recurrence of the cysts. However, these patients are also at significant risk for postprocedural aseptic meningitis.對(duì)于有癥狀的骶管囊腫的最佳治療尚無(wú)共識(shí)。經(jīng)皮囊腫穿刺引流術(shù)是一種非手術(shù)治療方法，已被用于治療這種情況。但這種治療效果只是暫時(shí)的，因?yàn)槟夷[會(huì)逐漸復(fù)原，癥狀會(huì)復(fù)發(fā)。除了經(jīng)皮穿刺引流外，一項(xiàng)研究已經(jīng)證明囊腫抽吸加纖維蛋白膠可以防止囊腫復(fù)發(fā)。然而，這些患者也存在術(shù)后無(wú)菌性腦膜炎的顯著風(fēng)險(xiǎn)。Surgical treatment of symptomatic cysts varies and can involve complete cyst removal with excision of the affected posterior root and ganglion, decompressive laminectomy, cyst wall resection, and cyst fenestration. The success and complication rates vary greatly by procedure. Again, there is no consensus regarding when surgical management for Tarlov cysts is warranted, though one study suggested that cysts larger than 1.5 cm with associated radicular pain or bowel/bladder dysfunction may benefit the most from surgical intervention.有癥狀的骶管囊腫的外科治療方法各不相同，可包括完全切除囊腫，切除病變的后根和神經(jīng)節(jié)，椎板減壓切除，囊腫壁切除，囊腫開(kāi)窗術(shù)。手術(shù)成功率和并發(fā)癥發(fā)生率因手術(shù)方式而異。同樣，對(duì)于何時(shí)手術(shù)治療骶管囊腫尚無(wú)共識(shí)，盡管一項(xiàng)研究表明，大于1.5 cm的囊腫伴有相關(guān)的神經(jīng)根痛或腸/膀胱功能障礙可從手術(shù)干預(yù)中獲益最大。We would also like to comment on the success of spinal cord stimulation in this patient. SCS has been proven to be effective for treating intractable neuropathic pain such as lumbar radiculopathy and postlaminectomy syndrome. There is also growing evidence that SCS can even be helpful for treating debilitating chronic visceral pelvic pain. We believe this case is of importance as it describes the complicated management of patients with symptomatic Tarlov cysts who ultimately fail to respond to conservative therapy. We also describe the use of SCS in this patient and the benefit it can provide for patients who are suffering from severe radiculopathy after surgery as well as those with chronic pelvic pain (Fig. 3).我們還想評(píng)論一下這個(gè)病人脊髓刺激治療的成功。脊髓電刺激已被證明是一種有效的治療難治性神經(jīng)源性疼痛的方法，如腰神經(jīng)根病和椎板切除術(shù)后綜合征。也有越來(lái)越多的證據(jù)表明，脊髓電刺激治療甚至可以幫助治療慢性盆底疼痛。我們相信這個(gè)病例很重要，因?yàn)樗枋隽擞邪Y狀的骶管囊腫患者的綜合處理，而且這些患者對(duì)保守治療無(wú)效。我們還描述了脊髓電刺激在該患者中的應(yīng)用及其對(duì)術(shù)后嚴(yán)重神經(jīng)根病以及慢性盆底疼痛患者的益處（圖3）。專家點(diǎn)評(píng)：鄭學(xué)勝主任認(rèn)為，該患者是繼發(fā)于骶管囊腫的慢性盆底疼痛，且本例患者骶管囊腫的治療方式值得商榷。骶管囊腫的手術(shù)治療核心在于封堵，而不是囊腫切除，切除的所謂“囊壁”是正常的神經(jīng)根袖，將囊腫完全切除勢(shì)必會(huì)損傷骶管內(nèi)正常的神經(jīng)，從而導(dǎo)致術(shù)后癥狀加重，甚至有大小便功能障礙的風(fēng)險(xiǎn)。此外，從術(shù)后磁共振上看，該患者切除了骶骨椎板，破壞骶骨的完整性，使得硬脊膜內(nèi)巨大的靜水壓直接作用于腰骶部肌肉，這也是導(dǎo)致患者術(shù)后腰骶部疼痛重要原因之一。該患者在手術(shù)治療后癥狀進(jìn)行性加重，最后采取了脊髓神經(jīng)電刺激治療緩解了疼痛癥狀。骶管囊腫可以引起腰骶部、會(huì)陰部、盆底、下肢疼痛，排尿排便功能障礙等癥狀，骶管囊腫的手術(shù)治療僅僅是針對(duì)病因治療，即使解除了病因，長(zhǎng)期慢性的神經(jīng)損傷會(huì)導(dǎo)致部分患者術(shù)后慢性盆底疼痛、排尿排便功能恢復(fù)不甚理想，而在藥物、理療、疼痛介入治療等方式效果不理想的情況，可以建議此類患者考慮行神經(jīng)電刺激治療。目前神經(jīng)電刺激治療日趨成熟，包括脊髓電刺激、骶神經(jīng)刺激對(duì)于改善慢性盆底疼痛均有良好的效果。此外，骶神經(jīng)刺激還可以針對(duì)排尿排便功能恢復(fù)不理想的患者進(jìn)行針對(duì)性的改善。臨床上，已經(jīng)有許多患者已經(jīng)從神經(jīng)電刺激治療中獲益。

