Surgical Intervention is Associated with Improved Outcomes in Patients with Symptomatic Cervical Spine Tarlov Cysts: Results from a Prospective Cohort Study

BACKGROUND

Tarlov cysts are known contributors to radiculopathy but are often misdiagnosed and mismanaged due to a paucity of information. This is particularly true of cervical spine Tarlov cysts because most attention has been focused on sacral cysts. In this study, we describe our longitudinal experience with patients who underwent surgery for cervical spine Tarlov cysts. We hypothesized that patients undergoing surgical treatment for cervical spine Tarlov cysts would report improvement following surgery.

METHODS

We conducted a prospective study of patients who underwent surgical treatment for cervical Tarlov cysts between 2010 and 2021. The Short-Form 36-item survey (SF-36) was administered at the preoperative and follow-up visits. Repeated measures analyses were used to assess changes from preoperatively to postoperatively.

RESULTS

A total of 37 patients with cervical spine cysts were included in the study. Follow-up data were available for 27 patients with a median follow-up of 1 year. Of the cohort, 97.3% were women, with an average age of 47.5 ± 10.3 years. Patients reported statistically significant improvement in 2 of the 4 SF-36 physical health domains (physical function, P< 0.001; and bodily pain, P < 0.001) and 2 of the 4 mental health domains (vitality/energy, P < 0.003; and social functioning, P = 0.007). Patients also reported less interference in work, education, and retirement activities at follow-up (P = 0.017).

CONCLUSIONS

Our longitudinal series consisted of patients with symptomatic cervical spine Tarlov cysts, which, to the best of our knowledge, is the largest series described. Significant improvements in the SF-36 domains were documented, indicating these patients can be successfully treated surgically.

Eight-year chronic wound caused by Tarlov's cyst: a case report

BACKGROUND

Tarlov's cyst is often underdiagnosed since it is difficult to identify without imaging assistance. Herein, we report the case of a young girl who presented with an 8-year history of chronic osteomyelitis of bilateral proximal phalanges and metatarsal bones caused by a Tarlov's cyst that did not contain a nerve root. The chronic wound in the forefoot is an unusual presentation and resulted from the Tarlov's cyst accompanied with tethered conus syndrome.

CASE PRESENTATION

A 10-year-old Asian girl presented with an 8-year history of chronic osteomyelitis of bilateral proximal phalanges and metatarsal bones. She received sequestrectomy five times, however the immune function tests were all normal. A neurological examination revealed diminished sensation and a slapping gait pattern. Magnetic resonance imaging (MRI) demonstrated a lobulated cyst at the right aspect of the sacrum (S) 1 to sacrum (S) 3 canal near the dorsal root ganglion. Tethered conus syndrome was highly suspected. She received laminectomy of lumbar (L) 5 and S1-S2, which led to the diagnosis of a right S1-S3 epidural cyst. The final diagnosis from the histopathological examination was a right sacral Tarlov's cyst. The clinical conditions of diminished sensation and slapping gait pattern greatly improved after successful surgical treatment.

CONCLUSION

In children who present with a recalcitrant chronic wound in the forefoot accompanied with a slapping gait pattern and foot hypoesthesia to pain, aggressive imaging examinations such as spine MRI should be arranged for further evaluation, especially in immunocompetent children.

Endoscopic transforaminal treatment of a thoracic perineural cyst: a case report

BACKGROUND AND IMPORTANCE

To describe the first case of a thoracic perineural cyst successfully treated using a direct thoracic transforaminal endoscopic approach.

METHODS

Case report.

CLINICAL PRESENTATION

A 66-year-old male presented with right-sided radicular pain in a T4 distribution. MRI of the thoracic spine revealed a right T4 perineural cyst caudally displacing the root in the T4-5 foramen. He had failed attempts at nonoperative management. The patient underwent an all endoscopic transforaminal perineural cyst decompression and resection as a same-day surgical procedure. Postoperatively, the patient noted near complete resolution of the preoperative radicular pain. A thoracic MRI with and without contrast was performed 3 months after surgery and showed no evidence of the preoperative perineural cyst and no symptom recurrence was noted by the patient.

CONCLUSION

This case report presents the first safe and successful report of an all endoscopic transforaminal decompression and resection of a perineural cyst in the thoracic spine.

