Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review

Thecaloscopy Reduces the Risk of Recurrent Perineural (Tarlov) Cysts after Microsurgical Resection

Sacral Tarlov cysts (TCs), often asymptomatic, can cause significant pain and severe neurological dysfunction. Conventional treatments are generally associated with high recurrence and complication rates. Specifically, the substantial recurrence rates, which can reach as high as 50%, significantly impact long-term outcomes. Recent evidence increasingly supports the hypothesis that the formation of Tarlov cysts (TCs) may be associated with inflammatory processes within the nerve root sheath, further exacerbated by elevated cerebrospinal fluid (CSF) pressure. This retrospective study explores thecaloscopy, combined with surgical techniques, as a more effective alternative. We observed a total of 78 patients, 48 of whom underwent endoscopic fenestration of the arachnoid sheath in addition to microsurgical resection of the TC. We found that the fenestration of the arachnoid sheath at the level of lumbosacral spinal nerve root entry led to a significantly decreased risk of developing recurrent TCs (5/48 vs. 9/30). Only one of the patients suffered from a persistent new bladder dysfunction after microsurgical resection. This presented technique provides a promising treatment path for the future management of TCs, offering a safe and more effective treatment option compared to previous methods. Additionally, the advantages of the thecaloscopy provide pathophysiological implications regarding the development of perineural cysts.

A Case of Symptomatic Multiple Tarlov Cysts Treated with Microsurgical Wrapping Technique -Efficacy and Limitation of Surgical Procedure

Tarlov cysts (TCs) rarely cause clinical symptoms, such as leg pain, buttock pain, and bladder/bowel dysfunction. Surgery is considered when these symptoms persist despite medical treatments. Among several surgical procedures, microsurgical wrapping (MSW) is a relatively novel, simple technique with few complications, including cerebrospinal fluid leakage. Herein, we report a case of multiple TCs treated with MSW and present the mechanism of symptoms generated by TC and the procedure's limitations. A 58-year-old man complained of severe right leg and buttock pain for 3 months and was admitted to our hospital. His symptoms aggravated with sitting and standing and improved with the prone position. Spinal magnetic resonance imaging (MRI) demonstrated multiple sacral cysts containing intense cerebrospinal fluid. The cysts connect to the right S3 and S4 nerve roots. He was treated conservatively with medications; however, his symptoms were not improved. Therefore, MSW was performed for TCs connected to the S3 and S4 roots. The postoperative course was uneventful, and cerebrospinal fluid leakage did not occur. MRI performed 1 year after the operation demonstrated no recurrence of the TCs, and his leg pain was completely relieved; however, the buttock pain remained. MSW for TCs is effective for symptoms of adjacent nerve root compression; however, repairing the damaged nerve root in TCs is sometimes difficult. This may be a limitation of present surgical interventions because these symptoms may be difficult to treat even with other interventions.

A bibliometric and visualization study of global research trends in sacral Tarlov cyst from 2000 to 2022

Background

Symptomatic sacral Tarlov cyst (STC) exerts a significant negative impact on the patient's quality of life, highlighting the significance of the increasing number of studies on STC. However, bibliometric analyses in this research field are scarce. Thus, this study aims to provide a comprehensive knowledge structure and identify the research trends of STC through bibliometrics.

Methods

Articles related to STC from 2000 to 2022 were sourced from the Web of Science Core Collection database. VOSviewer 1.6.16, CiteSpace 6.1.6, GraphPad Prism 8.2.1 and R-package "bibliometrix" were used to analyse the data and generate knowledge maps.

Results

A total of 930 studies on STC from 2000 to 2022 were included. The findings revealed a consistent yet upward trend in the number of annual publications in this field. The United States, China and Turkey were the most prolific and influential countries contributing to this field, with the University of Illinois, the University of Maryland and the National Institute of Standards & Technology being the most notable research institutions. Key journals include World Neurosurgery [Impact Factor (IF) = 2.210], Journal of Vascular Surgery (IF = 4.860) and Journal of Neurosurgery-Spine (IF = 3.467). Additionally, Tarlov Mj, Tarlov E and Zachariah Mr exhibit the highest number of publications, making them the leading authors in this field. A twenty-year retrospection of research trends using keyword analysis reveals four principal directions, namely "definition", "pathogenesis", "diagnosis" and "treatment". Currently, therapeutic surgical intervention is the key treatment for this disease, with future treatments primarily hinging on minimally invasive methodologies rooted in microendoscopic and endoscopic techniques.

