What are the management options for symptomatic Tarlov cysts?

Management of Tarlov Cysts

Initial Assessment and Risk Stratification

For asymptomatic Tarlov cysts discovered incidentally on imaging, conservative management with observation is the appropriate approach, as these lesions are benign and most remain stable over time. 1, 2

Determine Symptom Status and Severity

• Asymptomatic cysts (incidental findings): These represent the majority of Tarlov cysts, found in approximately 1-9% of imaging studies 3, 4

  • Provide patient counseling and reassurance about the benign nature of the finding 2
  • No routine imaging follow-up is necessary 2
  • Consider a single follow-up MRI at 1 year to demonstrate stability, then discontinue surveillance if stable 2

• Symptomatic cysts: Assess for specific clinical features that predict treatment success 5, 3, 4

  • Radicular pain in dermatomal distribution (best predictor of surgical success) 4
  • Bladder/bowel dysfunction 4
  • Cyst size >1.5 cm (strongly correlates with excellent surgical outcomes) 4
  • Sensory deficits in corresponding dermatomes 6
  • Duration of symptoms <47 months (longer duration associated with poorer outcomes) 3

Management Algorithm for Symptomatic Tarlov Cysts

First-Line: Conservative Management

For smaller symptomatic cysts (<1.5 cm) or those causing primarily non-radicular pain, attempt conservative management first. 4

• Epidural steroid injection is effective for smaller cysts without motor symptoms 6

  • Can provide sustained symptom relief for at least 1 year 6
  • Particularly effective for sensory symptoms and localized pain 6

• Reserve conservative management for patients with:

  • Cysts <1.5 cm diameter 4
  • Non-radicular pain patterns 4
  • Mild sensory symptoms without motor deficits 6

Second-Line: Minimally Invasive Intervention

For patients failing conservative management with cysts of any size, C-arm fluoroscopy-guided percutaneous fibrin gel injection is the preferred minimally invasive option. 5

• Outcomes: 61% complete resolution, 39% substantial resolution 5
• Advantages: No CSF leakage, no recurrence in reported series 5
• Superior to conservative management: Only 25% substantial resolution with conservative approach alone 5

Third-Line: Microsurgical Treatment

Microsurgical cyst fenestration with ostium closure is indicated for patients with large cysts (>1.5 cm), radicular symptoms, or bladder/bowel dysfunction who fail less invasive measures. 4, 7

Surgical Technique Considerations

• Modified ostium obstruction with complete closure of the communication between cyst and subarachnoid space achieves the best outcomes 7

  • 94.3% overall improvement rate 7
  • No cyst recurrence or CSF leakage when ostium completely closed 7
  • All cysts disappeared or significantly reduced on postoperative MRI 7

• Traditional microsurgical fenestration and imbrication has variable results 5, 3

  • 50% complete resolution, 50% substantial resolution 5
  • Major complications: 21% CSF leakage rate, 21% recurrence rate 5
  • Consider lumbar drainage for 8-9 days postoperatively 3

Predictors of Surgical Success

Surgical outcomes are excellent when all three factors are present 4:

• Cyst diameter >1.5 cm
• Radicular pain pattern
• Bladder/bowel dysfunction

Predictors of Poor Surgical Outcome

Avoid surgery or counsel extensively when these factors are present 3:

• Advanced patient age
• Multiple perineural cysts on imaging (>3 cysts)
• Symptom duration >47 months
• Cysts <1.5 cm with non-radicular pain 4

Common Pitfalls

• Do not perform routine long-term imaging surveillance on asymptomatic cysts, as >80% remain stable and imaging does not change management 2
• Do not rush to surgery for small cysts (<1.5 cm) with non-radicular pain, as outcomes are poor (0% significant improvement in this subset) 4
• Ensure complete ostium closure during microsurgery to prevent the 21% recurrence and CSF leakage rates seen with incomplete closure 5, 7
• Screen for multiple cysts preoperatively, as their presence predicts worse outcomes 3