Tarlov Cysts: An Overlooked Clinical Problem

ABSTRACT

Symptomatic Tarlov cysts typically cause chronic pelvic and lower extremity pain and sacral nerve root radiculopathy. Historically, open surgical treatment involved significant patient morbidity, particularly postoperative cerebrospinal fluid (CSF) leaks and infection. These CSF leaks often required multiple surgical procedures to seal. Over the past 20 years, there have been two or three isolated case reports of computed tomography (CT)-guided needle aspirations that offered limited evidence of treatment efficacy and safety. Some have reported high rates of postprocedure aseptic meningitis that were not well explained. These poor results dissuaded physicians from caring for these patients. As a group these patients are usually treated dismissively and told their cysts are asymptomatic and their pain must be coming from somewhere else. Many of them have had an unnecessary discectomy or a spinal fusion, and when these procedures did not relieve their pain they were told they are a “failed back patient.” We have treated more than a hundred patients with symptomatic Tarlov cysts by CT fluoroscopic-guided needle aspiration and fibrin injection and have had excellent results with no meaningful complications and never a case of aseptic meningitis. We believe this is a safe, highly effective first-line treatment for symptomatic Tarlov cysts.

KEYWORDS

Tarlov cysts - fibrin - radiculopathy - MRI

REFERENCES

• 1 Tarlov I M. Cysts of the sacral nerve roots; clinical significance and pathogenesis.  AMA Arch Neurol Psychiatry. 1952;  68 (1) 94-108
• 2 Nadler S F, Bartoli L M, Stitik T P, Chen B. Tarlov cyst as a rare cause of S1 radiculopathy: a case report.  Arch Phys Med Rehabil. 2001;  82 (5) 689-690
• 3 Acosta F, Quinones-Hinojosa A, Schmidt M, Weinstein P. Diagnosis and management of sacral Tarlov cysts, case report and review of the literature.  Neurosurg Focus. 2003;  15 (2) 1-7
• 4 Mitra R, Kirpalani D, Wedemeyer M. Conservative management of perineural cysts.  Spine (Phila Pa 1976). 2008;  33 (16) E565-E568
• 5 Langdown A J, Grundy J R, Birch N C. The clinical relevance of Tarlov cysts.  J Spinal Disord Tech. 2005;  18 (1) 29-33
• 6 Paulsen R D, Call G A, Murtagh F R. Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts).  AJNR Am J Neuroradiol. 1994;  15 (2) 293-297 discussion 298-299
• 7 Patel M R, Louie W, Rachlin J. Percutaneous fibrin glue therapy of meningeal cysts of the sacral spine.  AJR Am J Roentgenol. 1997;  168 (2) 367-370
• 8 Lee J Y, Impekoven P, Stenzel W, Löhr M, Ernestus R I, Klug N. CT-guided percutaneous aspiration of Tarlov cyst as a useful diagnostic procedure prior to operative intervention.  Acta Neurochir (Wien). 2004;  146 (7) 667-670
• 9 Murphy K, Wyse G, Schnupp S et al.. Two-needle technique for the treatment of symptomatic Tarlov cysts.  J Vasc Interv Radiol. 2008;  19 (5) 771-773