Prospective Validation of a Quality-of-Life Measure for Women Undergoing Surgical Intervention for Symptomatic Sacral Tarlov Cysts: The Tarlov Cyst Quality of Life Scale

BACKGROUND

The use of health-related quality-of-life scales has expanded into most areas of medicine. Established quality-of-life scales are used in several areas of neurosurgery, but none have been validated for use in patients with symptomatic Tarlov cysts. The majority of symptomatic Tarlov cysts are found in the sacral spinal canal of women. We, therefore, validated a site-specific quality-of-life measure for women with symptomatic sacral nerve root compression caused by Tarlov cysts.

METHODS

Women undergoing surgical treatment for sacral Tarlov cysts at a single institution between 2017 and 2020 were enrolled in this prospective validation study. Participants were administered a 13-item version of the survey along with other validated quality-of-life measures preoperatively and at 3 months postoperatively. Psychometric analyses were performed to validate the measure.

RESULTS

One hundred twelve patients met inclusion criteria and completed surveys preoperatively and at 3 months postoperatively. Patients' mean scale scores decreased significantly preoperatively to postoperatively, reflecting good discriminability (P < 0.001). Interitem correlations suggested 2 items were correlated at >0.80, which were dropped to create an 11-item scale. The internal consistency of the 11-item scale was 0.822. Concurrent validity was established by correlating scale scores with the Oswestry Disability Index (P < 0.001) and the physical function (P < 0.001) and pain (P < 0.001) subscales of the Short-Form 36 Survey.

CONCLUSIONS

We prospectively validated a site-specific, health-related quality-of-life survey for women with symptomatic sacral Tarlov cysts. This measure will be useful in future studies to inform clinicians and researchers about the progression of Tarlov cysts and patient response to surgical treatment.

Elimination of the check-valve mechanism of the sacral Tarlov cyst using a rotation flap technique in a pediatric patient: technical note

OBJECTIVE

Symptomatic Tarlov cysts in children are not sufficiently reported and treatment methods for Tarlov cysts are still controversial. The goal of this manuscript is to introduce a new variation of the surgical technique.

METHODS

We performed surgery to eliminate the one-way check valve mechanism of the Tarlov cyst in a 7-year-old female who presented with urinary and fecal incontinence. A relatively large S3 nerve root cyst showed a one-way check valve on computed tomography myelography. The inlet of the check valve was enlarged with rotation flap reconstruction.

RESULTS

Two months after surgery, the patient had established normal sphincter control. MRI performed two years later showed that the treated cyst was collapsing, and no recurrence occurred.

CONCLUSIONS

Rotation flap enlargement of the check valve inlet is a safe and efficacious option for the treatment of pediatric patients with sacral Tarlov cysts.

Findings of subarachnoid fat after trauma to a tarlov cyst

Subarachnoid fat is an uncommon finding that has several etiologies. It is important to determine the etiology in order to plan appropriate treatment. We present a case report of an 80-year-old female brought to the emergency department after a fall with complaints of headache and pain in the sacral region. Computed tomography and magnetic resonance images of the head demonstrated fat in the subarachnoid space. Computed tomography and magnetic resonance images of the sacrum demonstrated a Tarlov cyst with a sacral fracture extending into the cyst, likely representing the origin of the fat in the subarachnoid space. This case demonstrates a rare etiology of fat in the subarachnoid space.

[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.

Management of perineural (Tarlov) cysts: a population-based cohort study and algorithm for the selection of surgical candidates

Objective

Perineural cysts, also known as Tarlov cysts, are cerebrospinal fluid-filled growths that develop at the intersection of a dorsal root ganglion and posterior nerve root. They are typically an asymptomatic and incidental finding during routine spine imaging. For symptomatic perineural cysts, there is little evidence on which treatment is most effective or when it is indicated. The aim of this study was to review our experience from a population-based cohort of patients with symptomatic perineural cysts and to propose an algorithm that could be used in the selection of surgical candidates.

Methods

A retrospective review was conducted of all adult (≥ 15 years) patients with symptomatic perineural cysts who were referred to Karolinska University Hospital between 2002 and 2018.

Results

Thirty-nine patients were included. The most common symptom was sciatica (n = 22). Cyst aspiration was performed in 28 patients, 24 of whom showed clinical improvement and were offered surgery. Microsurgical cyst fenestration was performed in 17 patients, 16 of whom showed clinical improvement at long-term follow-up. There were no surgical complications. Ten of the patients who were offered surgery chose to be treated conservatively instead, four of whom showed progression of symptoms at long-term follow-up.

Conclusions

Microsurgical cyst fenestration seems to be a safe and effective option for symptomatic relief in patients with perineural cysts. Based on the results from our series and those of others, we propose an algorithm for the selection of surgical candidates.

Electronic supplementary material

The online version of this article (10.1007/s00701-019-04000-5) contains supplementary material, which is available to authorized users.

