Tarlov cyst is a rare disease which often causes backache and pain shooting down the arms and leg. The cyst is filled with spinal fluid and is attached to the meningeal covering of spinal nerves within spinal canal. The smaller Tarlov cyst may not cause any symptoms unless cyst irritates or pinches the spinal nerve. The larger cyst may cause pinch of spinal nerve and rarely may press spinal cord resulting in symptoms spread along several nerves. The pain symptoms when felt along the nerve is known as radicular pain. Pain may be associated with symptoms like numbness and weakness of muscles in arms, chest, abdomen and lower extremity depending on the site of cyst in spinal canal.
Tarlov Cyst Treatment
The choice of treatments for Tarlov cysts are either trying symptomatic conservative treatment or surgery. The symptomatic treatment of Tarlov cyst includes pain medications, muscle relaxants, TENS unit and physical therapy. In most cases the symptoms of Tarlov cyst such as pain, numbness and weakness may not respond to conservative treatment or medications. The publish data suggests several surgical treatments have been tried to treat symptoms caused by Tarlov cyst. Individual suffering with pain, numbness and weakness are considered for surgical treatment only when all other treatments have failed to relieve symptoms. Few patients do get symptomatic relief following conservative treatment for short to substantial period of time. Surgical treatments are performed by experience neurosurgeon. Surgical treatment is often attempted when patient is suffering with urinary retention or incontinence.
Non-Surgical Treatment of Tarlov Cyst-
NSAIDs – Non-steroidal anti-inflammatory drugs are often used during initial symptomatic phase of acute pain caused due to Tarlov cyst. Pain caused by nerve irritation or inflammation may be associated with symptoms like tingling and numbness. The NSAID helps to relieve pain caused by nerve irritation and also improves symptoms of tingling and numbness caused due to Tarlov cyst.
Opioids – Opioids are useful for intolerable acute and chronic pain. Long term opioid therapy is avoided to prevent dependence and addiction. Most often opioid pain medication is prescribed for severe radicular nerve pain for 2 to 3 weeks. Hydrocodone and oxycodone are most frequently used for treatment of pain caused due to Tarlov cyst.
Muscle Relaxants – Treating Tarlov Cyst with muscle relaxants such as baclofen and flexeril are recommended for muscle spasm resulting from irritation of motor division of spinal nerve or spinal cord. Muscle relaxants frequently causes drowsiness and sleepiness. The side effects are significant when combined with opioids, so muscle relaxants are avoided with opioids to prevent life threatening side effects like sleep apnea.
TENS – Trans cutaneous electrical nerve stimulation treatment for Tarlov Cyst involves transmission of low voltage electrical stimulation between two or more pads that are attached to skin over the most painful area of back or extremities. The low voltage electrical current stimulates the peripheral sensory nerves of the skin over the affected area. The periodic transmission of transcutaneous impulses through sensory nerve to spinal cord modulates the pain impulses as well as increases secretion of endorphin in spinal cord. The modulation of pain impulses and secretion of endorphin at the intermediate neuron in spinal cord helps to block or modify pain impulses passing to the brain. The treatment often has high failure rate when pain is intense and constant.
Epidural Steroid Injection – Epidural steroid injection to treat Tarlov Cyst is recommended to reduce the pain when all other conservative treatment fails. Experienced interventional pain specialist should perform the procedure to avoid any needle manipulation or puncture of Tarlov Cyst. The paper published by Freidenstrin J in the journal of Pain Physician recommends caudal approach of epidural steroid injection for treatment of pain caused by Tarlov cyst in lumbar spine.1
Physical Therapy – Physical therapy is recommended only if patient is suffering with frequent muscle spasm and bladder symptoms. Physical therapy is useful in patient suffering with severe spinal nerve damage resulting in muscle spasm and atrophy.
Surgical Treatment of Tarlov Cyst
Fibrin Glue Therapy – The treatment involves needle aspiration of CSF within Tarlov Cyst and then application of fibrin glue over the needle puncture hole. The cerebrospinal fluid frequently leaks after needle puncture through puncture hole after deflation of cyst. Thus to prevent CSF leak the puncture hole is then closed by placing a fibrin glue on top of the leaking cyst.2,3 The treatment helps to deflate the Tarlov Cyst and thus helps to relieve the pressure caused by Tarlov Cyst over the spinal nerve and spinal cord. The case report published suggests the glue may get dislodged and move to different location within spinal canal. Such complication is known to cause adhesive arachnoiditis following migration of glue upward within spinal canal causing complaint of pain spread over different dermatome.4
Microsurgical Excision of Tarlov Cyst- Eleven patient had microsurgical excision of Tarlov Cyst and each patient were followed for 6 months to 10 years depending on year of surgery. The results were published in Neurosurgery Journal in 2007. The results of the study suggest 9 (82%) out of 11 patients had substantial relief of symptoms.5
Surgical Clipping of Tarlov Cyst- Nineteen patients suffering with symptomatic Tarlov Cyst were treated by surgery involving clipping of cyst. Patients were followed for 9 months to 25 years. All patient had relief of symptoms, none of the 19 patients had signs of cyst leakage and symptoms of bladder dysfunction.6
Tarlov Cyst is rare but often undiagnosed when asymptomatic or small but causing irritation of spinal nerve resulting in back pain and radicular pain. The symptomatic Tarlov Cyst is often difficult to treat.
- Tarlov Cyst or Perineural Cysts: Causes, Symptoms, Diagnosis
- Tarlov Cyst or Perineural Cysts: Prevention, Social Security, Prognosis, Coping
Minimally invasive interventional therapy for Tarlov cysts causing symptoms of interstitial cystitis.
Freidenstein J1, Aldrete JA, Ness T., Pain Physician. 2012 Mar-Apr;15(2):141-6.
Percutaneous fibrin glue therapy for meningeal cysts of the sacral spine with or without aspiration of the cerebrospinal fluid.
Zhang T, Li Z, Gong W, Sun B, Liu S, Zhang K, Yin D, Xu P, Jia T.
J Neurosurg Spine. 2007 Aug;7(2):145-50.
Percutaneous fibrin glue therapy of meningeal cysts of the sacral spine.
Patel MR, Louie W, Rachlin J., AJR Am J Roentgenol. 1997 Feb;168(2):367-70.
Adhesive arachnoiditis after percutaneous fibrin glue treatment of a sacral meningeal cyst.
Hayashi K1, Nagano J, Hattori S., J Neurosurg Spine. 2014 Jun;20(6):763-6. doi: 10.3171/2014.2.SPINE13763. Epub 2014 Apr 4.
Microsurgical treatment of symptomatic sacral perineurial cysts.
Guo D1, Shu K, Chen R, Ke C, Zhu Y, Lei T., Neurosurgery. 2007 Jun;60(6):1059-65; discussion 1065-6.
Sacral Tarlov cyst: surgical treatment by clipping.
Cantore G1, Bistazzoni S, Esposito V, Tola S, Lenzi J, Passacantilli E, Innocenzi G.,
World Neurosurg. 2013 Feb;79(2):381-9.