Conclusion

This pioneering, comprehensive scientific bibliometric study provides a holistic summary of STC research trends and hot spots spanning the past 22 years. The results identify existing research frontiers and chart maps for future studies, serving as a valuable reference for scholars vested in this field.

Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals

Tarlov cysts were thought to be anatomic variants of uncertain etiology and clinical significance when initially described over 80 years ago. They are often detected in routine lumbosacral imaging and generally not reported in a differential diagnosis. There is increasing evidence that at least some Tarlov cysts are symptomatic and can have a significant adverse impact on patients' health and well-being. Women are disproportionately affected with this condition, often presenting with long-standing pain and neurological dysfunctions. Significant gender bias has been a concern in the management of these patients. Unfortunately, there is no consensus on patient selection or management approaches for symptomatic Tarlov cysts. This review article updates information on the prevalence, diagnosis, clinical significance, and treatments of these cysts. Based on these findings and experience with over 1000 patient referrals, a treatment decision algorithm for symptomatic Tarlov cysts was constructed to provide guidance for appropriate management of patients with these complex cysts.

Sacral Tarlov cysts: Neurophysiology abnormalities and correlation with pelvic sensory and visceral symptoms

BACKGROUND AND PURPOSE

Recent studies suggest a possible association between Tarlov cysts (TCs), usually considered as incidental radiological findings, and neurological symptoms such as pain, numbness and urogenital complaints. The aim was to explore the relationship between TCs and sacral nerve root functions using pelvic neurophysiology tests, and to correlate changes with clinical symptoms and magnetic resonance imaging (MRI) findings.

METHODS

Consecutive patients with sacral TCs, referred for pelvic neurophysiology testing and presenting with at least one symptom related to the pelvic area, participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamics testing were collected retrospectively. The relationship between neurophysiology, MRI findings and patients' symptoms was assessed using Fisher and ANOVA tests.

RESULTS

Sixty-five females were included (mean age 51.2 ± 12.1 years). The commonest symptom was pain (92%). Urinary (91%), bowel (71%) and sexual (80%) symptoms were also frequently reported. Thirty-seven patients (57%) had abnormal neurophysiology findings reflecting sacral root dysfunction. No association was seen between MRI findings (size, location of the cysts, severity of compression) and neurophysiology. A negative association was observed between neurophysiology abnormalities and occurrence of urgency urinary incontinence (p = 0.03), detrusor overactivity (p < 0.01) and stress urinary incontinence (p = 0.04); however, there was no association with voiding difficulties.

CONCLUSIONS

Contrary to current understanding, TCs are associated with injury to the sacral somatic innervation in the majority of patients with presumed symptomatic cysts. However, urinary incontinence is unlikely to be related to TC-induced nerve damage.

A novel surgical technique for treatment of symptomatic Tarlov cysts

BACKGROUND

The aim of this retrospective study was to describe a novel, simple surgical technique for the treatment of symptomatic Tarlov cysts.

METHODS

A total of 40 patients with symptomatic Tarlov cysts, admitted to our tertiary center between 1998 and 2019 constituted the study group. All patients underwent microsurgical puckering of the cyst, the technique we described to prevent a recurrence. Patients' symptoms, radiological findings, intraoperative findings, and clinical results were evaluated.

RESULTS

Of the 40 patients (5 males, 35 females) whose charts were reviewed, the mean age was 28.4 (range, 17-61) years. The mean follow-up was 8 (range, 3 months to 21 years) years. Preoperatively, the most common symptoms were leg pain and numbness of the lower extremity. Postoperatively, no major complications were observed. Clinical progression was halted in all patients; 33 (82%) patients recovered completely and seven (17%) patients reported partial recovery. Cystic cavity persisted radiologically in five (12%) patients, decreased in size in 30 (75%) patients, and regressed completely in the remaining five (12%) patients. None of the patients had permanent neurological deficits.

CONCLUSION

Puckering of the cyst membrane is a safe and easy-to-perform surgical technique for symptomatic Tarlov cysts. This technique can be used almost in all cases instead of the commonly used microsurgical cyst excision or cyst fenestration.

Symptomatic sacral Tarlov cyst: Case report and review of literature

Tarlov cysts are a common finding in MRI. Most of them are asymptomatic but in some cases can cause pain in urogenital region. Diagnosis and treatment are controversial and most of the symptomatic cases are not well diagnosed and treated because of unawareness of neurosurgeons about them. Treatment of symptomatic TC is effective and good results have been published with percutaneous and surgical techniques. A case of a young woman with a symptomatic sacral cyst treated surgically successfully is presented and literature about it is reviewed.