上海新華醫(yī)院神經(jīng)外科 腰骶神經(jīng)中心鄭學(xué)勝 楊敏 沈霖很多骶管囊腫患者會(huì)問(wèn)，醫(yī)生是怎么根據(jù)疼痛部位來(lái)判斷哪一個(gè)神經(jīng)根出了問(wèn)題？下面的兩張圖說(shuō)明下肢和臀部、會(huì)陰部的皮膚感覺(jué)所對(duì)應(yīng)的神經(jīng)根分布區(qū)，醫(yī)學(xué)上稱為皮節(jié)。其中T代表胸神經(jīng)，L代表腰神經(jīng)，S代表骶神經(jīng)。例如：S2就代表骶2神經(jīng)根。如圖：骶1神經(jīng)根主要負(fù)責(zé)小腿后方、足跟、足底的皮膚感覺(jué)；骶2神經(jīng)根主要負(fù)責(zé)大腿后方、大腿內(nèi)上方、小腿后方的感覺(jué)。而臀部、肛門、會(huì)陰部的皮膚感覺(jué)主要由骶3、4、5神經(jīng)根分布。由于骶管囊腫對(duì)神經(jīng)根是一個(gè)囊性的壓迫，所以隨著壓力的變化，癥狀時(shí)輕時(shí)重，一般久站、久坐以后，壓力越來(lái)越高，則疼痛加重，平臥休息以后好轉(zhuǎn)。癥狀性骶管囊腫一般體積較大，所以左側(cè)起源的骶管囊腫，只要其體積夠大，也可以壓迫右側(cè)的神經(jīng)根，因?yàn)檎５镊竟芤话阒挥?.5cm寬度，大于1.5cm的骶管囊腫都可能影響雙側(cè)。同理，上位神經(jīng)根起源的骶管囊腫不僅壓迫對(duì)應(yīng)的神經(jīng)根，而且可以壓迫下位的神經(jīng)根；例如，骶1神經(jīng)根起源的骶管囊腫，可以引起足跟、小腿后方疼痛，也可以引起肛門、會(huì)陰部墜脹痛；但是，下位神經(jīng)根起源的骶管囊腫一般不會(huì)影響到上位的神經(jīng)根。上述這兩方面原理，就導(dǎo)致了臨床上骶管囊腫疼痛部位呈游走性，疼痛程度呈波動(dòng)性。需要強(qiáng)調(diào)的一點(diǎn)是，疼痛的皮節(jié)分布在人群中有很大的個(gè)體差異，不能機(jī)械的理解，需要結(jié)合其它神經(jīng)系統(tǒng)體征綜合判斷。

上海新華醫(yī)院神經(jīng)外科 腰骶神經(jīng)中心鄭學(xué)勝 楊敏 沈霖骶管囊腫患者通常是有慢性疼痛的。常見(jiàn)的疼痛癥狀包括骶尾部酸痛，肛門墜脹痛，會(huì)陰部墜脹痛，臀部脹痛，小腿、足跟、足底抽痛。雖然疼痛本身只有3分左右（VAS評(píng)分：0-10分），但是因?yàn)樘弁吹某志眯?，?jīng)常導(dǎo)致患者焦慮和抑郁癥，焦慮和抑郁進(jìn)一步加重患者的疼痛感，本來(lái)3分的疼痛，病人感到8-9分，常說(shuō)“痛不欲生”，這樣疼痛又進(jìn)一步強(qiáng)化了焦慮和抑郁癥，所以這是一個(gè)相互加重的惡性循環(huán)。而且焦慮和抑郁一旦出現(xiàn)，有可能持續(xù)多年，越來(lái)越嚴(yán)重，無(wú)法自拔，并可能產(chǎn)生次生危害。所以，骶管囊腫患者及家屬要特別注意主動(dòng)克服焦慮。以下是我們的提示：（1）骶管囊腫不是什么惡性的疾病，最嚴(yán)重的后果無(wú)非就是疼痛、大小便障礙；在整個(gè)疾病譜當(dāng)中，不算很嚴(yán)重的病種。既不會(huì)影響生命，也不會(huì)惡變，而且是一種可以治愈的疾病，不需要恐慌，從戰(zhàn)略上要藐視它。但是由于網(wǎng)絡(luò)上有些病友的渲染，把它說(shuō)得非?？膳拢@對(duì)于一些本來(lái)就疑心很重的中老年人，容易引起他們的焦慮；所以患者和家屬要主動(dòng)遠(yuǎn)離那些有意渲染疾病恐懼的人——他們除了加重你的恐慌和焦慮，并不能提供任何有價(jià)值的信息。（2）如果骶管囊腫疼痛真的很明顯，就不要久拖，觀察一段時(shí)間不能緩解，應(yīng)及時(shí)微創(chuàng)手術(shù)治療，手術(shù)風(fēng)險(xiǎn)不大，治愈率很高，復(fù)發(fā)率低于5%。根據(jù)日本學(xué)者M(jìn)inami教授的研究報(bào)道（Journal of Neuroscience），如果疼痛嚴(yán)重，并且持續(xù)時(shí)間長(zhǎng)，就會(huì)慢慢地在大腦紋狀體和丘腦增強(qiáng)CRF神經(jīng)肽信號(hào)傳導(dǎo)，從而引發(fā)抑郁癥。早期的焦慮是可以通過(guò)心理疏導(dǎo)治愈，而如果長(zhǎng)期疼痛導(dǎo)致大腦神經(jīng)遞質(zhì)變化引起抑郁癥就不是個(gè)人意志能夠?qū)沽?，必須通過(guò)長(zhǎng)期抗抑郁藥物治療才能逆轉(zhuǎn)。（3）骶管囊腫手術(shù)兩周后，病人恢復(fù)直立活動(dòng)，骶管囊腫的手術(shù)切口就必須承受強(qiáng)大的靜水壓（高達(dá)1100mm水柱）的牽張，所以會(huì)有持續(xù)壓力的感覺(jué)，這是和其它手術(shù)都不同的地方。因此，骶管囊腫的手術(shù)切口我們會(huì)縫合得非常嚴(yán)密，并且臥床時(shí)間相對(duì)較長(zhǎng)，然后逐步增加直立活動(dòng)的時(shí)間，慢慢地傷口越長(zhǎng)越好，一般要半年或一年左右，才能達(dá)到完全承受靜水壓的強(qiáng)度，這就是為什么骶管囊腫術(shù)后需要一個(gè)較長(zhǎng)恢復(fù)時(shí)間的道理。美國(guó)賓夕法尼亞大學(xué)的臨床觀察也證實(shí)這個(gè)修復(fù)時(shí)間大約需要一年左右。在這個(gè)恢復(fù)期，如果長(zhǎng)時(shí)間站立，會(huì)感到切口周圍和切口下方的墜脹感，這是完全正常的，只要稍微平臥休息一下就會(huì)緩解。我們鼓勵(lì)逐漸增加活動(dòng)量，因?yàn)槿梭w組織“用進(jìn)廢退”，只有慢慢增加活動(dòng)量，切口周圍的肌肉才會(huì)逐漸增強(qiáng)，最終達(dá)到足夠強(qiáng)度。遺憾的是，有的病人對(duì)恢復(fù)期癥狀心存疑慮，天天上網(wǎng)收集負(fù)面消息，選擇性地相信那些負(fù)面內(nèi)容，自我誘導(dǎo)或病友之間相互誘導(dǎo)，不斷強(qiáng)化負(fù)面情緒，最終導(dǎo)致焦慮癥和抑郁癥，陷入泥淖不能自拔。