Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals.

Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.

A Hidden Condition: Multiple Tarlov Cysts Unveiled in a Young Woman Seeking Primary Care for Debilitating Low Back Pain.

BACKGROUND Tarlov cysts are rare, with a prevalence of 3.3% in the Asian population, and symptomatic cases are even rarer. Here, we report a case of a young woman with multiple Tarlov cysts presenting in primary care with severe low back pain. CASE REPORT A 23-year-old Malay woman presented to a primary care clinic with sudden-onset, severe, and persistent low back pain for 1 week, affecting her activities of daily living (ADL), especially as a medical student, as she could not stand for more than 10 minutes. There were no other associated symptoms or recent trauma prior to the onset of back pain. Examinations revealed para-vertebrae muscle tenderness and restricted movements at the L4/L5 lumbosacral spine. A plain radiograph of the lumbosacral spine showed sclerosis and erosion of the right pedicle at the L4/L5 levels. Tuberculosis and haematological tests were normal. A lumbosacral MRI of the spine was ordered and the patient was urgently referred to the orthopaedic spine team. The MRI confirmed the diagnosis of multiple Tarlov cysts, with the dominant cyst located at the S2 level. Her symptoms and ADL improved with conservative management. She is being monitored closely by the orthopaedic team and primary care physician. CONCLUSIONS This case highlights red flag symptoms, ie, sudden-onset, severe, and persistent low back pain, that warrant further investigation. Tarlov cysts should be considered as a differential diagnosis. Close monitoring is vital and early surgical intervention is indicated if symptoms worsen, to prevent potential irreversible nerve damage.

Spontaneous Rupture of a Huge Presacral Tarlov Cyst Leading to Dramatic Neurologic Recovery.

BACKGROUND: This manuscript discusses the case of huge presacral Tarlov cysts (TCs) and the substantial neurologic recovery noted in the patient following spontaneous rupture of the most prominent cyst. Perineural or TCs are nerve root cysts, which are usually incidental findings on magnetic resonance imaging (MRI) and are most frequently observed in the sacral spine. Symptomatic lesions are rarely encountered. CASE DESCRIPTION: In this case, a 44-year-old woman presented with anal and vulva pain on the right side, and bladder and bowel dysfunction. MRI of the lumbosacral spine showed multiple huge bilateral TCs located within the presacral space from S1-3. There was a substantially large right-sided S3 cyst that was presumed to be responsible for her symptoms. Surgical intervention was considered; however, her symptoms improved significantly during the waiting period for surgery because of spontaneous rupture of the right-sided S3 cyst, as confirmed on follow-up MRI. On follow-up over a 1-year period, the patient had been very well with no recurrent symptoms. CONCLUSIONS: To our knowledge, this is the first report of spontaneous cyst rupture and resultant neurologic improvement in a case of symptomatic presacral TCs.

Shrinking of a Tarlov cyst.

A 65-year-old patient presenting with left labial and perirectal pain was diagnosed with bilateral Tarlov cysts. Upon treatment of the left Tarlov cyst (the right was asymptomatic) using image-guided aspiration and subsequent injection of the cyst with fibrin sealant, the cyst reduced in size. To our knowledge, there are currently no other documented cases in which the Tarlov cyst reduced in size following this procedure. This case would seem to suggest that clinicians are poorly informed with regard to Tarlov cysts. These cysts are more common in Caucasian women, many of whom are told their cysts are not responsible for their pain or that they are not treatable. However, there is clear evidence that some Tarlov cysts are symptomatic and minimally invasive procedures have been developed to treat them. As they primarily occur in women, it is possible gender bias may also play a role in the delayed diagnosis of the patient's pain.

[Perineural cysts]. / Torbiele okolokorzeniowe.