Spinal manifestations of Ehlers-Danlos syndrome: a scoping review

OBJECTIVE

Since its initial description, the definition of Ehlers-Danlos syndrome (EDS) has notably changed. At present, it broadly refers to disorders of the connective tissue that are heritable and have similar features including joint hypermobility, dermal dysplasia, and vascular as well as internal organ fragility. There has been no comprehensive review of spinal manifestations of EDS in the recent literature. That has led to controversies in management protocols of this so-called orphan disease.

METHODS

The authors used the latest version of the EDS classification from 2017, in which 13 subtypes were recognized. EDS has 19 different causal genes, mainly associated with collagen synthesis. Of these, 5 subtypes have associated spinal manifestations.

RESULTS

Some of the spinal pathologies associated with EDS include Chiari malformation, craniocervical instability, kyphoscoliosis, segmental instability and kyphosis, spontaneous CSF leaks, Tarlov cyst syndrome, tethered cord, and problems associated with wound healing. Here, the authors briefly discuss the demographics, etiology, pathophysiology, clinical features, management strategies, and directions for further research for each of these manifestations.

CONCLUSIONS

EDS belongs to the group of orphan diseases, with the total patient population being below 200,000. Further research on spinal manifestations of EDS is the need of the hour to establish clinical practice guidelines and close the significant knowledge gaps that currently exist.

Microsurgical sealing for symptomatic sacral Tarlov cysts: a series of 265 cases

OBJECTIVE

Tarlov cysts (TCs) are a common cystic entity in the sacral canal, with a reported prevalence between 1.5% and 13.2%; 10%-20% of patients are symptomatic and need appropriate clinical intervention. However, the choice of treatment remains controversial. The goal of this study was to describe a new microsurgical sealing technique for symptomatic sacral TCs (SSTCs) as well as its long-term outcomes.

METHODS

Microsurgical sealing was performed using a short incision, leakage coverage with a piece of autologous fat, and cyst sealing with fibrin glue. Postoperative data were collected at three stages: discharge, 1-year follow-up, and a follow-up of 3 years or more. According to the improvement in neurological deficits and degree of pain relief, outcomes were divided into four levels: excellent, good, unchanged, and deteriorated.

RESULTS

A total of 265 patients with SSTCs were treated with microsurgical sealing from January 2003 to December 2020. The mean follow-up was 44.69 months. The percentages of patients who benefited from the operation (excellent and good) at the three stages were 87.55%, 84.89%, and 80.73%, respectively, while those who received no benefit (unchanged and deteriorated) were 12.45%, 15.11%, and 19.27%, respectively. Of the patients with postoperative MRI, the cysts were reduced in size or disappeared in 209 patients (94.14%). CSF leakage from the wound was observed in 15 patients, and 4 patients experienced an infection at the incision. There were no cases of new-onset nerve injury or aseptic meningitis after the operation.

CONCLUSIONS

SSTC patients undergoing microsurgical sealing had persistently high rates of symptom relief and few postoperative complications. Microsurgical sealing is an effective, simple, and low-risk method for treating SSTCs.

Management of Symptomatic Sacral Perineural Cysts: A New Surgical Method

BACKGROUND

Microsurgical techniques are increasingly being recommended for the treatment of symptomatic Tarlov cysts (TCs) due to improved long-term outcomes compared to those of other strategies. However, these techniques are associated with a high risk of cyst recurrence and cerebrospinal fluid (CSF) leakage, resulting in the surgical strategy of TCs remaining controversial. We hypothesize that incomplete closure of the ostium between the cyst and the subarachnoid space is the probable cause of surgical failure. Accordingly, we present a novel method of cyst separation and ostium closure that aims to block the ostium more firmly and reliably.

METHODS

Thirty-five consecutive patients (21 females) underwent the modified ostium obstruction surgery due to symptomatic TCs. We collected and compared their outcomes at the final follow-up to evaluate the surgical effect.

RESULTS

Thirty-five patients had 74 TCs (S2 level, 48.7%; mean diameter, 2.0 ± 1.0 cm); ostia nerve root fibers were found in all TCs. The mean follow-up duration was 37.8 (range, 13.5-76.8) months. At the final follow-up, 33 patients experienced complete or substantial resolution of the preoperative symptoms. The symptom with the highest improvement rate was radicular pain. Both the modified evaluation criteria for the efficacy of lumbar function criterion and Japanese Orthopedic Association score 29 showed an overall improvement rate of 94.3%. Two patients experienced surgery-related neurological dysfunction. No cyst recurrence or CSF leakage was observed. Magnetic resonance imaging showed that all cysts disappeared or significantly reduced postoperatively.

