What is the management approach for patients with Tarlov cysts?

Management of Tarlov Cysts

Tarlov cysts are perineural cysts that should be treated with CT-guided percutaneous fibrin gel injection when symptomatic, as this approach provides the best outcomes with minimal complications compared to other treatment options. This recommendation is based on recent evidence showing superior symptom resolution and lower complication rates compared to surgical approaches or conservative management 1.

Diagnosis and Clinical Presentation

Tarlov cysts are cerebrospinal fluid-filled perineural cysts typically located at the sacral nerve roots. They are often incidental findings on imaging (approximately 1% of lumbar MRIs) 2, but can become symptomatic in about 20% of cases 3.

Common symptoms include:

• Low back pain (present in up to 94% of symptomatic cases) 3
• Sensory radiculopathy (69%) 3
• Bladder and bowel dysfunction (61%) 3
• Sexual dysfunction (17%) 3
• Motor dysfunction (8%) 3

Diagnostic Imaging

• MRI is the gold standard for diagnosis, showing cystic lesions that appear:
  • Hypointense on T1-weighted images
  • Hyperintense on T2-weighted images 2
• CT scan may show bony remodeling around the affected vertebra 2

Treatment Algorithm

1. Conservative Management

• First-line approach for small, mildly symptomatic cysts
• Options include:
  • Epidural steroid injections 2
  • Pain management medications
  • Physical therapy

Caution: Conservative management alone has shown poor outcomes, with one study reporting 75% of patients experiencing symptom aggravation with this approach 1.

2. Interventional Treatment

For patients with persistent symptoms despite conservative management:

CT-guided percutaneous fibrin gel injection is the recommended treatment based on:

• 61% complete resolution and 39% substantial resolution of symptoms 1
• No reported CSF leakage or symptom recurrence 1
• Long-term satisfaction rate of 74% at 3-6 years follow-up 4
• Minimal invasiveness compared to surgical options 5

Technique: The procedure involves CT-guided aspiration of the cyst followed by injection of fibrin sealant (Tisseel VH) using a two-needle technique under local anesthesia 4.

3. Surgical Management

Consider only when interventional treatment fails:

Microsurgical options:

• Cyst fenestration with fibrin glue injection
• Nerve root imbrication

Surgical outcomes:

• Complete resolution: 50% of cases
• Substantial resolution: 50% of cases
• Complications: 21% CSF leakage, 21% symptom recurrence 1

Follow-up Recommendations

• MRI follow-up every 6 months until resolution of cystic lesions 6
• Regular assessment of pain using visual analog scale (VAS) 1
• Monitoring of neurological symptoms

Important Considerations and Pitfalls

1. Misdiagnosis: Tarlov cysts are often mistakenly considered incidental or asymptomatic findings, leading to delayed treatment 4.

2. Differential diagnosis: Must rule out other causes of similar symptoms including:

   • Herniated discs
   • Spinal stenosis
   • Sacroiliitis
   • Facet joint disease

3. Treatment selection pitfalls:

   • Overreliance on conservative management may lead to symptom progression 1
   • Surgical approaches carry higher complication risks than percutaneous treatments 1, 3
   • Untreated symptomatic cysts may lead to progressive neurological deterioration

4. Diagnostic confirmation: Temporary symptom relief after cyst aspiration can serve as a useful diagnostic tool to confirm that the cyst is the source of symptoms 5.

By following this management approach, patients with symptomatic Tarlov cysts can achieve significant improvement in pain and neurological function with minimal risk of complications.