我們近期發(fā)現(xiàn)了這種趨勢(shì)，所以要求所有骶管囊腫患者退出微信群、QQ群，任何問(wèn)題直接咨詢醫(yī)生，這是對(duì)患者負(fù)責(zé)任的做法。（4）多吃肉類食品、增強(qiáng)營(yíng)養(yǎng)，適度慢跑，切口局部用按摩器進(jìn)行按摩，可以促進(jìn)切口周圍的肌肉生長(zhǎng)，加快愈合過(guò)程。這對(duì)于本身瘦弱的病人尤其重要。（5）患者家屬要始終樂(lè)觀地引導(dǎo)病人，避免病人焦慮。有的家屬看起來(lái)比病人自己還要恐慌，好像越驚慌就是越關(guān)心，這樣的家屬表面上好像很關(guān)心病人，其實(shí)是誤導(dǎo)了病人，加重了病人的憂慮。正確的做法是保持樂(lè)觀，始終鼓勵(lì)。如果發(fā)現(xiàn)病人經(jīng)常失眠、食欲很差、表情淡漠，就要及時(shí)看心理衛(wèi)生科，如果必要，及時(shí)抗焦慮、抗抑郁藥物治療，打斷這個(gè)惡性循環(huán)，因?yàn)橐钟舭Y的危害要比骶管囊腫更大。

上海新華醫(yī)院神經(jīng)外科 腰骶疾病診治中心 編譯原文：Comparative Outcomes of the Two Types of Sacral Extradural Spinal Meningeal Cysts Using Different Operation Methods: A Prospective Clinical Study作者：Jian-jun Sun, Zhen-yu Wang, Mario Teo, Zhen-dong Li, Hai-bo Wu , Ru-yu Yen , Mei Zheng , Qing Chang , Isabelle Yisha LiuDepartment of Head and Neck Surgery, UCLA Medical Center, Los Angeles, California, United States of America （美國(guó) 洛杉磯）編譯：楊敏、沈霖 校對(duì)：鄭學(xué)勝摘要：This prospective study compares different clinical characteristics and outcomes of patients with two types of sacral extradural spinal meningeal cysts (SESMC) undergoing different means of surgical excision. Using the relationship between the cysts and spinal nerve roots fibers (SNRF) as seen under microscope, SESMCs were divided into two types: cysts with SNRF known as Tarlov cysts and cysts without. The surgical methods were tailored to the different types of SESMCs. The improved Japanese Orthopedic Association (IJOA) scoring system was used to evaluate preoperative and postoperative neurological function of the patients. Preoperative IJOA scores were 18.5±1.73, and postoperative IJOA scores were 19.6±0.78. The difference between preoperative and postoperative IJOA scores was statistically significant (t = -4.52, p = 0.0001), with a significant improvement in neurological function after surgery. Among the improvements in neurological functions, the most significant was sensation (z=-2.74, p=0.006), followed by bowel/bladder function (z=-2.50, p=0.01). There was a statistically significant association between the types of SESMC and the number (F=12.57, p=0.001) and maximum diameter (F=8.08, p=0.006) of the cysts. SESMC with SNRF are often multiple and small, while cysts without SNRF tend to be solitary and large. We advocate early surgical intervention for symptomatic SESMCs in view of significant clinical improvement postoperatively.這項(xiàng)前瞻性研究比較了兩種不同類型骶管囊腫（SESMC），經(jīng)過(guò)不同手術(shù)方式治療后的不同臨床特征和預(yù)后。根據(jù)囊腫與脊神經(jīng)根纖維（SNRF）在顯微鏡下的關(guān)系，將骶管囊腫分為兩種類型：一種是有脊神經(jīng)根纖維的囊腫，稱為Tarlov’s囊腫，另一種是沒(méi)有脊神經(jīng)根纖維的囊腫。根據(jù)不同類型的骶管囊腫，采用不同的手術(shù)方法。采用改良的日本骨科協(xié)會(huì)（IJOA）評(píng)分系統(tǒng)進(jìn)行評(píng)價(jià)，患者手術(shù)前后神經(jīng)功能狀況。術(shù)前IJOA評(píng)分為18.5±1.73，術(shù)后IJOA評(píng)分為19.6±0.78。手術(shù)前后IJOA評(píng)分的差異有統(tǒng)計(jì)學(xué)意義（t=-4.52，p=0.0001），術(shù)后神經(jīng)功能顯著改善。