【摘要】 研究背景相较其他手术策略，显微外科手术治疗症状性Tarlov囊肿的长期预后更佳，但仍存在较高的囊肿复发率和脑脊液漏发生率，阻碍这一技术的临床推广。假设囊肿与蛛网膜下腔之间的瘘口未完全闭合是手术失败的原因，并基于此提出一种囊肿分离和瘘口封堵的新方法，旨在更牢固地封堵瘘口。方法 纳入2016年1月至2021年3月在南方医科大学南方医院行显微改良瘘口封堵术的35例症状性骶管Tarlov囊肿患者，记录手术时间、术中出血量、术后住院时间、随访时间，以及囊肿内神经根穿行和术后囊肿转归。分别于术前、出院时和末次随访时采用视觉模拟评分（VAS）以及术前和末次随访时采用脊髓功能临床评价评分系统（SCPS）、Oswestry功能障碍指数（ODI）、日本骨科协会下腰痛评分（JOA29）和腰椎功能MacNab评定标准评估神经功能，记录术后并发症（切口感染、神经损伤、脑脊液漏、术后粘连等）发生率，并随访复查MRI有无囊肿复发。结果 共35例患者计74个囊肿，其中大囊肿（直径> 1.50 cm）49个（66.22%），囊肿主要压迫S1神经根（22个，29.73%）和S2神经根（36个，48.65%），均有瘘口及穿行其中的神经根。平均随访（37.78±17.19）个月，至末次随访时，症状改善率最显著的是神经根性疼痛（94.29%,33/35），其次依次为会阴部疼痛（13/14）、腰骶部疼痛（85.19%,23/27）、直立性头痛（2/3）、神经源性跛行（5/8）、下肢麻木（12/20）、会阴部麻木（7/14）、性功能障碍（4/9）、大便障碍（8/19）、小便障碍（6/17）。末次随访时神经根性疼痛评分（P=0.000,0.000）、腰骶部疼痛评分（P=0.000,0.001）和会阴部疼痛评分（P=0.001,0.009）低于术前和出院时，出院时亦低于术前（P=0.000,0.000,0.001）；末次随访时SCPS总评分（P=0.000）及疼痛和感觉障碍（P=0.000）、肌力（P=0.000）、步态（P=0.000）和小便功能（P=0.019）分评分高于术前；ODI指数（P=0.000）及疼痛程度（P=0.000）、提/携物（P=0.000）、行走（P=0.000）、坐（P=0.000）、站立（P=0.000）、睡眠（P=0.000）、个人护理（P=0.000）、社会活动（P=0.000）和旅行（P=0.000）分评分低于术前；JOA29量表和MacNab评定标准的总体改善率均为94.29%(33/35)。术后有2例新发下肢麻木，无一例出现囊肿复发或脑脊液漏。结论 显微改良瘘口封堵术是治疗症状性骶管Tarlov囊肿安全、有效的手术策略，可以完全封堵瘘口，降低术后囊肿复发和脑脊液漏风险。更多还原

【Abstract】 Background Microsurgical techniques are increasingly being recommended for the treatment of symptomatic Tarlov cysts(TCs) due to improved long-term outcomes compared to those of other strategies. However, these techniques are associated with a high risk of cysts recurrence and cerebrospinal fluid(CSF) leakage, resulting in the surgical strategy of TCs remains controversial. We hypothesize that incomplete closure of the ostium between the cysts and the subarachnoid space is the probable cause of surgical failure. Accordingly, we present a novel method of cysts separation and ostium closure that aims to block the ostium more firmly and reliably.Methods Thirty-five consecutive patients underwent the microscopic modified ostium obstruction surgery in Nanfang Hospital, Southern Medical University due to symptomatic sacral TCs from January 2016 to March 2021. The operation time, intraoperative blood loss,postoperative hospitalization time, follow-up time, as well as the situation of nerve roots passing through the cysts and the postoperative outcome of the cysts were recorded. Visual Analogue Scale(VAS) was used before surgery, at discharge and at the last follow-up, and Scoring System for the Clinical Evaluation of Patients with Spinal Processes(SCPS), Oswestry Disability Index(ODI), Japanese Orthopedic Association Scores(JOA29) and MacNab criteria were used before surgery and at the last follow-up to evaluate neurological function. Postoperative complications(infection, nerve injury, CSF leakage, postoperative adhesion, etc.) were recorded, and the cysts recurrence was observed by follow-up MRI.Results A total of 74 cysts were detected in 35 patients, among which 49(66.26%) were large cysts(diameter > 1.50 cm),and cysts mainly compressed S1nerve roots(22 cysts, 29.73%) and Sas and nerve roots passing through them. Average f2nerve roots(36 cysts, 48.65%), all of which had fistulollow-up was(37.78 ± 17.19) months.To the last follow-up, the most significant symptom improvement rate was nerve root pain(94.29%, 33/35),followed by perineal pain(13/14), lumbosacral pain(85.19%, 23/27), orthostatic headache(2/3), neurogenic claudication(5/8), lower limb numbness(12/20), perineal numbness(7/14), sexual dysfunction(4/9), bowel dysfunction(8/19) and bladder dysfunction(6/17). The nerve root pain score(P = 0.000, 0.000),lumbosacral pain score(P = 0.000, 0.001) and perineal pain score(P = 0.001, 0.009) at the last follow-up were lower than those before surgery and at discharge, while those at discharge were lower than those before surgery(P = 0.000, 0.000, 0.001). The total score of SCPS(P = 0.000), pain and sensory disturbance(P =0.000), muscle strength(P = 0.000), gait(P = 0.000) and urinal function(P = 0.019) at the last follow-up were higher than those before surgery. ODI index(P = 0.000) and pain level(P = 0.000), lifting/carrying(P =0.000), walking(P = 0.000), sitting(P = 0.000), standing(P = 0.000), sleeping(P = 0.000), personal care(P =0.000), social activities(P = 0.000) and travel(P = 0.000) at the last follow-up were lower than those before surgery. The overall improvement rate of both JOA29 and MacNab criteria was 94.29%(33/35). After surgery, 2C patients had new symptoms of lower limb numbness, and none had recurrence of cysts or CSF leakage.Conclusions The microscopic modified ostium obstruction surgery is a safe and effective strategy for management of patients with symptomatic sacral TCs, and is associated with a low incidence of cysts recurrence and CSF leakage since it achieves complete closure of cysts ostium.更多还原