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Murphy K, Nasralla M, Pron G, Almohaimede K, Schievink W. Management of Tarlov cysts: an uncommon but potentially serious spinal column disease-review of the literature and experience with over 1000 referrals. Neuroradiology 2024; 66:1-30. [PMID: 37828278 PMCID: PMC10761484 DOI: 10.1007/s00234-023-03226-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 09/19/2023] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- Kieran Murphy
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada.
| | - Mehran Nasralla
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Gaylene Pron
- Dalla Lana School of Public Health, Institute Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, ON, M5T 3M7, Canada
| | - Khaled Almohaimede
- Department of Medical Imaging, Toronto Western Hospital, University Health Network, 399 Bathurst St, Toronto, ON, M5T 2S8, Canada
| | - Wouter Schievink
- Department of Neurosurgery, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, 6Th Floor, Los Angeles, CA, 90048, USA
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Almansa AH, Infante AMJ, Cutillas AMR, Álvarez LG. Symptomatic sacral Tarlov cyst: Case report and review of literature. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:101-104. [PMID: 36754756 DOI: 10.1016/j.neucie.2022.11.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 05/11/2022] [Indexed: 02/08/2023]
Abstract
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.
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Mahajan UV, Labak KB, Labak CM, Herring EZ, Lineberry K, Miller JP, Smith G. Pudendal tumor mimicking cauda equina syndrome and acute radiculopathy: case report. Spinal Cord Ser Cases 2022; 8:71. [PMID: 35918325 PMCID: PMC9345956 DOI: 10.1038/s41394-022-00537-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 07/17/2022] [Accepted: 07/18/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Cauda equina syndrome (CES) is most caused by lumbar disc herniation, and the associated treatment involves prompt surgical decompression. Rarer causes of CES include perineural (Tarlov) cysts. CLINICAL PRESENTATION A 62-year-old female with history of rheumatoid arthritis, hip and knee replacements, and chronic low back pain presented with worsening back pain, left leg weakness and pain for 6 weeks, and bowel/bladder incontinence with diminished sensation in the perianal region for 24 h prior to presentation. MRI demonstrated severe spinal stenosis at L4-S1, central disc herniation at L5-S1, and compression of the cauda equina, consistent with CES. A lumbar decompression was performed. Patient did well at 2-week follow up, but presented 5 weeks post-discharge with increased left leg pain/weakness and genitalia anesthesia. Imaging was unremarkable. Two months later, the patient presented with diminished sensation in the buttocks and bilateral lower extremities and bowel/bladder incontinence. Imaging demonstrated a large cystic presacral mass with involvement of the left sciatic foramen and S3 neural foramen. A team of plastic, orthopedic, and neurological surgeons performed an S3 sacral laminectomy, foraminotomy, partial sacrectomy, and S3 rhizotomy, and excision of the large left hemorrhagic pudendal mass. Final pathology demonstrated a perineural cyst with organizing hemorrhage. On follow-up, the patient's pain and weakness improved. CONCLUSION CES-like symptoms were initially attributed to a herniated disk. However, lumbar decompression did not resolve symptoms, prompting further radiographic evaluation at two separate presentations. This represents the first reported case of a pudendal tumor causing symptoms initially attributed to a herniated disc.
