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Symptomatic Tarlov Cyst: A Rare Case Report and Its Management
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What are the main claims of the paper and how important are they?
1. Tarlov Cysts are rare sacral nerve root meningeal sheath dilatations (Important claim)
2. They are rare causes of back pain (Important claim)
3. Asymptomatic Tarlov cysts should be left alone (Important claim)
4. Significantly symptomatic Tarlov cysts should be operated (Important claim)
5. Exact surgical procedure is debatable, but nerve roots should be preserved (Important claim)
6. Tarlov cysts should be considered in the Differential diagnosis of back pain (Not important, because of rarity)
7. Medical fraternity should be made aware of this condition (Not important clinically because of rarity, but may be an interesting academic exercise)
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Are these claims novel? If not, please specify papers that weaken the claims to the originality of this one.
No, these claims are not novel. They are generally accepted by most authorities in the field.
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Are the claims properly placed in the context of the previous literature?
Yes, mostly. However there are certain caveats.
1. The authors have given 3 references to Tarlov in their bibliography (References 1, 6, 8). "Tarlov cysts were first described in 1938 as an incidental finding at autopsy1 Tarlov described a case of symptomatic perineural cyst and recommended its removal." They have not given the reference for the second statement.
2. First line of Case Report: "1-year history of progressive, intractable sacrococcygeal pain..."; Fifth line: "it used to get relieved by non steroidal antiinflammatory drugs..." This contradicts the word 'intractable' in the first line.
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Do the results support the claims? If not, what other evidence is required?
Yes, mostly. Anecdotally the authors claim that the patient became asymptomatic after surgery and at 3-month follow up, and he joined work. However, a post-operative MRI would have added weight to the claim. But the patient's socio-economic status precluded a repeat MRI because these images are expensive propositions.
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If a protocol is provided, for example for a randomized controlled trial, are there any important deviations from it? If so, have the authors explained adequately why the deviations occurred?
No protocol is explicitly provided, but the authors have not deviated significantly from the accepted norms of managing these types of cases.
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Is the methodology valid? Does the paper offer enough details of its methodology that its experiments or its analyses could be reproduced?
Yes, to both questions
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Would any other experiments or additional information improve the paper? How much better would the paper be if this extra work was done, and how difficult would such work be to do, or to provide?
The following additional information would have improved the quality of the paper considerably
1. The pre-operative MRI: Authors have not specified what type of MRI and whether contrast was used or not. However, they have mentioned in a later "The cyst did not fill with contrast material" So one would assume that contrast was used. However, on examining the MRI image, this reviewer feels it is Non-contrast T2 MRI, showing Hyperintensity of the CSF and the cyst content, as would be expected. This point requires clarification
2. A post-operative MRI would have been ideal. But the patient's socio-economic status precluded a repeat MRI because MRIs are expensive
3. Higher resolution Intra-operative pictures, zooming on the pathology, with proper references to patient's orientation and anatomy would have been even better
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Is this paper outstanding in its discipline? (For example, would you like to see this work presented in a seminar at your hospital or university? Do you feel these results need to be incorporated in your next general lecture on the subject?) If yes, what makes it outstanding? If not, why not?
While not exactly OUTSTANDING, it is a GOOD paper. This reviewer may wish to present it in his University seminar as an interesting academic curiosity. However, it would not be included in the next general lecture because of its relative rarity.
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Other Comments:
Well done, authors!! Quite a good paper, especially after the revision
The following points were noted
1. Typos: "Ganeral Surgery"
2. Punctuation Errors: No space between comma and the next word in numerous places; Space before a comma in several places - Both sets of errors should be rectified
3. Grammatical Errors: "These cyst communicate..."; "These cyst can enlarge..."; "Knee jerks was normal" (Plurality Errors)
4. Sentence Construction: "We report a case of symptomatic Tarlov cyst, its clinical presentation, treatment, and results of surgical cyst wall resection in a case of a symptomatic sacral Tarlov cyst" (Repetition of phrase)
5. Word Usage: "The pain had progressed to the lower back and bilateral upper thigh up to the ankle"
6. Illustrations: Appropriate areas should be labeled and arrows should be inserted, pointing to the object of interest.
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Competing interests:
None
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Invited by the author to review this article? :
Yes -
Have you previously published on this or a similar topic?:
No
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References:
None
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Experience and credentials in the specific area of science:
1. This reviewer has operated on cystic spinal lesions on patients in the past
2. This reviewer is a Professor and Course Director of Neuroscience and FCM-III Clinical Neurology
3. This reviewer takes regular lectures and gives practical demonstrations to Med 3 Neuroscience Medical Students in a medical university in the Caribbean - How to cite: Sanyal S .Critical Appraisal of a Case of Sacral Nerve Root Sheath Cyst[Review of the article 'Symptomatic Tarlov Cyst: A Rare Case Report and Its Management ' by Kania H].WebmedCentral 2015;5(3):WMCRW003018
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What are the main claims of the paper and how important are they?
This is a case report presenting with back pain: the claim is to increase the knowledge of it in surgical comunity
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Are these claims novel? If not, please specify papers that weaken the claims to the originality of this one.
Yes
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Are the claims properly placed in the context of the previous literature?
Yes
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Do the results support the claims? If not, what other evidence is required?
Yes, the results support the claim
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If a protocol is provided, for example for a randomized controlled trial, are there any important deviations from it? If so, have the authors explained adequately why the deviations occurred?
No protocol is provided
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Is the methodology valid? Does the paper offer enough details of its methodology that its experiments or its analyses could be reproduced?
Yes, the metodology is valid
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Would any other experiments or additional information improve the paper? How much better would the paper be if this extra work was done, and how difficult would such work be to do, or to provide?