其中神經(jīng)功能改善最為顯著（z=-2.74,p=0.006），其次是腸道/膀胱功能（z=-2.50，p=0.01）。骶管囊腫的類型、數(shù)量（F=12.57，p=0.001）和最大直徑（F=8.08，p=0.006），在統(tǒng)計(jì)學(xué)上有顯著的相關(guān)性。有脊神經(jīng)根纖維的囊腫通常是多發(fā)的小囊腫，而沒(méi)有脊神經(jīng)根纖維的囊腫往往是孤立的和大的。鑒于術(shù)后臨床顯著改善，我們提倡對(duì)有癥狀的骶管囊腫進(jìn)行早期手術(shù)干預(yù)。手術(shù)時(shí)機(jī)：When neural irritation symptoms occurred in patients with sacral extradural spinal meningeal cysts (SESMCs), and when bone erosion was found in the neuroimaging, surgical intervention was highly recommended for these patients. When sacral extradural spinal meningeal cyst was discovered incidentally, the patient would be kept under yearly surveillance. Surgical intervention would only be carried out if the cyst progressively enlarged, or patient became symptomatic.骶管囊腫患者出現(xiàn)神經(jīng)刺激癥狀時(shí)，當(dāng)神經(jīng)影像學(xué)發(fā)現(xiàn)骶骨被囊腫侵蝕時(shí)，強(qiáng)烈建議這兩類患者進(jìn)行外科手術(shù)治療。當(dāng)體檢偶然發(fā)現(xiàn)骶管囊腫時(shí)，患者應(yīng)進(jìn)行每年的復(fù)查。當(dāng)囊腫逐漸增大或病人出現(xiàn)癥狀時(shí)，即應(yīng)進(jìn)行手術(shù)治療。手術(shù)方式：Our operative technique followed the standard procedures for SESMCs surgery. An incision was made from L5 to S3, and the sacral laminae were completely exposed according to the location of SESMCs. Laminectomy was performed with a rongeur, while carefully preserving the integrity of the underlying cyst. The surgical microscope was then brought into the field. The terminal thecal sac was identified and dissected free from the overlying cysts. Each cyst was dissected from surrounding structures to reveal its origin and relationships with SNRFs by the senior authors (ZY Wang, JJ Sun). If the SESMCs were identified as those with SNRFs (Figure 1), the cysts were partially resected and the defect oversewn to prevent CSF leakage from the subarachnoid space and the nerve root sheath reconstructed. Redundant cyst wall was shrunk using bipolar cautery. If the SESMCs were identified as those without SNRFs, which originated in the armpit of SNRFs (Figure 2) or extremity of terminal pool (Figure 3), the neck of cyst was transfixed, ligated and the remaining cyst wall resected distal to the ligation. If the cysts were associated with a tethered cord, then untethering would be performed during the same procedure. Intraoperative neurophysiological monitoring was used to differentiate SNRFs from other tissues. Electrical stimulation was used to verify that no motor nerve fibers were involved. The closure was reinforced with a local muscle flap.我們的手術(shù)技術(shù)遵循硬膜外脊膜囊腫手術(shù)的標(biāo)準(zhǔn)程序。從L5至S3切口，根據(jù)囊腫的位置完全暴露骶骨椎板。椎板切除術(shù)是用咬骨鉗進(jìn)行的，同時(shí)小心地保護(hù)下一層囊腫的完整性。在手術(shù)顯微鏡下操作。確認(rèn)硬脊膜囊的終末端，并解剖出囊腫。最后的鞘囊被確定和解剖沒(méi)有覆蓋的囊腫。每一個(gè)囊腫都從周圍結(jié)構(gòu)中解剖出來(lái)的，以揭示其起源和與神經(jīng)根纖維的關(guān)系。如果囊腫被鑒定為神經(jīng)根纖維型（圖1），囊腫部分切除，缺損部分閉合，以防止腦脊液漏，重建神經(jīng)根鞘。用雙極燒灼法縮小多余的囊壁。