Tarlov cysts are fluid-filled sacs that affect the nerve roots of the spine, especially near the base of the spine (sacral region). Individuals may be affected by multiple cysts of varying size. Symptoms can occur depending upon the size and specific location of the cyst. Generally, the larger a Tarlov cyst is, the more likely it is to cause symptoms. Symptoms sometimes caused by Tarlov cysts include pain in the area served by the affected nerves, numbness and altered sensation, an inability to control bladder and bowel movements (incontinence), impotence, and, rarely, weakness in the legs.

 

Small, asymptomatic cysts can slowly increase in size eventually causing symptoms. The exact cause of Tarlov cysts is unknown, but they may occur due to variation in normal development of the nerve sheath. Tarlov cysts were first described in the medical literature in 1938. 1

 

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Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia​

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Background: Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms.

Objective: To evaluate the prevalence of S2-S4 Tarlov cysts at the pudendal nerve origin (S2-S4 sacral nerve roots) in patients specifically diagnosed with pudendal neuralgia, and establish association of patient symptoms with location of Tarlov cyst.

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Conclusion: The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.

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What are the non-surgical and non-surgical treatments for Tarlov cysts that cause pain?

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Tarlov cysts may be discovered when patients with low back pain or sciatica have a magnetic resonance imaging (MRI) performed. Follow-up radiological studies, in particular, computed tomographic (CT) myelography are usually recommended.

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If a patient has bladder problems and seeks medical help from an urologist, there are tests that can help diagnose Tarlov cyst. The standard urological tests for Tarlov cyst help determine if the patient has a neurogenic (malfunctioning) bladder. In urodynamics, the bladder is filled with water through a catheter and the responses are noted. Cystoscopy involves inserting a tube with a miniature video camera into the bladder via the urethra. A neurogenic bladder shows excessive muscularity. A third possible test is a kidney ultrasound to see if urine is backing up into the kidneys.

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Nonsurgical Treatment

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Nonsurgical therapies include lumbar drainage of the cerebrospinal fluid (CSF), CT scanning-guided cyst aspiration and a newer technique involving removing the CSF from inside the cyst and then filling the space with a fibrin glue injection. Unfortunately, none of these procedures prevent symptomatic cyst recurrence.

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Surgery

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Tarlov cyst surgery involves exposing the region of the spine where the cyst is located. The cyst is opened and the fluid drained, and then in order to prevent the fluid from returning, the cyst is occluded with a fibrin glue injection or other matter.

Neurosurgical techniques for symptomatic Tarlov cysts include simple decompressive laminectomy, cyst and/or nerve root excision and microsurgical cyst fenestration and imbrication.

The authors of one study found that patients with Tarlov cysts larger than 1.5 cm and with associated radicular pain or bowel/bladder dysfunction benefited most from surgery. The benefits of surgery should always be weighed carefully against its risks.

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Outcome

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Postoperative CSF leak is the most common complication, but in some cases, these leaks may self-heal. Patients may be advised to stay in bed with the foot of the bed raised and to wear a corset to control swelling. Although it is low, there is a risk of developing bacterial meningitis. Although some patients have noted a considerable decrease in pain, the most common negative outcome is the failure of the surgery to eliminate the symptoms. In some cases, the surgery may cause an existing symptom to worsen or it may cause a new one.

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When all treatment options have been exhausted, it is very important for the patient to make any necessary lifestyle changes and to undertake a pain management strategy with his or her physician. Supervised pain management, as well as support groups, can help a patient cope and improve his or her quality of life.

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The AANS does not endorse any treatments, procedures, products or physicians referenced in these patient fact sheets. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific neurosurgical advice or assistance should consult his or her neurosurgeon, or locate one in your area through the AANS’ Find a Board-certified Neurosurgeon online tool. 3

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1  https://rarediseases.org/rare-diseases/tarlov-cysts/  (NORD)

2  https://pubmed.ncbi.nlm.nih.gov/31319080/

3. https://www.aans.org/en/Patients/Neurosurgical-Conditions-and-Treatments/Tarlov-Cyst#:~:text=Neurosurgical%20techniques%20for%20symptomatic%20Tarlov,microsurgical%20cyst%20fenestration%20and%20imbrication. 
© 2024 American Association of Neurological Surgeons.

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Pudendal Neuralgia Alliance

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