[Spinal cysts : Diagnostic workup and therapy]

CLINICAL ISSUE

Spinal cysts can be classified as meningeal, not meningeal, and tumor-associated cysts. Due to the widespread availability of high-resolution computed tomography and magnet resonance imaging, spinal cysts can be detected with high sensitivity these days. Concerning the variety of potential cystic differential diagnoses, a precise classification is difficult and can often only be realized after surgical inspection or histological examination.

PRACTICAL RECOMMENDATIONS

Spinal cysts are generally incidental findings during a routine diagnostic workup and need no further therapy. Surgical treatment can be necessary if the spinal cyst reaches a certain size and causes neurological symptoms due to the compression of the spinal cord or the nerve root.

A Giant Tarlov Cyst Presenting with Hydronephrosis in a Patient with Marfan Syndrome: A Case Report and Review of the Literature

BACKGROUND

Giant Tarlov cysts are always symptomatic and mimic many serious pathologic entities. We present the largest, to our knowledge, reported Tarlov cyst.

CASE DESCRIPTION

A 33-year-old woman with Marfan syndrome suffered from right kidney hydronephrosis because of ureter obstruction, for which she was treated with nephrostomy. Her neurologic examination was unremarkable. The role of magnetic resonance imaging in the management of this case is described. Absence of intractranial hypotension symptoms after cerebrospinal fluid (CSF) overdrainage suggested the presence of a valve-like mechanism. The patient was planned for surgical cyst remodeling by the application of titanium clips. The cyst's neck was exposed through an L5-S2 laminectomy. L5 and S1 laminae were severely eroded. CSF leaked out of the underlying, bulging, and thinned dura at each attempt for clip application. Intraoperatively, multiple responses from the S1, S2, and S3 roots were simultaneously recorded at each stimulation. Therefore, we decided to abandon this technique and performed a nonwatertight duroplasty followed by a layered wound closure instead. A week later, the patient received a lumbar-peritoneal shunt. The patient remained neurologically intact, the cyst shrunk, and the nephrostomy was removed.

CONCLUSIONS

Indirect evidence was helpful to assess for the presence of a valve-like mechanism. Intraoperatively, the surgeon must keep on high alert for sacral erosion to avoid inadvertent dural tear and rootlet injury. Finally, lumboperitoneal diversion remains a valid alternative in the management of our giant Tarlov cyst because it reduced the intracystic pressure that resulted in cyst regression.

Giant Tarlov Cyst of Infancy

We report an 8-month-old female infant with complaints of irritability and recent inability to sit in a stable position. On physical examination, a palpable mass in the left upper quadrant of her abdomen was evident. Sonography and magnetic resonance imaging showed a giant cyst, consisting of 2 communicating compartments: dorsal and ventrolateral. The dorsal part compressed the conus medullaris, and the ventrolateral part compressed the left kidney. Partial cyst wall resection and imbrication for the dorsal pouch were done, and diagnosis of Tarlov cyst was confirmed via the visualization of the endocystic nerve root during surgery. Familiarizing physicians with this unusual presentation of Tarlov cyst may help them in early recognition of this lesion, and subsequent surgery might be considered to prevent clinical sequela. To our knowledge, a lumbar Tarlov cyst presenting as a giant abdominal cyst in an infant has not been reported in the English-language literature.

Growth of a Sacral Perineural (Tarlov) Cyst: Clinical Images

Although Tarlov cysts (TC) were first described in 1938, our understanding of these common spinal lesions remains poor. As TCs represent incidental findings in the vast majority of cases, evidence to guide their management is limited to small case series. When they are symptomatic, the presentation can have significant overlap with degenerative spine disease. This is the first report demonstrating growth of TCs. The patient underwent open surgical reduction of the symptomatic TCs, leading to improvement in her symptoms.

Idiopathic Intracranial Hypertension Associated with Symptomatic Perineural Cysts: Presentation of 2 Cases

OBJECTIVES

Idiopathic intracranial hypertension refers to cases of intracranial hypertension and normal brain parenchyma without ventriculomegaly or any kind of mass lesion. Perineural cysts are cerebrospinal fluid-filled cysts that usually arise from nerve roots near the dorsal ganglia. Often asymptomatic, they rarely cause mass effect symptoms. The association of these conditions is discussed herein.

METHODS

We describe 2 patients with idiopathic intracranial hypertension and symptomatic sacral perineural cysts. In both cases the treatment of idiopathic intracranial hypertension ameliorated the sacral perineural cyst symptoms, and in 1 case we observed shrinking of the sacral perineural cysts.