如果確定囊腫是不含神經(jīng)根纖維的，起源于神經(jīng)根的腋窩（圖2）或終末期池的末端（圖3），則將囊腫頸部縫合、結(jié)扎，并切除結(jié)扎遠(yuǎn)端的剩余囊壁。如果囊腫與系帶有關(guān)，則在同一程序中進(jìn)行解除栓系。術(shù)中神經(jīng)生理監(jiān)測(cè)用于區(qū)分神經(jīng)根纖維與其他組織。用電刺激證實(shí)沒(méi)有運(yùn)動(dòng)神經(jīng)纖維參與。局部肌肉瓣加強(qiáng)閉合。專家點(diǎn)評(píng)：1、新華醫(yī)院神經(jīng)外科鄭學(xué)勝主任指出，關(guān)于手術(shù)時(shí)機(jī)，新華的觀點(diǎn)和本文觀點(diǎn)一致，當(dāng)有神經(jīng)刺激癥狀時(shí)，或當(dāng)神經(jīng)影像學(xué)發(fā)現(xiàn)骶骨被侵蝕時(shí)，強(qiáng)烈建議這些患者進(jìn)行外科手術(shù)治療。當(dāng)偶然發(fā)現(xiàn)骶骨硬膜外脊膜囊腫時(shí)，建議患者應(yīng)每年進(jìn)行核磁共振的復(fù)查。當(dāng)發(fā)現(xiàn)囊腫逐漸有增大或病人出現(xiàn)癥狀時(shí)，即應(yīng)進(jìn)行手術(shù)治療。2、本文發(fā)現(xiàn)有神經(jīng)根纖維的囊腫通常是多發(fā)的小囊腫，而沒(méi)有神經(jīng)根纖維的囊腫往往是孤立的和大的。根據(jù)新華的經(jīng)驗(yàn)，囊腫的大小通常與漏口的大小有正相關(guān)性。有神經(jīng)根纖維的囊腫，當(dāng)漏口大、流量高時(shí)，亦可形成較大的囊腫，甚至有個(gè)別成為突入盆腔的巨大囊腫。我們發(fā)現(xiàn)終絲性囊腫（文中的圖3），此類囊腫往往較大并伴有栓系，對(duì)于此類囊腫，我們的經(jīng)驗(yàn)是在硬脊膜下切斷終絲，在囊腫內(nèi)切斷終絲并縫合結(jié)扎漏口。3、有些患者在囊腫存在的同時(shí)，合并有脊柱裂、脊髓栓系，在處理囊腫的同時(shí)，一定要解除栓系，對(duì)提高術(shù)后療效有必要的作用。4、本文中提到有神經(jīng)纖維通過(guò)的囊腫，新華主張骶管囊腫漏口封堵 + 神經(jīng)根袖重建的微創(chuàng)手術(shù)，可以有效降低復(fù)發(fā)率。具體可參考鄭學(xué)勝好大夫網(wǎng)站文章《一文看懂骶管囊腫微創(chuàng)手術(shù)的方方面面（圖文詳解，建議收藏?。?、我們同意本文中關(guān)于顯微鏡和神經(jīng)電生理術(shù)中檢測(cè)的應(yīng)用，這兩項(xiàng)措施可以有效減少術(shù)中神經(jīng)損傷并發(fā)癥。

上海新華醫(yī)院神經(jīng)外科 腰骶神經(jīng)中心鄭學(xué)勝 楊敏 沈霖我們的好大夫在線科普文章 《一文看懂骶管囊腫微創(chuàng)手術(shù)的方方面面（圖文詳解，建議收藏！）》介紹了骶管囊腫漏口封堵 + 神經(jīng)根袖重建的手術(shù)方法。圖1：這是正常骶神經(jīng)根的示意圖，神經(jīng)根外面包裹了一層神經(jīng)根袖（綠色）圖2：骶管囊腫示意圖：由于某個(gè)神經(jīng)根袖和硬脊膜囊的移行之處，即神經(jīng)根離開(kāi)硬脊膜囊的地方先天薄弱，所以腦脊液在巨大靜水壓的驅(qū)動(dòng)下涌入神經(jīng)根袖，把神經(jīng)根袖撐開(kāi)，就形成了骶管囊腫。囊壁就是被撐大的神經(jīng)根袖。圖3：骶管囊腫微創(chuàng)手術(shù)分3步：第一步通過(guò)顯微縫合技術(shù)，用一小片肌肉把腦脊液漏口嚴(yán)密封堵，盡量做到滴水不漏，同時(shí)保護(hù)好穿行的神經(jīng)根，漏口封堵是決定手術(shù)成敗最關(guān)鍵的技術(shù)。第二步把囊腫內(nèi)的腦脊液吸掉，把囊壁（即擴(kuò)張的神經(jīng)根袖）折疊包住神經(jīng)根，稱為神經(jīng)根袖重建。圖4：手術(shù)的第三步，由于骶骨被骶管囊腫的靜水壓長(zhǎng)期侵蝕，骨性的骶管已經(jīng)明顯擴(kuò)大了，而骨質(zhì)不會(huì)再生，所以在骨性骶管里需要填入一些脂肪和肌瓣。這一步其實(shí)無(wú)關(guān)緊要，因?yàn)榍懊嬉呀?jīng)把骶管囊腫的漏口嚴(yán)密封堵了，不再有腦脊液漏了，所以脂肪和肌瓣不需要填的很緊，只要大體填滿就可以。現(xiàn)在有個(gè)問(wèn)題：有的國(guó)外專家不做漏口封堵，只做神經(jīng)袖重建，這樣能行嗎？我們認(rèn)為是不妥的。圖5：有的國(guó)外專家不封堵漏口，只做神經(jīng)根袖重建。圖6：他們考慮神經(jīng)根袖重建以后的強(qiáng)度不夠，兜不住腦脊液漏，于是在神經(jīng)根袖的外面再包一層牛心包（即人工硬膜，紫色）。圖7：然后在骶管里填入一些脂肪和肌瓣。圖8：我們認(rèn)為，國(guó)外專家的這種做法并不可靠。1. 牛心包的強(qiáng)度并不足以抵抗強(qiáng)大的靜水壓！靜水壓連4cm厚的骶骨都可以侵蝕掉，區(qū)區(qū)牛心包根本兜不住這個(gè)靜水壓；2. 牛心包并不能嚴(yán)密包裹整個(gè)神經(jīng)根袖全長(zhǎng)，特別是和硬脊膜囊移行的地方，無(wú)法緊密包裹，只要有一小段包不住，很快就重新被腦脊液撐開(kāi)，并越撐越大，因?yàn)闆](méi)有封堵漏口。圖9：所以，神經(jīng)根袖重建不能代替漏口封堵，很容易復(fù)發(fā)。

