Management of lumbar radiculopathy due to disc herniation with interlaminar epidural steroid injection in the presence of multilevel Tarlov cysts in the neural foramina

Abstract

Rationale:Perineural cysts, commonly referred to as Tarlov cysts, are cerebrospinal fluid-filled dilations between the perineurium and endoneurium typically arising at the junction of posterior and dorsal root ganglia in the neural foramina. This anatomical location is in close proximity to usual needle trajectory during performing transforaminal epidural injection, and therefore presents a potential risk of dural puncture and associated complications.Patient concerns:Severe lower extremity pain interfering with activities of daily living.Diagnoses:Lumbar radiculopathy secondary to left-sided L4-5 disc herniation in the presence of multilevel Tarlov cysts in the neural foramina.Interventions:Posterior interlaminar epidural steroid injection technique was preferred, as opposed to transforaminal approach, to avoid potential risk of dural puncture and associated complications in the presence of multilevel Tarlov cysts in the neural foramina.Outcomes:The patient responded favorably to epidural steroid injection via interlaminar approach with complete resolution of pain, symptoms, and signs. There were no complications. The patient was able to tolerate physical therapy, wean pain medications, and achieve normal activities of daily living without any significant limitations.Lessons:In patients presenting with an MRI report of “Tarlov cysts”, meticulous evaluation of diagnostic images should be an essential first step before considering invasive spinal procedures. Should there be any presence of Tarlov cyst in close proximity to planned needle trajectory, we recommend appropriate modification of spinal intervention to avoid potential complications.

Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better

“…Laminectomies, direct dural occlusion of dural/subarachnoid fistulas, imbrication and marsupialization often result in cyst resolution. If and when they recur, TP shunts or lumboperitoneal shunts[ 8 ] may become an option.…”

Tarlov Cyst Rupture and Intradural Hemorrhage Mimicking Intraspinal Carcinomatosis

“…TCs, or perineural cysts, are intradural CSF-filled sacs found within the lumbosacral spine [3]. They arise at or just distal to the dorsal root ganglion between the layers of the endo-and perineurium [4][5][6][7][8][9][10]. The incidence of TC is estimated to be between 1.5% and 4.6% with a prevalence of approximately 13% [11][12][13].…”