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Almansa AH, Infante AMJ, Cutillas AMR, Álvarez LG. Symptomatic sacral Tarlov cyst: Case report and review of literature. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Porche K, Hoh DJ. Editorial. Microsurgical treatment of sacral Tarlov cysts. J Neurosurg Spine 2022; 37:902-903. [PMID: 35901713 DOI: 10.3171/2022.4.spine22293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Kanagawa A, Matsumiya H, Sasaki M, Koyama T, Yamamura M, Moriwaki M, Onodera Y, Oda Y, Sugiura M, Yamada T. Large presacral Tarlov cysts in pregnancy. Clin Case Rep 2022; 10:e05837. [PMID: 35592042 PMCID: PMC9097754 DOI: 10.1002/ccr3.5837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 03/26/2022] [Accepted: 04/22/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Akiyoshi Kanagawa
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
| | - Hiroko Matsumiya
- Department of Obstetrics and Gynecology Obihiro Kosei General Hospital Obihiro Japan
| | - Mizue Sasaki
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
| | - Takahiro Koyama
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
| | - Mie Yamamura
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
| | - Masashi Moriwaki
- Department of Obstetrics and Gynecology Obihiro Kosei General Hospital Obihiro Japan
| | - Yasumasa Onodera
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
| | - Yasunari Oda
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
| | - Mitsuru Sugiura
- Department of Diagnostic Radiology JCHO Hokkaido Hospital Sapporo Japan
| | - Takashi Yamada
- Department of Obstetrics and Gynecology Japan Community Health care Organization (JCHO) Hokkaido Hospital Sapporo Japan
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Hulens M, Bruyninckx F, Thal DR, Rasschaert R, Bervoets C, Dankaerts W. Large- and Small-Fiber Neuropathy in Patients with Tarlov Cysts. J Pain Res 2022; 15:193-202. [PMID: 35115823 PMCID: PMC8801331 DOI: 10.2147/jpr.s342759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 01/08/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Mieke Hulens
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
- Correspondence: Mieke Hulens, Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, Leuven, Belgium, Tel +32 478 338003, Fax +32 16 32 91 97, Email
| | - Frans Bruyninckx
- Department of Physical Medicine & Rehabilitation, EMG-Laboratory, University Hospitals of Leuven, Leuven, Belgium
| | - Dietmar Rudolf Thal
- Department of Imaging and Pathology, Laboratory of Neuropathology, and Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Pathology, University Hospitals of Leuven, Leuven, Belgium
| | | | - Chris Bervoets
- Department of Neurosciences, Adult Psychiatry, KU Leuven, Leuven, Belgium
- Department of Ophthalmology, University Hospitals of Leuven, Leuven, Belgium
- Department Adult Psychiatry, University Psychiatric Center of KU Leuven, Leuven, Belgium
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, KU Leuven, Leuven, Belgium
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Hulens M, Bruyninckx F, Dankaerts W, Rasschaert R, De Mulder P, Stalmans I, Vansant G, Bervoets C. High Prevalence of Perineural Cysts in Patients with Fibromyalgia and Chronic Fatigue Syndrome. PAIN MEDICINE 2021; 22:883-890. [PMID: 33260218 DOI: 10.1093/pm/pnaa410] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Mieke Hulens
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | - Frans Bruyninckx
- Clinical Electromyography Laboratory, Department of Academic Consultants, Faculty of Medicine, University Hospitals UZ Leuven, Leuven, Belgium
| | - Wim Dankaerts
- Department of Rehabilitation Sciences, Musculoskeletal Rehabilitation Research Unit, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Leuven, Belgium
| | | | - Peter De Mulder
- Department of Anesthesiology and Pain Therapy, Imelda Hospital, Bonheiden, Belgium
| | - Ingeborg Stalmans
- Department of Neurosciences, Ophthalmology Research Group, University of Leuven, Leuven, Belgium.,Department of Ophthalmology, University Hospitals UZ Leuven, Leuven, Belgium
| | - Greet Vansant
- Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Leuven, Belgium
| | - Chris Bervoets
- Department of Neurosciences, Adult Psychiatry, University of Leuven, Leuven, Belgium.,Department of Ophthalmology , University Hospitals UZ Leuven, Leuven, Belgium.,Department Adult Psychiatry, University Psychiatric Center UPC, University of Leuven, Leuven, Belgium
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Sun P, Xu W, Ye Y, Zhong F, Wan X, Li Y. Neglected Tarlov cysts: a case of a Tarlov cyst with spermatorrhea. Eur J Med Res 2021; 26:44. [PMID: 33964972 PMCID: PMC8106831 DOI: 10.1186/s40001-021-00514-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 04/28/2021] [Indexed: 11/29/2022] Open
Abstract
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.
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Affiliation(s)
- Pan Sun
- Academy of Integrative Medicine, Fujian University of Traditional Chinese Medicine, Fuzhou, 350122, Fujian, People's Republic of China
| | - Wangbing Xu
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Yongxiang Ye
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Faming Zhong
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Xuan Wan
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China
| | - Yong Li
- Spinal Department of Orthopedics, Affiliated Hospital of Jiangxi University of Traditional Chinese Medicine, 445, Bayi Avenue, Donghu, Nanchang, 330004, Jiangxi, People's Republic of China.
