Surgical management of anterior sacral meningoceles: a case series and systematic review

Anterior sacral meningoceles (ASMs) are rare forms of spinal dysraphism caused by anterior herniation of meninges through a sacral defect. Surgical management is the treatment of choice, yet the optimal approach remains debated. This study compares outcomes of three main surgical approaches-anterior transabdominal, posterior transsacral, posterior sagittal (PSARP-type)-focusing on the efficacy and safety of the PSARP-type.

A retrospective single-center analysis was conducted on eight patients treated for ASM between 2008 and 2025. Demographic, clinical, radiological, functional data were reviewed. Outcomes included recurrence, reoperation, sac size reduction, bladder function; complications were categorized as early or late. A systematic literature review was performed according to PRISMA guidelines.

Eight patients (6 females, 2 males; mean age 19.4 years) underwent surgery (five anterior Pfannenstiel incision, two posterior sagittal, one posterior transsacral). All were symptomatic, 87.5% had associated malformations. Sac reduction was achieved in 87.5% of cases, with no new neurological deficits. Complications were mild and self-limiting, including transient urinary retention and cerebrospinal fluid fistula managed with lumboperitoneal shunt. The literature review (49 studies, 68 patients) confirmed female predominance (81%), association with Marfan and Currarino syndromes (35%), preference for posterior approaches (70%), which showed lower morbidity and recurrence rates. One postoperative death (1.4%) was reported.

Posterior approaches-particularly the PSARP-type-provide safe, effective, and functionally favorable alternatives to anterior surgery for ASM, offering optimal exposure, precise dural closure, superior cosmetic outcomes with minimal morbidity. The anterior route should be reserved for large or high-lying lesions. Further multicenter studies with longer follow-up are warranted.