Perineural cyst (Tarlov cyst) is a lesion in a form of fluid-filled sacks, usually located within the nerve root sheath at the posterior root of a spinal nerve, whose wall is formed by: endoneurium, peripheral nerve fibers and ganglion cells and areolar tissue. Depending on the studied population, the frequency of lesion occurence was estimated at 1.5- 13.2%, with its significant majority occuring in women. Cyst development may be the result of ischemia, hemorrhage, inflammation or trauma. Cysts are usually asymptomatic theefore they are likely to bo detected accidentally. However, in approximately 1/4 of the cases, the cyst puts so much pressure on the nerve and the neighbouring nerve roots that it becomes symptomatic (causes pain). The presence of clinical symptoms may be an indication for conservative treatment (i.e. analgesics, rehablitation, cyst puncture) or surgery (usually laminectomy).

Treatment of a symptomatic cervical perineural cyst with ultrasound-guided cervical selective nerve root block: A case report.

RATIONALE: Symptomatic cervical perineural cysts are extremely rare, and they cause radicular pain by compressing the cervical nerve root. Several methods have been applied to manage the radicular pain induced by cervical perineural cysts, including medication, percutaneous procedures, and surgery. However, these methods are associated with various outcomes and complications. The percutaneous procedure is simple and easy to perform, but if the perineural cyst wall is punctured, it can lead to secondary complications, which include aseptic meningitis and intracranial hypotension. PATIENT CONCERNS: A 51-year-old woman presented with a dull pain in the left shoulder and a tingling sensation in the left dorsal arm, hand, and middle finger. DIAGNOSIS: The patient was diagnosed with left C7 radicular pain caused by a perineural cyst. INTERVENTIONS: The left C7 radicular pain did not respond to treatment with medication. Therefore, a left C7 nerve root block with local anesthetics and steroids was performed under ultrasound guidance. Adjunctively, real-time fluoroscopy with contrast was used to avoid intravascular injection. OUTCOME: The symptoms resolved without any complications. LESSONS: In this case, perineural cyst-induced radicular pain, which was resistant to medication, was treated using ultrasound guided cervical selective nerve root block with local anesthetics and steroids. Ultrasound guidance can enable successful cervical selective nerve root block without perineural cystic wall puncture. Therefore, ultrasound-guided cervical nerve root block is an effective treatment option for radicular pain caused by a symptomatic perineural cyst.

Idiopathic Intracranial Hypertension Associated with Symptomatic Perineural Cysts: Presentation of 2 Cases.

OBJECTIVES: Idiopathic intracranial hypertension refers to cases of intracranial hypertension and normal brain parenchyma without ventriculomegaly or any kind of mass lesion. Perineural cysts are cerebrospinal fluid-filled cysts that usually arise from nerve roots near the dorsal ganglia. Often asymptomatic, they rarely cause mass effect symptoms. The association of these conditions is discussed herein. METHODS: We describe 2 patients with idiopathic intracranial hypertension and symptomatic sacral perineural cysts. In both cases the treatment of idiopathic intracranial hypertension ameliorated the sacral perineural cyst symptoms, and in 1 case we observed shrinking of the sacral perineural cysts. RESULTS: On the basis of this review, it is impossible to conclude whether there is an association between idiopathic intracranial hypertension and symptomatic perineural cysts. However, as an initial observation, this report can reveal a possible association. CONCLUSIONS: In some instances, idiopathic intracranial hypertension can be associated with symptomatic sacral perineural cysts. In this clinical scenario, the treatment of idiopathic intracranial hypertension may improve perineural cyst symptoms.

Tarlov Cysts in a Woman With Lumbar Pain.

A 25-year-old woman presented to her primary care physician with thoracic spine pain; two weeks later, she returned to her primary care physician with lumbar spine pain that limited exercise and sitting for 30 minutes or less. The patient was referred to physical therapy for examination, then referred back to her primary care physician after complaints raised concern for a mass or other source of neurologic compression. Magnetic resonance imaging was performed and revealed 4 sacral perineural (Tarlov) cysts. J Orthop Sports Phys Ther 2018;48(2):121. doi:10.2519/jospt.2018.7644.

Management of Symptomatic Tarlov Cysts: A Retrospective Observational Study.

