Tarlov Cyst / Perineural Cysts

Reviewed by Liji Thomas, MD

Tarlov cysts are formed within the nerve root sheath at the posterior root of a spinal nerve. This disease is more common in women than in men. These perineural/perineurial cysts appear as ballooned areas of the outer covering of the nerve root.

The fluid-filled abnormal sacs affect the sacral region of the spine, in particular, and are also known as sacral nerve root cysts. The cysts can form anywhere along the spine, although the base of the spine is the most common area. Some patients have cysts at many or even at all sections of the spine.

Causes

Although the root cause of Tarlov cyst disease is yet to be elucidated, there are a number of studies which suggest that the Tarlov cyst is owing to the dilation of the nerve root covering. This leads to the cerebrospinal fluid that fills the subarachnoid space (the space between the arachnoid layer and the innermost pia mater coverings of the brain and the spinal cord) becoming locked inside the perineurium to form a cyst.

Significant clinical evidence shows that patients with connective tissue disorders, for example, those with Marfan, Ehlers–Danlos, Sjogren's, and Loeys–Deitz syndromes, are at a greater risk for developing Tarlov cysts. Some other conditions such as traumatic injuries and pain in the spinal cord may also result in cyst formation.

Symptoms

Tarlov cyst disease is often asymptomatic. However, when the fluid in the cyst puts pressure on the nerve and the nearby nerve roots, the cyst grows in size and becomes symptomatic.

Depending on the section of the spinal column, the location, and the size of the cyst, the symptoms and severity of the condition vary across patients as follows:

  • Pain in the lower back, buttocks, back of thighs, abdomen, legs, and feet
  • Pain in the upper back, hands, arms, and chest
  • Paresthesia/dysesthesia in the legs/feet
  • Pain when sitting or standing, and sneezing or coughing
  • Difficulty in emptying the bladder and sexual dysfunction
  • Diminished reflexes, loss of sensation on the skin
  • Chronic headaches, blurred vision, double vision, dizziness

Diagnosis

The most commonly used methods for the diagnosis of Tarlov cysts are:

  • Magnetic resonance imaging (MRI) and
  • Computed tomography (CT) scan

An MRI gives a clearer picture of the cyst and surrounding nerve tissue as well as its coats, and is widely preferred. If the symptoms are related to the lower sections of the spine (as is common in most patients), then a full sacral spine MRI covering the S1–S5 vertebra up to the coccyx/tailbone is recommended. For symptoms in the upper spine (which is seen less frequently), appropriate cervical (C1–C7), thoracic (T1–T12), or lumbar (L1–L5) MRI is carried out.

CT scan employs multiple X-rays to disclose the typical bone erosion of the spine, while the cross-sectional image of the organ’s tissue structure is also visualized.

Another useful diagnostic imaging procedure is the myelogram test. The examination involves the introduction of a spinal needle into the spinal canal. The contrast fluid is injected into the subarachnoid space using real-time X-ray. It outlines the spinal cord, nerve roots, and other tissues

Treatment

Asymptomatic Tarlov cyst disease should be closely monitored at frequent intervals to see if there is an increase in cyst size or if any other symptoms develop. There is no specific proven treatment for patients with symptomatic Tarlov cysts.

Treatment is patient-specific, ranging from simple drugs to complex surgery and other procedures. In general, treatments are classified as 1) nonsurgical and 2) surgical procedures.

Non-surgical

Pain may be temporarily controlled using nonsteroidal anti-inflammatory drugs (NSAIDs), which treat nerve irritation and inflammation. Some patients may find relief immediately, whereas for others it may take some time to reap the benefits. Another proven technique in pain management is the transcutaneous electrical nerve stimulation (TENS). Electrical impulses are sent through the skin to the cutaneous and deep nerves that help control pain.

Physical therapy (PT) such as heat, ultrasound, and transcutaneous electronic stimulation are found to be very effective. However, these treatments may, like the above, work for some patients but not for others.