如果您門診查體報(bào)告單有“骶管囊腫”,怎么辦？ 　　1.骶管囊腫是什么樣的囊腫？ 　　2.骶管囊腫會(huì)產(chǎn)生癥狀嗎？ 　　3.骶管囊腫需要處理嗎？ 　　4.骶管囊腫的處理方法？ 　　今天我們結(jié)合病例分享和文獻(xiàn)回顧，來(lái)回答這些問(wèn)題吧！ 　　1 典型病例分享 男性，67歲，手術(shù)后臀部及右下肢疼痛麻木、便秘基本消失。 　　2 骶管囊腫及其分類 　?。ㄊ裁词趋竟苣夷[？） 　　骶管囊腫 　　骶管囊腫是骶管內(nèi)囊性病變的總稱，包括神經(jīng)束膜囊腫、脊膜囊腫、脊膜憩室、蛛網(wǎng)膜囊腫等多種類型。最常見(jiàn)的是神經(jīng)束膜囊腫（Tarlov Cyst），比例超過(guò)90%以上。 　　Tarlov 　　1938年，Tarlov對(duì)30例終絲標(biāo)本進(jìn)行研究時(shí)，偶然發(fā)現(xiàn)了骶神經(jīng)周圍囊腫，囊腫起自脊神經(jīng)節(jié)與脊神經(jīng)后根交界處，神經(jīng)內(nèi)膜和神經(jīng)束膜之間，囊壁由神經(jīng)纖維或脊神經(jīng)節(jié)細(xì)胞覆以脊膜上皮組成，稱為神經(jīng)束膜囊腫或Tarlov囊腫。Tarlov囊腫多發(fā)或單發(fā)，多見(jiàn)于骶椎，以骶2及骶3最為多見(jiàn)。影像學(xué)資料顯示成年人Tarlov囊腫發(fā)生率可達(dá)1%~4.9%,但多數(shù)是無(wú)癥狀的。 　　Tarlov囊腫 　　Langdown等分析了3535例有腰骶椎癥狀患者的腰椎MRI,診斷Tarlov囊腫54例（1.5%），年齡27~83歲，70%為女性，病程數(shù)月至數(shù)年。進(jìn)一步分析Tarlov囊腫與臨床表現(xiàn)的關(guān)系，發(fā)現(xiàn)僅有7例（13%）是癥狀性Tarlov囊腫，需特殊的局部減壓治療。 　　Paulsen等分析了500例的腰骶椎MRI,發(fā)現(xiàn)Tarlov囊腫的發(fā)生率為4.6%,其中20%是癥狀性的。 　　由此可見(jiàn)，絕大多數(shù)Tarlov囊腫沒(méi)有臨床癥狀，是由影像學(xué)檢查意外發(fā)現(xiàn)的，有臨床癥狀、需要治療的是少數(shù)。 　　分類 　　1988年，華盛頓大學(xué)的Nabors,依據(jù)22例脊髓脊膜囊腫的病理，提出了三分法： 　　I型：硬膜外囊腫，無(wú)神經(jīng)根纖維； 　　II型：硬膜外囊腫，含神經(jīng)根纖維；（Tarlov囊腫就屬于這一型）III型：硬膜內(nèi)囊腫。 　　3 　　骶管囊腫的發(fā)病機(jī)制 　?。槭裁磿?huì)得骶管囊腫？） 　　骶管囊腫的致病因素目前尚不明確，一般認(rèn)為和先天發(fā)育異常和后天繼發(fā)創(chuàng)傷、炎癥等有關(guān)。 　　先天因素結(jié)合腦脊液?jiǎn)蜗蛄鲃?dòng)的 “ 球閥 ” 說(shuō)較為被認(rèn)可球閥（Ball valve）機(jī)制，簡(jiǎn)單解釋就是腦脊液于壓力高（咳嗽、用力）時(shí)進(jìn)入囊腔，而流出受阻。 　　美國(guó)賓夕法尼亞州費(fèi)城大學(xué)神經(jīng)外科的Andrew I. Yang等發(fā)表在2020年1月《Neurosurgery》上的“Growth of Lumbar Perineural （Tarlov） Cysts:A Natural History Analysis”（骶管囊腫的自然病程分析）通過(guò)觀察癥狀性骶管囊腫患者的MRI隨訪圖像，分析癥狀性骶管囊腫發(fā)展的自然病程。該研究觀察到骶管囊腫增長(zhǎng)的臨床表現(xiàn)，與“球閥機(jī)制”學(xué)說(shuō)相符。 　　但在看病的患者中，也常常遇見(jiàn)自述受過(guò)外傷（比如摔過(guò)跤、跌過(guò)屁股等）而發(fā)表在2016年4月《中國(guó)現(xiàn)代醫(yī)學(xué)雜志》的“骶管囊腫的治療及發(fā)病機(jī)制的探討（附 25例病例報(bào)告）”,表明骶管囊腫并非來(lái)自于先天性硬脊膜發(fā)育異常，而是后天創(chuàng)傷引起的馬尾神經(jīng)束膜樣結(jié)構(gòu)擴(kuò)張。 　　4 　　骶管囊腫的癥狀 　?。ǖ昧索竟苣夷[都會(huì)出現(xiàn)癥狀嗎？） 　　癥狀 　　根據(jù)由林江凱、王振宇等在2019年的《中華神經(jīng)外科雜志》“骶管囊腫診治專家共識(shí)”中的表述。 　　骶管囊腫累及的骶神經(jīng)根，可引起坐骨神經(jīng)、臀中皮神經(jīng)、臀下皮神經(jīng)、股后皮神經(jīng)、陰部神經(jīng)等不同程度的刺激與損害。主要表現(xiàn)： 　　臀部、馬鞍區(qū)、下肢后部、足外側(cè)的感覺(jué)和運(yùn)動(dòng)功能障礙（疼痛、麻木、乏力等）大小便功能障礙（尿道或肛門括約肌障礙、便秘、神經(jīng)源性膀胱、尿潴留等）性功能障礙（性交困難、勃起障礙等） 　　患者一般會(huì)出現(xiàn)上述部分癥狀，通常早期呈間歇性，當(dāng)咳嗽、站立位、做Valsalva動(dòng)作時(shí)癥狀會(huì)加重，平躺則減輕?；颊呔米芰档?，工作和社會(huì)活動(dòng)受限等。 　　此外，神經(jīng)根型的骶管囊腫還有腹痛、不孕癥、腿痛趾動(dòng)綜合癥等罕見(jiàn)癥狀。 　　那是不是得了骶管囊腫都會(huì)出現(xiàn)癥狀？ 　　并非，不含有脊神經(jīng)根纖維的硬膜外脊膜囊腫患者多數(shù)無(wú)癥狀；小部分含有脊神經(jīng)根纖維的硬膜外脊膜囊腫患者有癥狀。 　　根據(jù)“骶管囊腫診治專家共識(shí)”中表述，大部分骶管囊腫沒(méi)有明顯的臨床癥狀，但約10%~20%的患者會(huì)出現(xiàn)癥狀，這類被稱為癥狀性骶管囊腫。 　　5 　　骶管囊腫都需要治療嗎？ 　　方法有哪些？ 　　都需要治療嗎？ 　　參考“骶管囊腫診治專家共識(shí)”中，認(rèn)為無(wú)癥狀的骶管囊腫患者，予以隨訪觀察；對(duì)癥狀性骶管囊腫患者，視病情輕重和患者意愿進(jìn)行保守治療、介入治療、手術(shù)治療。 　　治療方法 　　01保守治療 　　參考“骶管囊腫診治專家共識(shí)”中，保守治療包括藥物治療和物理療法等，推薦首次就診的癥狀性骶管囊腫患者先行適當(dāng)?shù)谋Ｊ刂委煛?　　02介入治療 參考“骶管囊腫診治專家共識(shí)”中，介入治療包括經(jīng)皮單純囊腫穿刺抽吸和抽吸后注射纖維蛋白膠兩種方式。 　　但介入治療作用有限，疼痛數(shù)天或數(shù)周后可能再出現(xiàn)，可能出現(xiàn)低顱壓綜合征和無(wú)菌性腦膜炎。 　　03 　　手術(shù)治療 　　顯微外科手術(shù)安全、微創(chuàng)、有效 　　手術(shù)方式：包括囊壁部分切除+神經(jīng)根袖套 成形術(shù)、自體脂肪/肌肉--蛋白膠囊腫顯微填塞術(shù)及其他術(shù)式。 　　（各種手術(shù)方式介紹如下：） 　　發(fā)布在 2017年12月的《中國(guó)微創(chuàng)外科雜志》“顯微手術(shù)治療骶管囊腫 43 例臨床分析”提到依據(jù)囊腫類型采取分類顯微外科手術(shù)治療骶管囊腫微創(chuàng)、安全，能夠明顯改善疼痛癥狀及神經(jīng)功能，囊腫漏口的處理和神經(jīng)根松解是治療的關(guān)鍵，應(yīng)早期治療以恢復(fù)骶管正常解剖學(xué)形態(tài)。 　　