CONCLUSIONS

The microscopic fenestration of cysts and modified ostium obstruction described herein is a safe and effective strategy for management of patients with symptomatic TCs and is associated with a low incidence of cyst recurrence and CSF leakage since it achieves complete closure of cyst ostium.

Multiple dimensions of radiographic reconstruction for the optimal operative strategy of sacral meningeal cysts

BACKGROUND AND PURPOSE

The contents and subtypes of sacral cysts are sophisticated in many cases. We applied multiple dimensional magnetic resonance imaging (MRI) reconstruction to preoperatively clarify the specific subtype of sacral meningeal cysts.

MATERIALS AND METHODS

We preoperatively used multimodal neural reconstruction MRI sequences to evaluate 76 patients with sacral cysts. The linear nerve roots were precisely traced based on sagittal or coronal images processed at various angles and levels which was conducive to the design of the operation strategy.

RESULTS

Cysts with nerve passage were detected in 47 cases (62%, 47/76), whereas cysts without nerve roots were detected in 24 cases (32%, 24/76). Five patients had mixed cysts with or without nerve roots. Intraoperative exploration results proved the high accuracy of image reconstruction; only one cyst without a nerve root was misdiagnosed prior to surgery.

CONCLUSION

MRI reconstruction based on the three-dimensional fast imaging employing steady-state acquisition T2 sequence precisely tracked the nerve roots of sacral cysts and guided the optimal strategy during surgery.

CT-Guided Aspiration of a Hemorrhagic Tarlov Cyst for the Treatment of a Post-Partum Sciatica: A Case Report and a Review of the Literature

Background

Tarlov or perineural cysts are dilations of nerve roots resulting from a pathologically increased cerebrospinal fluid pressure. Although it is very common in the general population, most of these cysts remain asymptomatic. In some cases, they can evolve and exert pressure on neural elements, independently from their initial size.

Case report

In this paper, we describe the case of a 33-year-old female known to have asymptomatic multiple and large radicular and pelvic Tarlov cysts. One cyst located in the right pelvic space progressed acutely after delivery, inducing a painful sciatica without neurological deficit. The intracystic bleeding can be a direct consequence of the delivery, leading to an acute and mechanical local compression of the right S1 root. A CT-guided puncture and aspiration allowed a complete recovery. This case report was completed by a review of the literature of these rare intracystic Tarlov bleedings.

Conclusions

Intracystic hemorrhage is a rare complication of Tarlov cysts. Delivery-induced cyst bleeding was not described before. Patients known to have large and multiple Tarlov cysts should be monitored in post-partum, as their presence is considered a risk factor. Percutaneous cyst aspiration seems to be an effective and safe treatment to relieve symptoms.

High Prevalence of Perineural Cysts in Patients with Fibromyalgia and Chronic Fatigue Syndrome

OBJECTIVE

Pain in fibromyalgia (FM) and chronic fatigue syndrome (CFS) is assumed to originate from central sensitization. Perineural cysts or Tarlov cysts (TCs) are nerve root dilations resulting from pathologically increased cerebrospinal fluid pressure. These cysts initially affect sensory neurons and axons in dorsal root ganglia and produce sensory symptoms (pain and paresthesia). Symptomatic TC (STC) patients often complain about widespread pain and fatigue. Consequently, STC patients may initially be diagnosed with FM, CFS, or both. The objective of this study was to document the prevalence of TCs in patients diagnosed with FM or CFS.

DESIGN

A retrospective study.

SETTING

An outpatient clinic for musculoskeletal disorders.

SUBJECTS

Patients diagnosed with FM according to the 1990 American College of Rheumatology criteria or with CFS according to the 1994 Centers for Disease Control criteria were selected.

METHODS

Review of lumbar and sacral magnetic resonance imaging scans including TCs ≥5 mm in size.

RESULTS

In total, 197 patients with FM, CFS, or both underwent magnetic resonance imaging. Ninety-one percent were women. The mean age was 48.1 (±11.9) years. TCs were observed in 39% of patients, with a mean size of 11.8 (±5.2) mm. In males, the prevalence was 12%, vs. 42% in females.

CONCLUSIONS

In patients diagnosed with FM or CFS, the prevalence of TCs was three times higher than that in the general population. This observation supports the hypothesis that STCs, FM, and CFS may share the same pathophysiological mechanism, i.e., moderately increased cerebrospinal fluid pressure, causing irritation of neurons and axons in dorsal root ganglia.