A minimally invasive technique, such as fibrin glue injection under C-arm fluoroscopy guidance, can be an effective procedure.

Surgical

If the above forms of therapy do not yield results, surgical removal of cysts may be suggested. However, in medical literature, there are ongoing discussions about this procedure, as the cyst is a part of the nerve and therefore cannot be excised. Therefore, to treat large Tarlov cysts, they are sliced with one or more cuts and the cerebrospinal fluid is drained out.

Outlook

The pooling of knowledge derived from the research and treatment of this disease by various investigators, sharing of information from procedures that are performed, studying and sharing the known side effects, and quantifying the improvement in each patient’s health will help in building effective treatment procedures. These data will provide a wealth of insights to the medical community to promote research toward determining the cause and cure of this rare disease.

References

Last Updated: May 10, 2017

Comments

  1. Mary Eischen Mary Eischen United States says:

    Who ever wrote this article is misinformed Tarlov Cysts cannot be removed, they can only be reduced in size, because they are attached to nerves which cannot be removed.  I know what I am talking about, I suffer with this disease and have had 2 surgeries. Also have multiple cysts throughout my spine.

    Sincerely
    Mary/TCD sufferer.

  2. Linda Ellis Linda Ellis United States says:

    Thank you for sharing.  This still is a good overview of Tarlov Cysts that every doctor should read and fully comprehend.  Most doctors tell those of us with this disease that the cysts are incidental findings and "Rarely cause pain" -- which translates into "it must be something else causing the pain" and there they let it stand literally closing the books on us.  

    Only a handful of doctors indeed in the whole world, not just the United States, have the needed knowledge, experience, and full grasp of these cysts to operate on them properly that gives the patient the best hope for recovery; which we are often told can take up to 2 years.  

    What is also desperately needed is more research, clinical trials to look for drugs that can also help reduce the pain without significant side effects until at least more surgeons learn how to properly handle these cysts and not make the patient much worse.  All surgeries have risks as we know, but with Tarlov Cysts involved the risks are much higher due to their nature.

    I belong to several Tarlov Cyst Facebook Groups and the number of members are growing and people of all ages; yes men as well as women, are learning that they have symptomatic Tarlov Cyst Disease.  It is listed as a "rare disease" when in reality it isn't as rare as some may think.  

    And, anyone who has asymptomatic Tarlov Cysts is at risk with them to one day become painful and once that happens the disease is on the march as it is a progressive disease.  

    Aspirating Tarlov Cysts offers only temporary relief at best; and it is my opinion that more needles jabbed into the spine is not good and can create more issues.  We're talking serious chronic pain with this disease and it affects bowel and bladder functions as well.  

    I pray every day that the medical profession takes this disease more seriously as a serious disease than it apparently does.

  3. Lisa Watts Lisa Watts United States says:

    The article suggests that draining the cysts and filling them with fibrin glue is an effective treatment. In reality,it has been proven to only give temporary relief because the cysts eventually fill back up. I do not know of one person that has had this done that benefited from it and didn't have to have the surgery anyway.

    The article also suggests that CT myelograms and spinal injections can be a form of treatment. Both of these things are contraindicated for those with this disease. They can cause a spinal fluid leak, more cysts to form, increase in pain and symptoms, and arachnoiditis (a horrendous and extremely painful spinal disease worse than tcd).

    The articles you referenced need to be more informed and change their information. I too suffer from this disease and have ran a private support group on Facebook for people that suffer from this disease for 4-5 years. I've seen thousands of people's stories and talked to hundreds of people with this disease. If you are someone you know suffer from this disease please join my group, "Tarlov Cyst Support for Cysters and Mysters" for one on one information and support from people that actually suffer from this disease.

    Thanks,
    Lisa

    TC Sufferer/ Owner and Admin of Tarlov Cyst Support for Cysters and Mysters

The opinions expressed here are the views of the writer and do not necessarily reflect the views and opinions of News-Medical.Net.
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