No
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Is this paper outstanding in its discipline? (For example, would you like to see this work presented in a seminar at your hospital or university? Do you feel these results need to be incorporated in your next general lecture on the subject?) If yes, what makes it outstanding? If not, why not?
This work is a case report but its results can be incorporated in next general lecture on this subject
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Other Comments:
For completeness it would be good to mention in the bibliography the article of Giampaolo Cantore Sacral Tarlov Cyst: surgical treatment by clipping pubblished in World Neurosurgery 79 (2): 381-389, Febrary 2013. This article reports the largest series in the literature of Sacral Tarlov Cyst.
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Competing interests:
None
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Invited by the author to review this article? :
Yes -
Have you previously published on this or a similar topic?:
No
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References:
None
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Experience and credentials in the specific area of science:
Professor of Neurosurgery
- How to cite: Lavano A .Symptomatic Tarlov cyst: case report and management[Review of the article 'Symptomatic Tarlov Cyst: A Rare Case Report and Its Management ' by Kania H].WebmedCentral 2015;5(2):WMCRW003007
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What are the main claims of the paper and how important are they?
The aim of the authors is to present a case report of a Tarlov Cyst.
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Are these claims novel? If not, please specify papers that weaken the claims to the originality of this one.
Yes
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Are the claims properly placed in the context of the previous literature?
Yes
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Do the results support the claims? If not, what other evidence is required?
Yes
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If a protocol is provided, for example for a randomized controlled trial, are there any important deviations from it? If so, have the authors explained adequately why the deviations occurred?
No
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Is the methodology valid? Does the paper offer enough details of its methodology that its experiments or its analyses could be reproduced?
Yes
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Would any other experiments or additional information improve the paper? How much better would the paper be if this extra work was done, and how difficult would such work be to do, or to provide?
No
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Is this paper outstanding in its discipline? (For example, would you like to see this work presented in a seminar at your hospital or university? Do you feel these results need to be incorporated in your next general lecture on the subject?) If yes, what makes it outstanding? If not, why not?
Yes- it would be a great lecture in a medical school.
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Other Comments:
Tarlov cysts are meningeal dilatations of the posterior spinal nerve root sheath that most often affect sacral roots. The authors present the case of a 47 year-old man with a Tarlov cyst. After surgery the patient experienced an immediate relief of pain.
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Invited by the author to review this article? :
No -
Have you previously published on this or a similar topic?:
No
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References:
None -
Experience and credentials in the specific area of science:
Clinical associate professor
- How to cite: Maloney W J.Tarlov Cyst[Review of the article 'Symptomatic Tarlov Cyst: A Rare Case Report and Its Management ' by Kania H].WebmedCentral 2015;5(2):WMCRW002976
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The authors' primary claim is that, in the patient case presented, a sacral Tarlov cyst caused the patient to have sacrococcygeal pain and S1-distribution numbness within the foot. Further, the authors claim that these symptoms were relieved by surgical treatment of the Tarlov cyst.
These claims are important because some clinicians may be unfamiliar with the clinical implications of sacral Tarlov cysts. Or, some clinicians may incorrectly believe that all sacral Tarlov cysts are always just incidental findings. Such physicians would fail to recognize that in a small but real percentage of patients such cysts may cause pain and neurologic deficits, as presented in this case report.
The claims are not particularly novel, as similar patient cases and conclusions have been previously published. However, this publication by Dr. Salgotra and colleagues is still worthwhile since many physicians remain unaware that sacral Tarlov cyst can indeed cause such symptoms and neurologic deficits.
Yes. Previous literature is quoted and referenced.
Yes, the claims are supported by the case presented. Theoretically, additional testing could have included electrodiagnostic studies (electromyography and nerve conduction studies) to confirm that the S-1 numbness in the foot was indeed coming from S-1 nerve irritation (S-1 radiculopathy), but based on the distribution matching the site of the sacral Tarlov cyst (at S-1) such electrodiagnostic testing would probably be unnecessary since the diagnosis is already relatively well-established from the symptoms, physical exam, and MRI images.
Not applicable.
Not applicable, as this was a case report.
Given that the patient reported not only sacral but actually sacrococcygeal pain (pain that included the coccyx), it would be helpful to know if the physical examination before surgery actually included direct palpation of the coccyx (tailbone) and if so whether it was tender to palpation. The reason I ask is that I wonder whether a sacral Tarlov cyst at the upper part of the sacrum (around S1 according to the case report) would be expected to cause symptoms into the coccyx region. Certainly it is possible that the sacral Tarlov cyst was causing nerve compression/irritation with referred pain down to the coccyx. But a focal physical examination at the coccyx would help to rule out any concomitant, independent diagnosis specifically at the coccyx itself.
While not necessarily outstanding, this is certainly a very respectable case presentation.
In the introduction section, it begins, "Tarlov cysts were first described in 1938 as an incidental finding at autopsy1 Tarlov described a case of symptomatic perineural cyst and recommended its removal."
This is a somewhat confusing. If the authors are saying that the 1938 article by Tarlov was just describing a Tarlov cyst as an "incidental" finding, this would not be consistent with the second part of the sentence where it says Tarlov was describing a "symptomatic" cyst. Typically, we only refer to something as being merely an "incidental" finding it if it is not causing any clinical symptoms or problems.
No
Yes
Foye, Patrick M. Tailbone Pain Relief Now! United States: Top Quality Publishing, 2015. Print.
I am a Professor of Physical Medicine and Rehabilitation at Rutgers New Jersey Medical School, where I teach medical students, resident physicians, and clinical fellows. Director, Coccyx Pain Center, Rutgers New Jersey Medical School.\\nCo-Director of an interventional spine pain fellowship training program. Co-Director of a low back pain clinic at University Hospital, Newark, New Jersey, United States.