BACKGROUND: Symptomatic Tarlov cysts are a common cause of chronic pain. Many methods have been reported to treat this disease, with variable results. Most previous reports concerning the treatment methods of symptomatic Tarlov cysts were either sporadic case reports or series of limited cases. OBJECTIVE: This study aimed to further optimize the management for patients with symptomatic Tarlov cysts (TCs) by analyzing the results of 82 patients who were treated with different strategies. STUDY DESIGN: Three different strategies were applied to 82 patients with symptomatic TCs and their clinical effects were evaluated in 13 months to 12 years follow-up. SETTING: A pain management practice, a medical center, major metropolitan city, China. METHODS: From June 2003 to August 2015, a total number of 82 patients with symptomatic TCs were treated with 3 different methods (microsurgical cyst fenestration and imbrication, C-arm fluoroscopy guided percutaneous fibrin gel injection, and conservative management) in the first affiliated hospital of Chongqing Medical University. The pain severity was assessed according to visual analog scale (VAS), and imaging changes were evaluated by magnetic resonance imaging (MRI). Patient improvements in pain and neurologic function were evaluated during a follow-up the period of 13 months to 12 years. RESULTS: All the patients who underwent microsurgical cyst fenestration and imbrication had either complete (7 patients, 50%) or substantial (7 patients, 50%) resolution of their preoperative symptoms and neurological deficits. However, 3 patients (21%) had cerebrospinal fluid (CSF) leakage and 3 patients (21%) suffered from recurrent symptoms. In C-arm fluoroscopy guided percutaneous fibrin gel injection group, 34 patients (61%) had complete resolution and 22 patients had (39%) substantial resolution, and no CSF leakage or recurrence occurred. Only 3 patients (25%) got substantial resolution in the conservative management group, but 9 patients (75%) had aggravation. LIMITATIONS: An observational study with a relatively small sample size. CONCLUSIONS: C-arm fluoroscopy guided percutaneous fibrin gel injection therapy could be recommend as a better consideration for symptomatic TCs. KEY WORDS: Tarlov cysts, C-arm fluoroscopy guided, fibrin gel, microsurgical cyst fenestration, conservative management.

Balloon-Assisted Fistula Sealing Procedure for Symptomatic Tarlov Cysts.

OBJECTIVE: Tarlov cyst is an abnormal expansion of the spinal nerve sleeve, and it communicates with the subarachnoid cavity via a perineural fistula. This study presents our experience of a balloon-assisted fistula sealing procedure in treating Tarlov cyst. METHODS: Twenty-two patients with symptomatic Tarlov cysts were surgically treated. An emulsion balloon was placed into the lumbar subarachnoid cistern through a trocar, so as to temporarily block cerebrospinal fluid flow, then the thecal sac was opened and the inlet of the fistula was sealed by suture of a muscular patch and reinforced by fibrin glue. Finally, the cyst wall was imbricated and the bony cavity was filled with pedicled muscle flaps. RESULTS: Comparing the preoperative and postoperative pain scores according to visual analog scale, 2 patients were slightly improved and 18 patients were substantially improved, including 3 completely pain-free cases. Only 2 patients were unchanged in pain, and both of them had multiple cysts. As a whole, the postoperative pain score was much better than the preoperative score (2.4 vs. 7.5; P < 0.01). Bladder weakness was slightly improved, and bowel dysfunction was almost unchanged after operation. During follow-up, cyst recurrence was found in 1 patient. CONCLUSIONS: The balloon-assisted fistula sealing procedure is safe and effective for Tarlov cyst, especially for the single cyst. It is a good complement to the cyst wall imbricating procedure.

Treatment of 213 Patients with Symptomatic Tarlov Cysts by CT-Guided Percutaneous Injection of Fibrin Sealant.