手術(shù)適應(yīng)證 　　發(fā)布在 2014年7月的《中華神經(jīng)外科雜志》“顯微荷包縫合及帶蒂脂肪填塞治療 癥狀性骶管囊腫的初步探討”中講到，癥狀性骶管囊腫應(yīng)在除外間盤突出、椎管狹窄或骶管腫瘤的前提下積極手術(shù)治療。目前公認(rèn)的癥狀性骶管囊腫手術(shù)適應(yīng)證為：腰骶部疼痛和（或）間歇性跛行，影響生活和工作，且保守治療無(wú)效者；伴下肢感覺(jué)、肌力減退者；會(huì)陰部疼痛或感覺(jué)減退，排便、性功能障礙者；囊腫巨大，椎板破壞嚴(yán)重者。 　　常用手術(shù)方式 　?、倌冶诓糠智谐?神經(jīng)根袖套成形術(shù)：是針 對(duì)Tarlov囊腫所采用的術(shù)式，為多數(shù)術(shù)者所采用，核心為對(duì)“神經(jīng)根袖套腦脊液漏口”處理由Ralf Weigel等發(fā)布在《Eur Spine J》的“Tarlov cysts:long-term follow-up after microsurgical inverted plication and sacroplasty ”（顯微外科手術(shù)反向折疊縫合與骶管成形治療Tarlov囊腫后長(zhǎng)期隨訪 ）表示，這種顯微反向折疊縫合與骶管成形手術(shù)可以有效減少Tarlov囊腫術(shù)后的復(fù)發(fā)率，效果好。 　　切除部分和修剪囊壁，重建神經(jīng)束膜，椎板復(fù)位技術(shù)②自體脂肪或肌肉--纖維蛋白膠囊腫顯微填塞術(shù)發(fā)布在 2018年11月的《中華神經(jīng)外科雜志》“脂肪塊封堵囊頸術(shù)治療骶管Tarlov囊腫”描述，目前使用較多的術(shù)式是囊壁部分切除術(shù)、重疊縫合以重建神經(jīng)根袖套輔加囊腔填充脂肪或者做帶蒂肌瓣轉(zhuǎn)入術(shù)、填充硬脊膜外腔術(shù)。 　　并表示脂肪塊封堵囊頸術(shù)可用于初次治療及復(fù)發(fā)的囊腫患者，是一種治療骶管Tarlov囊腫簡(jiǎn)單、有效的方法。 　　發(fā)布在 2018年5月的《中國(guó)臨床神經(jīng)外科雜志》“顯微切除并脂肪填塞治療骶管囊腫的臨床應(yīng)用”研究追蹤了21例，表明顯微切除并自體脂肪瓣填塞可消除或明顯減少殘腔，可有效預(yù)防皮下積液和腦脊液漏等并發(fā)癥；而且填塞的脂肪對(duì)硬膜囊縫合的薄弱處起承托作用，大大減少了囊腫的復(fù)發(fā) . 　　總之，參考中華醫(yī)學(xué)會(huì)神經(jīng)外科學(xué)分會(huì)“骶管囊腫專家共識(shí)”手術(shù)推薦意見(jiàn)： 　?。?）術(shù)中顯微鏡下確認(rèn)無(wú)神經(jīng)根的單純型骶管囊腫推薦直接實(shí)施囊壁切除并結(jié)扎漏口。 　?。?）對(duì)神經(jīng)根型的骶管囊腫推薦采用囊壁部分切除+神經(jīng)根袖套成形術(shù)或自體脂肪（肌肉）--纖維蛋白膠囊腫顯微填塞術(shù)。

中國(guó)腰椎間盤突出的發(fā)病率是18%，每個(gè)小區(qū)、每個(gè)村莊里都有很多，所以無(wú)怪乎醫(yī)生們一見(jiàn)腰腿痛，第一反應(yīng)就是腰椎間盤突出的可能。然而還有一個(gè)引起腰腿痛的常見(jiàn)?。瑚竟苣夷[，卻長(zhǎng)期被醫(yī)學(xué)界所忽視了！骶管囊腫不是罕見(jiàn)病，而是地地道道的常見(jiàn)病，人群發(fā)病率達(dá)到5%，在腰骶部核磁共振檢查時(shí)經(jīng)常發(fā)現(xiàn)，其中大概五分之一是有癥狀的。有的醫(yī)生可能會(huì)說(shuō)，骶管囊腫就是一個(gè)水囊，不要緊。固然，骶管囊腫不會(huì)惡變、不會(huì)危及生命、只是痛苦（到底有多痛苦？）。那么同樣的邏輯，人們也可以說(shuō)，腰椎間盤突出也不是腫瘤、也不會(huì)惡變、也不會(huì)危及生命、只是痛苦。骶管囊腫會(huì)導(dǎo)致骶尾部、肛周、會(huì)陰、下肢疼痛、行走困難，大小便嚴(yán)重障礙、性功能障礙，痛苦程度一點(diǎn)不亞于腰突癥——有的病友因此而無(wú)法上班工作，辭職在家臥床，部分患者因不明原因嚴(yán)重便秘而行直腸切除術(shù)，少數(shù)最嚴(yán)重的患者可以出現(xiàn)直腸膀胱功能完全喪失（我們有真實(shí)的病例證明以上所述沒(méi)有夸大）。同樣是給患者帶來(lái)嚴(yán)重折磨的常見(jiàn)病，骶管囊腫卻長(zhǎng)期被醫(yī)學(xué)界所漠視，所以很多病友自發(fā)組織起來(lái)，希望成立中國(guó)骶管囊腫協(xié)會(huì)，以喚起大眾、尤其是醫(yī)學(xué)界的關(guān)注。同樣的聲音也來(lái)自歐洲！以下是比利時(shí)醫(yī)生發(fā)表在《歐洲脊柱雜志 / Eur Spine J.》的論文，提出了骶管囊腫被醫(yī)學(xué)界嚴(yán)重低估的十大原因：（1）骶管囊腫被一些醫(yī)生認(rèn)為與臨床無(wú)關(guān)；（2）一些醫(yī)生認(rèn)為臨床上難以確定骶管囊腫是疼痛的原因；（3）磁共振或肌電圖檢查僅針對(duì)L1到S1神經(jīng)，而沒(méi)有包括大多數(shù)骶神經(jīng)根；（4）放射科醫(yī)生經(jīng)常不報(bào)告骶管囊腫；（5）腰椎的退行性改變幾乎總是被確定為患者疼痛的原因，而同時(shí)存在的骶管病變卻被忽視；（6）一些醫(yī)生尚不知道小型骶管囊腫可能是有癥狀的；（7）外科醫(yī)生常常把骶管囊腫的形態(tài)當(dāng)作致病機(jī)制，所以手術(shù)都致力于改變骶管囊腫的內(nèi)部形態(tài)；殊不知，從根本上說(shuō)，骶管囊腫內(nèi)部靜水壓的增高才是產(chǎn)生癥狀的主要機(jī)制。因此，骶管囊腫的癥狀往往在手術(shù)后并未改善或短時(shí)間緩解后很快復(fù)發(fā)加重。（8）在病史記錄中不詢問(wèn)膀胱，腸和括約肌功能障礙。（9）因果顛倒:無(wú)法解釋的疼痛通常歸因于抑郁，而抑郁更可能是神經(jīng)性疼痛的結(jié)果。