Diagnosis and Management of Sacral Tarlov Cysts

Frank L. Acosta, Jr.; MD, Alfredo Quinones-Hinojosa, MD; Meic H. Schmidt, MD; Philip R. Weinstein, MD


Neurosurg Focus. 2003;15(2) 

In This Article

Abstract and Introduction


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 lumbosacral 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, eventually 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 symptomatic sacral Tarlov cyst. They review the medical literature, describe various theories on the origin and pathogenesis of Tarlov cysts, and assess alternative treatment strategies.


Tarlov or perineurial cysts are pathological formations located in the space between the peri-and endoneurium of the spinal posterior nerve root sheath at the DRG.[17,39,41] These lesions have been estimated to affect between 4.6 and 9% of the adult population.[24,34] Although originally believed by Tarlov[39] to be asymptomatic lesions, these cysts, when present in the sacral neural canal and foramina, have since been found to cause a variety of symptoms, including radicular pain, paresthesias, and urinary or bowel dysfunction.[4,5,7,15,16,18,24,31,32,38,46] The development of CT myelography has led to an improvement in our ability to diagnose "Tarlov cysts" as a cause of sacral radiculopathy.[16,17,20,21,42] Although the term Tarlov cyst has often been erroneously applied to other cystic spinal lesions,[9,13,17,19,26,27,29,34,35] the distinctive feature of the Tarlov perineurial 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 great deal of controversy regarding the optimal treatment of symptomatic Tarlov cysts. Nonsurgical therapies include lumbar CSF drainage[2,4] and CT scanning guided cyst aspiration,[23,24] neither of which prevents symptomatic cyst recurrence. Neurosurgical techniques for symptomatic perineurial cysts include simple decompressive laminectomy,[33] cyst and/or nerve root excision,[20,37,38,41,42] and microsurgical cyst fenestration and imbrication.[16] Although no consensus exists on the definitive treatment of symptomatic Tarlov cysts, we believe surgical methods have yielded the best long-term results to date. We describe the case of one patient with a symptomatic Tarlov cyst to illustrate the surgical treatment involving cyst fenestration, partial resection of the cyst wall, and myofascial cutaneous flap closure reinforcement. We also review the literature, summarizing various theories on the origin and pathogenesis of Tarlov cysts, and assess current treatment options.


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