RESULTS

On the basis of this review, it is impossible to conclude whether there is an association between idiopathic intracranial hypertension and symptomatic perineural cysts. However, as an initial observation, this report can reveal a possible association.

CONCLUSIONS

In some instances, idiopathic intracranial hypertension can be associated with symptomatic sacral perineural cysts. In this clinical scenario, the treatment of idiopathic intracranial hypertension may improve perineural cyst symptoms.

Symptomatic cervical perineural (Tarlov) cyst: a case report

BACKGROUND

Perineural (Tarlov) cysts are benign, usually asymptomatic, cerebrospinal fluid filled cysts of the spine, most often found in the sacral region.

DESCRIPTION OF CASE

We report a Tarlov cyst, located in the cervical spine, in a 44-year-old woman who presented with a 3-week history of radicular symptoms of the right C6 root. The perineural cyst was identified at the C5-C6 level following magnetic resonance imaging of the cervical spine. A conservative approach was chosen, with the use of a soft cervical collar for two weeks, a 15-day-course of oral non-steroidal anti-inflammatory medication and instructions concerning limitation of her activities. The outcome of this approach was 90% improvement of her symptoms 24 months after her diagnosis.

CONCLUSION

This is the first report of a cervical Tarlov cyst treated conservatively without the use of oral or injected steroids. The perineural cyst should be included in the differential diagnosis of patients presenting with radicular symptoms. Hippokratia 2015, 19 (1): 76-77.

Cervical perineural cyst masquerading as a cervical spinal tumor

Tarlov (perineural) cysts of the nerve roots are common and usually incidental findings during magnetic resonance imaging of the lumbosacral spine. There are only a few case reports where cervical symptomatic perineural cysts have been described in the literature. We report such a case where a high cervical perineural cyst was masquerading as a cervical spinal tumor.

Delayed diagnosis of cauda eqina syndrome with perineural cyst after combined spinal-epidural anesthesia in hemodialysis patient

Symptomatic Tarlov (perineural cysts) are uncommon. In the following hemodialysis case, cauda equina syndrome was not detected after combined spinal-epidural anesthesia untilthe patient reported a lack of sensation in the perianal area 14 days postoperatively. She had normal motor function of her extremities. A laminectomy and cyst irrigation was performed. After the operation, her sphincter disturbance subsided gradually and her symptoms had disappeared.

Symptomatic calcified perineural cyst after use of bone morphogenetic protein in transforaminal lumbar interbody fusion: a case report

BACKGROUND CONTEXT

Human recombinant bone morphogenetic protein-2 (BMP-2) is commonly used in spinal surgery to augment arthrodesis, and a number of potential complications have been documented.

PURPOSE

To present the case of a delayed radiculopathy that occurred because of a calcified perineural cyst that formed after an L4-L5 transforaminal lumbar interbody fusion (TLIF) in which BMP-2 was used.

STUDY DESIGN/SETTING

Case report of a 70-year-old man presented with back and right lower extremity pain.

METHODS

A 70-year-old man who had previously undergone a right L4-L5 TLIF presented 20 months after surgery with progressively radiating right leg pain. Imaging revealed a right-sided L4-L5 cystic lesion posterior to the interbody cage. The patient underwent reexploration, and a calcified mass was discovered.

RESULTS

Histopathology revealed fragments of organized collagenous connective tissue, new collagen, and partially calcified fragments of fibrocartilage, bone, and ligament.

CONCLUSIONS

This is the first reported case of a symptomatic calcified perineural cyst developing after a fusion procedure in which BMP-2 was used. The presence of connective tissue with metaplastic bone formation and maturation within the lesion suggests that formation of the cyst was secondary to application of BMP-2, as it possesses both osteogenic and chondrogenic capabilities.

Lumbar epidural varix mimicking perineural cyst

Lumbar epidural varices are rare and usually mimick lumbar disc herniations. Back pain and radiculopathy are the main symptoms of lumbar epidural varices. Perineural cysts are radiologically different lesions and should not be confused with epidural varix. A 36-year-old male patient presented to us with right leg pain. The magnetic resonance imaging revealed a cystic lesion at S1 level that was compressing the right root, and was interpreted as a perineural cyst. The patient underwent surgery via right L5 and S1 hemilaminectomy, and the lesion was coagulated and removed. The histopathological diagnosis was epidural varix. The patient was clinically improved and the follow-up magnetic resonance imaging showed the absence of the lesion. Lumbar epidural varix should be kept in mind in the differential diagnosis of the cystic lesions which compress the spinal roots.