（10）骶管囊腫的認(rèn)知常會(huì)伴隨著性別偏見(jiàn)（如更年期綜合癥等）。結(jié)論：骶管囊腫被忽視的原因有很多，既有主觀原因，也有客觀原因，但主要是由于持續(xù)的誤解和偏見(jiàn)。原文：Eur Spine J. 2019 Oct;28(10):2237-2248. doi: 10.1007/s00586-019-05996-1.Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review.Hulens M, Rasschaert R, Bruyninckx F, Dankaerts W, Stalmans I, De Mulder P, Vansant G.Author informationMusculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001, Heverlee, Belgium. miekehulens@skynet.be., Sint-Joris-Weert, Belgium. miekehulens@skynet.be.Department of Neurosurgery, AZ Rivierenland, Kasteelstraat 23, 2880, Bornem, Belgium.Clinical Electromyography Laboratory, University Hospitals UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001, Heverlee, Belgium.Ophthalmology Research Group, Department of Neurosciences, University of Leuven, Herestraat 49, 3000 Leuven, Belgium.Department of Ophthalmology, University Hospitals UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.Department of Anesthesiology and Pain Therapy, Imelda Hospital, 2820 Bonheiden, Belgium.Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Herestraat 49, 3000, Leuven, Belgium.AbstractPURPOSE:Tarlov cysts (TCs) are dilations of nerve roots arising from pathologically increased hydrostatic pressure (HP) in the spinal canal. There is much controversy regarding whether these cysts are a rare source of pain or often produce symptoms. The aim of this review was to identify the reasons that symptomatic TCs (STCs) are easily overlooked.METHODS:The literature was searched for data regarding pathogenesis and symptomatology.RESULTS:TCs may be overlooked for the following reasons:(1) STCs are considered clinically irrelevant findings;(2) it is assumed that it is clinically difficult to ascertain that TCs are the cause of pain;(3) MRI or electromyography studies only focus on the L1 to S1 nerves;(4) TCs are usually not reported by radiologists;(5) degenerative alterations of the lumbosacral spine are almost always identified as the cause of a patient's pain;(6) it is not generally known that small TCs can be symptomatic;(7) examinations and treatments usually focus on the cysts as an underlying mechanism; however, essentially, increased HP is the main underlying mechanism for producing symptoms. Consequently, STCs may relapse after surgery;(8) bladder, bowel and sphincter dysfunction are not inquired about during history taking.(9) Unexplained pain is often attributed to depression, whereas depression is more likely the consequence of debilitating neuropathic pain.(10) The recognition of STCs is subject to gender bias, confirmation bias and cognitive dissonance and unconscious bias in publishing.CONCLUSION:There are several reasons STCs are underdiagnosed, mostly due to persistent misconceptions and biases. These slides can be retrieved under Electronic Supplementary Material.