What is the best management approach for a Tarlov cyst at S2?

Management of Tarlov Cysts at S2

Conservative management should be the initial approach for Tarlov cysts at S2, as most are asymptomatic and do not require invasive intervention. 1

Diagnostic Considerations

• Tarlov cysts are perineural cysts filled with cerebrospinal fluid that occur near the dorsal root ganglion
• They are often incidental findings (approximately 1% of lumbar MRIs) 2
• MRI is the preferred imaging modality:
  • Cysts appear hypointense on T1 and hyperintense on T2-weighted images 2
  • Helps differentiate from other sacral lesions

Management Algorithm

Step 1: Determine if the cyst is symptomatic

• Most Tarlov cysts are asymptomatic and require only observation 1
• Symptoms may include:
  • Sensory disturbances in S2 dermatome (inner thigh, gluteal region)
  • Bladder/bowel dysfunction (due to S2-S4 nerve root involvement)
  • Sexual dysfunction
  • Pain that worsens with Valsalva maneuvers

Step 2: For asymptomatic cysts

• Observation only
• No invasive procedures are indicated 1
• Periodic follow-up imaging is not routinely necessary unless symptoms develop

Step 3: For symptomatic cysts - Conservative management

• First-line treatment options:
  • Epidural steroid injections - shown to be effective for smaller cysts without motor symptoms 2
  • Pain management
  • Physical therapy
  • Avoidance of activities that increase intrathecal pressure

Step 4: For persistent symptomatic cysts - Minimally invasive options

• CT-guided aspiration with or without fibrin glue injection
  • 66% of patients show improvement in one or more symptoms 3
  • Can serve as both diagnostic and therapeutic intervention
  • May help identify candidates for more definitive surgical treatment 3

Step 5: For refractory cases - Surgical intervention

• Surgical criteria:

  • Persistent symptoms despite conservative management
  • Significant impact on quality of life
  • Correlation between symptoms and cyst location
  • Positive response to temporary aspiration 3

• Surgical options:

  • Microsurgical techniques: laminectomy with cyst imbrication 4
  • Cyst fenestration
  • Paraspinous muscle flap closure

Important Considerations and Caveats

• Surgical outcomes may be less favorable with:

  • Advanced age
  • Multiple cysts on imaging
  • Longer duration of preoperative symptoms 4

• Surgical risks:

  • Potential for CSF leak and meningitis
  • Risk of damage to S2-S4 nerve roots that control urinary and anal sphincters 1
  • Approximately 48% of patients may not return to normal activities after surgery 4

• Despite variable outcomes, 93.8% of surgically treated patients in one study reported they would undergo the operation again if given the choice 4

• For extremely large cysts causing significant anatomical distortion, CSF diversion with lumboperitoneal shunting may be considered 5

The management approach should be guided by symptom severity, impact on quality of life, and response to initial conservative measures, with surgery reserved for cases that fail non-operative management.