Neglected Tarlov cysts: a case of a Tarlov cyst with spermatorrhea

Background

Tarlov cysts are a commonly misdiagnosed condition, which can present with many rare symptoms. We report a case of a Tarlov cyst with spermatorrhea and review the pertinent literature.

Case presentation

A 42-year-old male patient had a history of spermatorrhea for > 10 years, but was incorrectly diagnosed as the patient and the doctors consistently mistook the symptoms for a genitourinary disease. Magnetic resonance imaging showed that two cysts in the sacral canal. The diagnosis was Tarlov cyst. We performed surgery to remove the cyst and the symptoms of spermatorrhea disappeared after the operation.

Conclusions

This case demonstrates that orthopedics and urologists should improve their understanding of Tarlov cysts to avoid misdiagnosis and mistreatment.

Tarlov Cysts Misdiagnosed as Adnexal Masses in Pelvic Sonography: A Literature Review

Introduction: A Tarlov cyst (TC) is a perineural cyst filled with cerebrospinal fluid that originates from the dorsal ganglion or the spinal posterior nerve root. TCs are usually asymptomatic and incidentally found in the sacral region. Endopelvic extension of TCs is uncommon and can be misdiagnosed as an adnexal mass on gynecological ultrasound imaging.

Methods: We performed a search for all clinical studies of TCs that mimicked adnexal masses that had been published through October 12, 2020. We placed no restrictions on language or year of publication in our search, and we performed searches with the following keywords: perineural cyst, Tarlov cyst, sclerotherapy, management, and prognosis. We included all misdiagnosed cases or cases considered as adnexal masses on pelvic sonography.

Results: We identified 21 cases of TCs mimicking adnexal masses and conducted a comprehensive analysis of these 21 cases to assess the epidemiology, symptoms, initial diagnoses, provisional ultrasound diagnoses, confirmative modalities, sizes, locations, treatments, and outcomes. The 21 cases included 16 symptomatic cases (76%) and 5 cases with incidental findings (24%), and the average patient age was 41.3 years. The initial diagnosis was performed with ultrasonography in all cases. The most frequent misdiagnosis was unspecified adnexal mass. Confirmative diagnostic modalities were MRI only (67%), CT only (5%), and both MRI and CT (28%). Treatments were surgery (33%), conservative treatment (19%), percutaneous intervention (5%), and alcohol sclerotherapy (5%). In two symptomatic cases misdiagnosed as pelvic masses, cystectomy was performed and leakage of cerebrospinal fluid occurred, necessitating repair of the leak. In one of the asymptomatic patients, cauda equina syndrome occurred after alcohol sclerotherapy for misdiagnosed TC. However, the patient improved with no neurologic deficit after 18 months of conservative treatment.

Conclusion: The possibility of large TCs should be considered when assessing adnexal masses in sonography. Since TCs can masquerade as pelvic masses, they should be considered if the mass appears tubular/cystic or multilocular/multiseptate, does not move with respiration, and originates from the sacrum in sonography with or without neurologic symptoms. Accurate diagnosis can prevent medical mismanagement and reduce patient discomfort.

The Role of Pelvic Neurophysiology Testing in the Assessment of Patients with Voiding Dysfunction

Purpose of Review

The role of pelvic neurophysiology testing in the evaluation of patients with lower urinary tract (LUT) symptoms is explored in this review.

Recent Findings

Different neurophysiology tests such as sphincter EMG and pudendal somatosensory evoked potentials are useful in evaluating the sacral somatic afferent and efferent innervation. S2 and S3 dermatomal evoked potentials assess individual sacral roots and are feasible to perform using standard neurophysiology machines.

Summary

The innervation of the LUT has a substantial contribution from splanchnic and somatic nerves arising from the sacral segments. Pelvic neurophysiology tests, which assess somatic nerve functions, are therefore a useful tool in assessing sacral nerve functions in patients presenting with unexplained voiding dysfunction. In this review, the commonly performed neurophysiology studies that assess the S2, S3 and S4 sacral afferent and efferent pathways are outlined, and their clinical applications reviewed.

[Tarlov cyst and faecal incontinence: A case report and literature review]

Tarlov, or perineural cysts, are lesions of the nerve root usually located at the sacral level of the spine. Their cause is unclear. These cysts are generally identified as an incidental finding and are usually asymptomatic. Symptomatic cysts are infrequent, with symptoms usually consisting of pain, radiculopathy and, less frequently, bladder, bowel and sexual dysfunction. We report the case of a 70-year-old woman with Tarlov cyst, provoking faecal incontinence, and review the aetiology, pathophysiology and management of this particular case.