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Diagnosis and Management of Sacral Tarlov Cysts Neurosurg Focus 15 (2):Article 15, 2003, Click here to return to Table of Contents Diagnosis and management of sacral Tarlov cysts Case report and review of the literature FRANK L. ACOSTA, JR., M.D., ALFREDO QUINONES-HINOJOSA, M.D., MEIC H. SCHMIDT, M.D., AND PHILIP R. WEINSTEIN, M.D. Department of Neurological Surgery, University of California, San Francisco, San Francisco, California; and University of Utah Medical Center, Salt Lake City, Utah Perineurial (Tarlov) cysts are meningeal dilations of the posterior spinal nerve root sheath that most often affect sacral roots and can cause a progressive painful radiculopathy. Tarlov cysts are most commonly diagnosed by lum- bosacral magnetic resonance imaging and can often be demonstrated by computerized tomography myelography to communicate with the spinal subarachnoid space. The cyst can enlarge via a net inflow of cerebrospinal fluid, even- tually causing symptoms by distorting, compressing, or stretching adjacent nerve roots. It is generally agreed that asymptomatic Tarlov cysts do not require treatment. When symptomatic, the potential surgery-related benefit and the specific surgical intervention remain controversial. The authors describe the clinical presentation, treatment, and results of surgical cyst fenestration, partial cyst wall resection, and myofascial flap repair and closure in a case of a sympto- matic sacral Tarlov cyst. They review the medical literature, describe various theories on the origin and pathogenesis of Tarlov cysts, and assess alternative treatment strategies. KEY WORDS • sacrum • Tarlov cyst • spinal lesion • outcome Tarlov or perineurial cysts are pathological formations cyst aspiration,23,24 neither of which prevents symptomatic located in the space between the peri- and endoneurium of cyst recurrence. Neurosurgical techniques for symptoma- the spinal posterior nerve root sheath at the DRG.17,39,41 tic perineurial cysts include simple decompressive lami- These lesions have been estimated to affect between 4.6 nectomy,33 cyst and/or nerve root excision,20,37,38,41,42 and and 9% of the adult population.24,34 Although originally microsurgical cyst fenestration and imbrication.16 Al- believed by Tarlov39 to be asymptomatic lesions, these though no consensus exists on the definitive treatment of cysts, when present in the sacral neural canal and forami- symptomatic Tarlov cysts, we believe surgical methods na, have since been found to cause a variety of symptoms, have yielded the best long-term results to date. We de- including radicular pain, paresthesias, and urinary or scribe the case of one patient with a symptomatic Tarlov bowel dysfunction.4,5,7,15,16,18,24,31,32,38,46 The development of cyst to illustrate the surgical treatment involving cyst fen- CT myelography has led to an improvement in our ability estration, partial resection of the cyst wall, and myofas- to diagnose “Tarlov cysts” as a cause of sacral radiculopa- cial–cutaneous flap closure reinforcement. We also review thy.16,17,20,21,42 Although the term Tarlov cyst has often been the literature, summarizing various theories on the origin erroneously applied to other cystic spinal lesions,9,13,17,19, and pathogenesis of Tarlov cysts, and assess current treat- 26,27,29,34,35 the distinctive feature of the Tarlov perineurial ment options. cyst is the presence of spinal nerve root fibers within the cyst wall, or the cyst cavity itself.9,17,37–41 Despite advancements in diagnosis, there remains a CASE REPORT great deal of controversy regarding the optimal treatment of symptomatic Tarlov cysts. Nonsurgical therapies in- Presentation. This 47-year-old woman presented with a clude lumbar CSF drainage2,4 and CT scanning–guided 1-year history of progressive, intractable sacrococcygeal pain and numbness as well as dysesthesias of both feet. At the time, she was becoming increasingly incapacitated, al- Abbreviations used in this paper: CSF = cerebrospinal fluid; though she was still able to work as a flight attendant. She CT = computerized tomography; DRG = dorsal root ganglion; rated her pain as 6 of 10 possible points on a visual ana- MR = magnetic resonance. log scale. Her symptoms were aggravated by standing, Neurosurg. Focus / Volume 15 / August, 2003 1 Unauthenticated | Downloaded 10/01/21 10:41 AM UTC F. L. Acosta Jr., et al. walking, lifting, and climbing stairs as well as by cough- CSF from the rostral subarachnoid space was not ob- ing. Pain was rapidly relieved by recumbency. She had a served, some seepage did occur, indicating that micro- history of renal calculi. She had no bowel or bladder dys- scopic communication was present. function, and sensation for urination and defecation was Fibrin glue was then applied to fill the cyst cavity. To