What is the initial management approach for patients presenting with Tarlov cysts?

Management of Tarlov Cysts

The initial management approach for patients with Tarlov cysts should focus on conservative measures, as most Tarlov cysts are asymptomatic and do not require invasive intervention. 1

What Are Tarlov Cysts?

Tarlov cysts (also known as perineural cysts) are cerebrospinal fluid-filled sacs that form on the nerve root sheaths, most commonly in the sacral region. They occur between the endoneurium and perineurium of spinal nerve roots and are typically found incidentally on imaging studies in approximately 1% of lumbar MRIs. 2

Diagnostic Evaluation

When a patient presents with suspected Tarlov cysts:

• MRI of the lumbosacral spine is the gold standard for diagnosis

  • Tarlov cysts appear hypointense on T1-weighted images and hyperintense on T2-weighted images 2
  • Look for cystic lesions around the sacral nerve roots, often at S2-S3 levels

• CT myelography may be used to confirm delayed filling of the cysts, which is characteristic of Tarlov cysts 3

• Clinical assessment should focus on:

  • Low back pain (present in 94% of symptomatic cases) 4
  • Sensory radiculopathy (69%) 4
  • Bladder and bowel dysfunction (61%) 4
  • Sexual dysfunction (17%) 4
  • Motor dysfunction (8%) 4

Management Algorithm

Step 1: Determine if the Tarlov Cyst is Symptomatic

Most Tarlov cysts are asymptomatic and should be managed with observation only. 1

For symptomatic cysts, proceed to Step 2.

Step 2: Initial Conservative Management

For symptomatic Tarlov cysts, begin with:

• Pain management with non-steroidal anti-inflammatory drugs (NSAIDs)
• Physical therapy to strengthen core and pelvic muscles
• Epidural steroid injections - shown to be effective in managing smaller symptomatic cysts without motor symptoms 2

Step 3: Evaluate Response to Conservative Management

If symptoms persist despite 3-6 months of conservative management, consider interventional approaches:

• CT-guided aspiration with fibrin glue injection:
  • First-line interventional approach
  • 66% of patients show improvement in one or more symptoms 5
  • In one study, 61% of patients had complete resolution and 39% had substantial resolution of symptoms 6
  • No CSF leakage or recurrence reported with this technique 6

Step 4: Consider Surgical Management for Refractory Cases

For patients who fail conservative management and percutaneous interventions, surgical options include:

• Microsurgical cyst fenestration and imbrication:
  • Reserved for severe cases with significant neurological deficits
  • 50% complete resolution and 50% substantial resolution reported 6
  • Higher complication rate (21% CSF leakage, 21% recurrence) 6

Factors Affecting Treatment Success

• Cyst size: Cysts larger than 1.5 cm in diameter with radicular symptoms have better surgical outcomes (70% success rate) compared to smaller cysts with nonradicular pain (30% success rate) 3

• Symptom type: Patients with radicular pain or bladder/bowel dysfunction respond better to intervention than those with nonspecific pain 3

Important Considerations and Pitfalls

1. Avoid unnecessary surgery: Since most Tarlov cysts are asymptomatic, incidental findings should not lead to invasive procedures 1

2. Rule out other causes: Many symptoms attributed to Tarlov cysts can be caused by other spinal pathologies, so thorough evaluation is necessary before attributing symptoms to the cysts

3. Surgical risks: Be aware that surgical intervention carries risks of CSF leakage, infection, and symptom recurrence 6, 4

4. Anatomical considerations: When considering surgery, be aware of the location of the dural tube and any potential spina bifida occulta or manifestations of dural ectasia, as inadvertent leakage of cerebrospinal fluid can lead to meningitis 1

5. Nerve preservation: The lower sacral nerve roots (S2-S4) innervate the urinary and anal sphincters, and care must be taken in non-paraplegic patients to avoid damage to these structures during surgical intervention 1

By following this management algorithm, clinicians can provide appropriate care for patients with Tarlov cysts while minimizing unnecessary interventions and their associated risks.