BACKGROUND AND PURPOSE: There has been a steady progression of case reports and a small surgical series that report successful surgical treatment of Tarlov cysts with concomitant relief of patients' symptoms and improvement in their neurological dysfunction, yet patients are still told that these lesions are asymptomatic by physicians. The purpose of this study was to analyze the efficacy and safety of intervention in 213 consecutive patients with symptomatic Tarlov cysts treated by CT-guided 2-needle cyst aspiration and fibrin sealing. MATERIALS AND METHODS: This study was designed to assess outcomes in patients who underwent CT-guided aspiration and injection of ≥1 sacral Tarlov cyst at Johns Hopkins Hospital between 2003 and 2013. In all, 289 cysts were treated in 213 consecutive patients. All these patients were followed for at least 6 months, 90% were followed for 1 year, and 83% were followed for 3-6 years. The aspiration-injection procedure used 2 needles and was performed with the patients under local anesthesia and intravenous anesthesia. In the fibrin-injection stage of the procedure, a commercially available fibrin sealant was injected into the cyst through the deep needle (Tisseel VH). RESULTS: One year postprocedure, excellent results were obtained in 104 patients (54.2% of patients followed), and good or satisfactory results were obtained in 53 patients (27.6%). Thus, 157 patients (81.8%) in all were initially satisfied with the outcome of treatment. At 3-6 years postprocedure, 74.0% of patients followed were satisfied with treatment. There were no clinically significant complications. CONCLUSIONS: The aspiration-injection technique described herein constitutes a safe and efficacious treatment option that holds promise for relieving cyst-related symptoms in many patients with very little risk.

Percutaneous fibrin gel injection under C-arm fluoroscopy guidance: a new minimally invasive choice for symptomatic sacral perineural cysts.

BACKGROUND: Symptomatic sacral perineural cysts are a common cause of chronic pain. Surgery is one choice for symptom relief but has a high risk of cyst recurrence and complications. As a simple and safe method to manage symptomatic sacral perineural cysts, C-arm fluoroscopy-guided fibrin gel injection may represent a new minimally invasive alternative. To evaluate the efficacy of this new method, we conducted a retrospective study of 42 patients. METHODS AND FINDINGS: From June 2009 to August 2012, a total of 42 patients with symptomatic sacral perineural cysts underwent C-arm fluoroscopy-guided percutaneous fibrin gel injection therapy. Patient outcomes in terms of improvements in pain and neurologic function were evaluated during a follow-up period of 13-39 months. The preoperative and postoperative pain severity were assessed according to a 10-cm visual analog pain scale, and imaging changes were evaluated by magnetic resonance imaging. We also assessed postoperative complications. Most patients experienced benefit from the procedure: twenty-five patients (59.5%) reported excellent recovery, eleven (26.2%) reported good recovery, three (7.1%) reported fair recovery, and three (7.1%) reported poor recovery. The overall effectiveness rate (excellent and good recoveries) was 85.7%. No serious postoperative complications were observed. CONCLUSION: Percutaneous fibrin gel injection under C-arm fluoroscopy guidance could be a simple, safe and effective treatment option for symptomatic sacral perineural cysts.

Minimally invasive interventional therapy for Tarlov cysts causing symptoms of interstitial cystitis.

BACKGROUND: Tarlov cysts (TC) are present in 4.6% of the population and represent a potential source of chronic pain. When present at lumbosacral levels, symptoms are classically described as perineal pain/pressure, radiculopathy, and headache. Treatment outlined to date primarily includes cyst drainage with fibrin glue sealant and surgical interventions. OBJECTIVES: We present 2 cases in which TC presented with signs and symptomatology consistent with interstitial cystitis who were treated with caudal epidural steroid injections. METHODS: Patients with urinary bladder pain and urgency received urological workups demonstrating hallmark features of interstitial cystitis including cystoscopic evidence of glomerulations. Radiographic imaging identified TC to be present on sacral nerve roots. Since pelvic pains could represent compressive radiculopathy of sacral roots, a cautious trial of minimally invasive caudal epidural steroid injections was performed. RESULTS: Both patients attained nearly 100% relief of pain for a period ranging from 6 months to 2 years following low volume, targeted caudal epidural steroid injection. They continue to be followed clinically and continue to report benefit with this treatment. LIMITATIONS: This limited case series is retrospective in nature and potential complications have been noted by others in association with TC. CONCLUSIONS: Use of caudal epidural steroid injections proved beneficial in the treatment of pelvic pain symptomatology and so may be considered as an option in patients with identified sacral TC.