Can Tarlov cysts cause pain?

Can Tarlov Cysts Cause Pain?

Yes, Tarlov cysts can cause pain in approximately 20% of cases, leading to symptoms such as lower back pain, radiculopathy, and bladder/bowel dysfunction that may require medical or surgical intervention. 1

What Are Tarlov Cysts?

Tarlov cysts (also known as perineural cysts) are cerebrospinal fluid-filled sacs that form between the endoneurium and perineurium of spinal nerve roots, most commonly affecting the sacral region. They are typically identified during imaging studies and can be specifically diagnosed on MRI or CT.

Clinical Presentation

When symptomatic, Tarlov cysts may cause:

• Lower back pain (present in 94% of symptomatic patients) 1
• Sensory radiculopathy/sciatica (69%) 1
• Bladder and bowel dysfunction (61%) 1
• Sexual dysfunction (17%) 1
• Motor dysfunction (8%) 1

Diagnosis

Tarlov cysts can be accurately diagnosed when they have specific imaging features:

• On MRI: Deep cystic masses communicating with sacral foramina 2
• On CT myelography: Delayed filling of the cysts with contrast 3

MRI is more sensitive than CT myelography for diagnosing these lesions and their relationship to neighboring structures 3. Ultrasound may be used for initial evaluation of cystic lesions, similar to the approach for other types of cysts 4.

Management Approach for Symptomatic Tarlov Cysts

Non-Surgical Management

Many patients with symptomatic Tarlov cysts can be managed non-surgically, especially those with smaller cysts or non-radicular pain 5.

Surgical Interventions

For patients with persistent symptoms, several interventional approaches may be considered:

1. CT-guided aspiration with fibrin glue injection

   • Most commonly performed procedure (74.7% of interventionally managed patients)
   • Can provide symptom improvement in many patients 6

2. Cyst fenestration

   • Surgical technique that can result in clinical improvement in approximately 82% of patients 1

3. Nerve root imbrication

   • Alternative surgical technique with approximately 80% improvement rate 1
   • May have a lower complication rate (22%) compared to fenestration (42%) 1

Prognostic Factors

Poor surgical outcomes are associated with:

• Advanced patient age 7
• Greater number of cysts on preoperative imaging 7
• Longer duration of preoperative symptoms 7

Better outcomes are observed in:

• Patients with cysts larger than 1.5 cm in diameter 5
• Those with radicular pain or bladder/bowel dysfunction 5
• Cases with additional compressive impingement components 3

Clinical Decision-Making

When evaluating a patient with suspected symptomatic Tarlov cysts:

1. Confirm the diagnosis with appropriate imaging (MRI preferred)
2. Assess cyst size (cysts >1.5 cm are more likely to be symptomatic)
3. Evaluate for radicular symptoms, which correlate with better treatment outcomes
4. Consider conservative management initially, especially for smaller cysts
5. For persistent symptoms with larger cysts (>1.5 cm), consider surgical intervention

Despite the potential for improvement with surgery, it's important to note that surgical intervention carries a significant complication rate (overall 28%) 1, so the decision to proceed with surgery should carefully weigh the severity of symptoms against potential risks.