Treatment of Cervical Perineural Cysts
Conservative management with observation is the preferred initial approach for most cervical perineural cysts, reserving surgical intervention only for patients with progressive neurological deficits or myelopathy that fail conservative treatment. 1, 2
Initial Assessment and Risk Stratification
The first critical step is determining whether the cyst is causing:
- Spinal cord compression or myelopathy 1, 2
- Nerve root impingement with radicular symptoms 3, 4
- Progressive neurological deficits 1
MRI of the cervical spine without IV contrast is the imaging modality of choice for evaluating suspected perineural cysts, assessing cyst location, size, number, and associated structural abnormalities. 1
Management Algorithm
For Asymptomatic or Mildly Symptomatic Cysts
Conservative management is strongly recommended as the first-line approach, particularly given that most perineural cysts (>80%) remain stable in size over time. 2
Conservative management includes:
- Patient counseling and reassurance about the benign nature of the finding 2
- Observation with serial MRI at 6-month intervals initially to document cyst stability 1
- After demonstrating stability at 1 year, long-term imaging follow-up is not necessary for asymptomatic cysts 2
- Routine clinical follow-up without mandatory imaging, with repeat imaging only if clinical deterioration occurs 2
For Symptomatic Cysts with Radicular Pain
When radicular pain is present but without progressive neurological deficits, interventional pain management should be attempted before considering surgery:
Ultrasound-guided cervical selective nerve root block with local anesthetics and steroids is an effective treatment option that avoids puncturing the cyst wall and associated complications such as aseptic meningitis and intracranial hypotension. 4
Alternative interventional approaches include:
- Repetitive transforaminal epidural steroid injection (TFESI) targeted at the affected nerve root, which can provide incremental relief lasting more than 6 months and may result in cyst shrinkage 3
- Oral or epidural steroid therapy as a nonsurgical alternative 5
Conservative non-interventional options for symptomatic cases:
- Soft cervical collar for 2 weeks 6
- 15-day course of oral non-steroidal anti-inflammatory medication 6
- Activity modification 6
This conservative approach without steroids has demonstrated 90% symptom improvement at 24 months in reported cases. 6
For Progressive Neurological Deficits or Myelopathy
Surgery should be considered only for patients with progressive neurological deficits or myelopathy that fail conservative management. 1
Microsurgical cyst fenestration or wrapping surgery are the recommended surgical techniques, as they provide safe and effective symptom relief with minimal complications. 1
CT myelography may be used as a complementary imaging modality when MRI findings are equivocal or for presurgical planning. 1
Postoperative Monitoring
Following surgical intervention:
- Clinical assessment of symptom improvement 1
- Repeat MRI to confirm cyst reduction and nerve root decompression 1
- Long-term surveillance for cyst recurrence 1
Critical Pitfalls to Avoid
Do not puncture the perineural cyst wall during interventional procedures, as this can lead to secondary complications including aseptic meningitis and intracranial hypotension. 4 Ultrasound guidance enables successful nerve root block without cystic wall puncture. 4
Avoid rushing to surgery for asymptomatic or mildly symptomatic cysts, as the natural history is benign with most cysts remaining stable over time. 2
Do not perform routine long-term imaging surveillance for stable asymptomatic cysts, as this provides no clinical benefit and increases healthcare costs. 2