Tarlov cysts: a study of 10 cases with review of the literature

Abstract

<jats:p content-type="fine-print"><jats:italic>Object.</jats:italic> Tarlov or perineurial cysts are lesions of the nerve root most often found in the sacral region. Although there is agreement that asymptomatic Tarlov cysts should be followed, it is still debated whether patients with symptomatic Tarlov cysts should be treated surgically. The authors assessed the outcome and efficacy of cyst wall resection in 10 patients with symptomatic Tarlov cysts. The medical literature is reviewed, theories of origin are evaluated, and suggestions as to their cause and pathogenesis are offered.</jats:p> <jats:p content-type="fine-print"><jats:italic>Methods.</jats:italic> Ten consecutive patients harboring symptomatic Tarlov cysts were treated by the senior author between 1989 and 1999. All patients were assessed for neurological deficits and pain by neurological examination and visual analog scale, respectively. Computerized tomography myelography was performed in all patients to diagnose delayed filling of the cysts. A sacral laminectomy with resection of the sacral cyst or cysts was performed in all patients. Resected material from eight of 10 patients was submitted for histopathological evaluation. Seven (70%) of 10 patients obtained complete or substantial resolution of their symptoms, with an average follow up of 31.7 months. All of these patients had Tarlov cysts larger than 1.5 cm in diameter, producing radicular pain or bladder and bowel dysfunction. Three (30%) of 10 patients experienced no significant improvement. All three patients harbored Tarlov cysts smaller than 1.5 cm in diameter, producing nonradicular pain. Histopathological examination was performed on specimens from eight of 10 patients, which demonstrated nerve fibers in 75% of cases, ganglion cells in 25% of cases, and evidence of old hemorrhage in half.</jats:p> <jats:p content-type="fine-print"><jats:italic>Conclusions.</jats:italic> Large cysts (&gt; 1.5 cm) and the presence of associated radicular symptoms strongly correlate with excellent outcome. Tarlov cysts may result from increased hydrostatic pressure and trauma.</jats:p>

Surgical Treatment of Sacral Perineural Cyst -Case Report-

“…However, whether patients with symptomatic perineural cysts should be treated surgically remains under discussion. 2,3,16,18) In fact, the majority of symptomatic perineural cysts have been treated surgically, but conservative treatment with steroid or gabapentin has been reported. 8,9) Successful surgical treatment of perineural cysts depends on appropriate patient selection.…”

“…8,9) Successful surgical treatment of perineural cysts depends on appropriate patient selection. 11,16,18) Several predictors of an effective operative outcome have been proposed, including large cysts greater than 15 mm in diameter, delayed filling of the cyst on CT myelography, and radicular pain or bowel/bladder dysfunction. 11,16,18) The curable symptoms are coccydynia, dyspareunia, sacral pain, and perianal pain.…”

“…6,13) Depending on the location, size, and relationship to the nerve roots, perineural cysts may cause local or radicular pain, sensory disturbance, motor deficits, neurogenic claudication, bowel and bladder dysfunction, or sexual impotence. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] Specific radicular pain may be the result of distortion, compression, or stretching of the nerve root by the space-occupying features of cysts. Symptoms can be exacerbated by changes in posture, coughing, Valsalva maneuvers, standing, lifting, and climbing stairs, all of which increase CSF pressure.…”

“…However, no consensus exists regarding the appropriate surgical procedures. 2,3,16,18) We describe a case of sacral perineural cyst treated successfully with microsurgical partial cyst removal and cyst wall imbrication, together with closure of the communication between the cyst and the arachnoid space with absorbable collagen sponge and fibrin glue.…”

“…17) Perineural cysts arise at the junction of the dorsal ganglion and posterior nerve root, and develop between the endoneurium and perineurium, most commonly at the S2 or S3 level. 17,18) The prevalence has been reported as approximately 1.5% to 4.6% in the general adult population. 6,13) Although most perineural cysts are asymptomatic, approximately 1% cause symptoms related to local compression.…”