From the Guidelines
Management of sacral Tarlov cysts, particularly for pain relief, should prioritize conservative approaches, including nonsteroidal anti-inflammatory drugs (NSAIDs) and neuropathic pain medications, before considering invasive interventions. The initial approach to managing pain associated with sacral Tarlov cysts involves the use of NSAIDs like ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily), along with neuropathic pain medications such as gabapentin (starting at 300mg daily, gradually increasing to 300-600mg three times daily) or pregabalin (starting at 75mg twice daily, increasing as needed up to 300mg daily) 1.
Key Considerations
- Physical therapy focusing on core strengthening and pelvic floor exercises can help stabilize the area and reduce pressure on the cyst.
- For patients with persistent pain, interventional procedures may be considered, including CT-guided aspiration of the cyst fluid combined with fibrin glue injection to prevent refilling, or epidural steroid injections (typically methylprednisolone 80mg with lidocaine) to reduce inflammation around nerve roots 1.
- In severe cases unresponsive to conservative treatment, surgical options include cyst fenestration, imbrication, or complete resection with nerve root preservation.
- Pain management should be multimodal, potentially including tricyclic antidepressants like amitriptyline (10-25mg at bedtime) for chronic pain and muscle relaxants such as cyclobenzaprine (5-10mg as needed) for associated muscle spasms.
Important Notes
- The characterization of an adnexal mass as a cyst is important for management, and US identification of a simple cyst establishes a benign process in 100% of premenopausal women 1.
- The sonographic characteristics of Tarlov cysts, such as deep cystic masses communicating with sacral foramina, can help in diagnosis 1.
- Interventional strategies, including neurostimulation procedures and ablation techniques, may be useful for painful conditions but should be considered based on individual patient needs and the presence of specific pain syndromes 1.
From the Research
Sacral Tarlov Cyst Management
Overview of Treatment Options
- Sacral Tarlov cysts are a potential source of chronic pain, with symptoms including perineal pain/pressure, radiculopathy, and headache 2
- Treatment options include cyst drainage with fibrin glue sealant, surgical interventions, and minimally invasive interventional therapies 2, 3, 4
Pain Management
- Caudal epidural steroid injections have been shown to provide significant pain relief for patients with sacral Tarlov cysts, with nearly 100% relief of pain for a period ranging from 6 months to 2 years 2
- Surgical intervention, including microsurgical treatment and open surgical decompression, has also been shown to be effective in managing pain and improving symptoms in patients with symptomatic Tarlov cysts 3, 5
- Interventional approaches, such as cyst aspiration and injection of fibrin glue, may also be useful in managing pain and determining symptom etiology 4
Surgical Intervention
- Microsurgical treatment of sacral perineural (Tarlov) cysts has been shown to be effective in improving symptoms and reducing pain, with 47.8% of patients able to return to normal activities and 93.8% of patients reporting that they would undergo the operation again if given the choice 3
- Open surgical decompression and repair of symptomatic Tarlov cysts has also been shown to be effective, with 81.0% of patients remaining symptom-free for more than 1 year 5
- Surgical intervention may be associated with complications, including surgical site infection and/or CSF leak, with a post-operative complication rate of 16.9% and cyst recurrence rate of 8.5% 5
Non-Surgical Management
- Non-surgical management, including conservative treatment and interventional approaches, may be effective in managing symptoms and improving pain in patients with sacral Tarlov cysts 4, 6
- Cyst aspiration and injection of fibrin glue may serve as a useful diagnostic tool to determine symptom etiology and identify patients who may benefit from neurosurgical intervention 4