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Luesma MJ, Galé I, Fernando J. Diagnostic and therapeutic algorithm for pudendal nerve entrapment syndrome. Med Clin (Barc) 2021; 157:71-78. [PMID: 33836860 DOI: 10.1016/j.medcli.2021.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 02/01/2021] [Accepted: 02/02/2021] [Indexed: 11/19/2022]
Abstract
Pudendal nerve entrapment syndrome is widely unknown and often misdiagnosed or confused with other pelvic floor diseases. The aim is to develop a diagnostic and therapeutic algorithm based on a review of the existing literature. For its diagnosis, an anamnesis will be carried out in search of possible aetiologies, surgical history, and history of pain, assessing location and irradiation, intensity on the visual analogue scale, timing, triggering factors and rule out alarm signs. A physical examination will be performed, looking for trigger points or areas of fibrosis with transvaginal / transrectal palpation of the terminal branches of the nerve. With a doubtful diagnosis, an anaesthetic block of the pudendal nerve can be performed. Once the diagnosis is confirmed, the treatment will begin staggered with lifestyle changes, drug therapy and physiotherapy. In view of the failure of these measures, invasive therapies such as botulinum toxin injection, pulsed radiofrequency and decompression surgery or spinal cord stimulation will be used.
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Affiliation(s)
- María José Luesma
- Departamento de Anatomía e Histología Humanas, Universidad de Zaragoza, Zaragoza, España.
| | - Inés Galé
- Complejo Hospitalario de Navarra, Pamplona, España
| | - José Fernando
- Servicio de Cirugía General y del Aparato Digestivo, Hospital Royo Villanova, Zaragoza, España
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Klepinowski T, Orbik W, Sagan L. Global incidence of spinal perineural Tarlov's cysts and their morphological characteristics: a meta-analysis of 13,266 subjects. Surg Radiol Anat 2021; 43:855-863. [PMID: 33452905 PMCID: PMC8164596 DOI: 10.1007/s00276-020-02644-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 12/02/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Spinal perineural Tarlov's cysts (TCs) are considered incidental findings that occasionally might exert pressure upon nerve roots and correspond with patients' signs and symptoms. Purpose of this meta-analysis is to deliver global incidence and characteristics (location, size, and shape) of TCs. METHODS Following PRISMA checklist, all major databases were searched by two authors for radiologic studies reporting incidence and morphologic features (location, size, and shape) of TCs. Anatomical Quality Assessment tool was applied for risk of bias evaluation. Meta-analysis of random-effects model was employed. Subgroup analysis for regional distribution, gender, sacral levels, age, correspondence with symptoms, and persistent genital arousal disorder (PGAD) were planned ahead. RESULTS 22 radiologic studies of level 3 evidence involving 13,266 subjects were included. Global pooled prevalence of TCs was 4.18% (95% CI 2.47-6.30). Mean pooled sagittal diameter was 11.86 mm (95% CI 10.78-12.93). Sacral cysts strongly prevailed over the other segments. Of the sacral, S2 level was the most common (46.7% [95% CI 29.4-60.5]). Geographically, the highest incidence was found in Europe (6.07% [95% CI 1.49-13.00]), followed by North America (3.82% [95% CI 0.49-9.44]), and Asia (3.33% [95% CI 1.52-5.75]). TCs were more common in women than in men (5.84% vs 3.03%, p < 0.001, test of homogeneity, χ2). Subjects with PGAD had incidence of 37.87% (95% CI 2.45-81.75). TCs in pediatric population are rare-0.53% (95% CI 0.02-1.51). 15.59% of TCs corresponded with symptoms. CONCLUSIONS Spinal perineural (Tarlov) cysts are found in a minority of population. S2 level of the sacral bone is affected most frequently. There is female predominance. Correspondence with symptoms is seen in less than one-fifth of TCs. Studies with stronger evidence level are needed to corroborate the results. The purported high incidence in PGAD requires confirmation in case-control studies for the risk-ratio calculation.
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Affiliation(s)
- Tomasz Klepinowski
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland.
| | - Wojciech Orbik
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
| | - Leszek Sagan
- Department of Neurosurgery, Pomeranian Medical University Hospital No. 1, Szczecin, Poland
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