normal. prevent cyst recurrence or CSF leakage, a sacral spinalis Examination. On physical examination, a grade of 5/5 muscle flap was then rotated into the epidural space creat- strength was demonstrated throughout all muscle groups. ed by evacuation of the S2–S4 cyst. Cyst closure was also Heel and toe walking and knee bends were well per- supported using a lumbar subarachnoid drain for postop- formed. Straight leg raising was negative. Jugular com- erative CSF diversion (Fig. 2). Although the cyst wall pression test induced sacrococcygeal paresthesias without specimen was sent to the laboratory for pathological ex- pain. Sensory examination showed diminished sensory amination, its volume was inadequate to determine wheth- perception to pinprick on the soles of her feet and in the er nerve root fibers were present. S1–2 distribution. There was no sensory deficit over the Postoperative Course. The patient’s postoperative perineum. Anal sphincter tone and constriction were nor- course was uneventful. The lumbar drain was removed on mal. Knee jerks were hyperreflexive with a Grade 4+ re- postoperative Day 3, and a CT myelography revealed a sponse bilaterally, and ankle jerks were Grade 2+ bilater- very small amount of contrast exiting from the thecal sac ally. Lumbar flexion seemed to relieve the pain, whereas to surround the myocutaneous flap. There was only mild extension made it worse. indentation of the posterior thecal sac (Fig. 3). She noted Preoperative MR imaging demonstrated a large sacral marked improvement in her pain symptoms prior to dis- cyst arising within the thecal sac at S-2, with expansion of charge home on Day 4 postoperatively. During the follow- the osseous sacral central canal and enlargement of S-1 up visit 5 weeks later, she reported that the burning in her and S-2 neural foramina causing compression of all adja- cent nerve roots. Postmyelography CT scanning revealed evidence of cauda equina compression. The cyst did not fill with contrast material and appeared to have no com- munication with the spinal subarachnoid space (Fig. 1). Operation. To relieve progressively incapacitating symptoms, surgery was recommended. After sacral lami- nectomy, microsurgical cyst fenestration was performed with the assistance of intraoperative electromyographic monitoring. Muscle flap closure reinforcement was con- ducted as described previously.16 Briefly, after exposure of the S2–S4 sacral nerve roots, a large meningeal cyst was identified arising from the S-2 nerve root. The thin trans- parent cyst wall membrane was widely fenestrated with a scalpel and microscissors. Clear fluid contents of the cyst drained spontaneously. The posterolateral wall of the cyst was resected after electrical stimulation verified that no motor nerve fibers were present. Anal sphincter electro- myography was activated by low intensity 0.4 mA electri- cal stimulation applied to the anterior and medial surfaces of the cyst wall. Although rapid high-volume drainage of Fig. 2. A: Intraoperative view of a large Tarlov cyst. B: Intraoperative view of the muscle flap, divided in the middle, used for the obliteration of the cystic space. C: Intraoperative view after cyst wall resection showing sacral spinalis muscle flap rotat- Fig. 1. Preoperative imaging studies. A: Sagittal T2-weighted ed into position in the presacral space to obliterate the cyst cavity. MR image revealing a high signal intensity cystic lesion in the D: Photograph obtained immediately after closure, demonstrating sacral spinal canal. B: Axial CT myelogram of the sacrum dem- a U-shaped incision over the lumbosacral area, with a lumbar sub- onstrating a Tarlov cyst. arachnoid drain placed for postoperative CSF diversion. 2 Neurosurg. Focus / Volume 15 / August, 2003 Unauthenticated | Downloaded 10/01/21 10:41 AM UTC Diagnosis and managment of sacral Tarlov cysts sacral region. In comparison, meningeal diverticula occur proximal to the DRG and develop throughout the verte- bral column, most often at thoracic levels. Last, Tarlov cysts occur in the perineurial space and have at least part of their wall composed of nerve fibers or ganglion cells. Conversely, meningeal diverticula have a wall lined with arachnoid mater, with or without a dural covering, and do not contain nerve fibers. Moreover, Tarlov noted that perineurial cysts, although often asymptomatic, were capable of producing clinical symptoms, whereas menin- geal diverticula were more often asymptomatic. Tarlov41 Fig. 3. A and B: Postoperative CT myelograms demonstrating also distinguished perineurial cysts from “unusually long obliteration of the cyst cavity with a muscle graft occupying the arachnoidal prolongations over nerve roots,” which he as- space formerly filled by the cyst. serted were of no pathological significance. Despite
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