Tarlov Cyst

Unveiling Tarlov Cysts

Tarlov cysts, also known as perineural cysts, are cerebrospinal fluid-filled sacs located along the nerve roots of the spine. These cysts can cause a range of symptoms, often leading to significant discomfort and neurological issues. Understanding their anatomy, epidemiology, clinical presentation, diagnostic process, and treatment options—especially interventional modalities—can aid in managing this complex condition effectively.

Basic Anatomy of Tarlov Cysts

Tarlov cysts are typically found in the sacral region of the spine. They are dilations of the nerve root sheaths filled with cerebrospinal fluid (CSF). These cysts form between the endoneurium and perineurium layers of the nerve root, potentially causing nerve compression and associated symptoms.


Tarlov cysts are relatively rare, with an estimated prevalence ranging from 1.5% to 13% in the general population. They are often discovered incidentally during imaging studies for other conditions. While both men and women can develop Tarlov cysts, they are more commonly reported in women, particularly in the age group of 30 to 60 years.

Clinical Presentation

Many individuals with Tarlov cysts are asymptomatic; however, symptomatic cases can present with a variety of symptoms depending on the cyst’s size and location:

  1. Low Back Pain: Chronic pain in the lower back, often exacerbated by prolonged sitting or standing.
  2. Radicular Pain: Pain radiating down the legs, similar to sciatica, due to nerve root compression.
  3. Sensory Disturbances: Numbness, tingling, or burning sensations in the lower extremities.
  4. Motor Weakness: Muscle weakness or atrophy in severe cases.
  5. Bowel and Bladder Dysfunction: In cases where cysts compress the sacral nerve roots affecting autonomic function.

Work-Up and Diagnosis

Diagnosing Tarlov cysts involves a thorough clinical evaluation and imaging studies:

  1. Clinical Examination: Assessing pain distribution, sensory changes, and motor deficits.
  2. Imaging Studies:
    • MRI: The gold standard for visualizing Tarlov cysts, providing detailed images of cyst size, location, and potential nerve root compression.
    • CT Myelography: Involves injecting contrast dye into the spinal canal to enhance imaging and identify CSF leaks or communication between cysts and the subarachnoid space.
  3. Electrodiagnostic Studies: Nerve conduction studies and electromyography (EMG) can assess nerve function and help differentiate Tarlov cysts from other neuropathies.

Treatment Options

While many Tarlov cysts are managed conservatively with observation and symptomatic treatment, interventional modalities are considered for symptomatic or progressively enlarging cysts.

Interventional Treatment Modalities

  1. Percutaneous Aspiration and Fibrin Glue Injection: A minimally invasive procedure where the cyst is aspirated to remove CSF, followed by an injection of fibrin glue to seal the cyst and prevent recurrence. This technique aims to reduce pressure and alleviate symptoms.
  2. CT-Guided Aspiration: Similar to percutaneous aspiration, this procedure uses CT imaging to guide the needle accurately into the cyst for fluid removal. It can provide temporary symptom relief and is often used for diagnostic purposes.
  3. Microsurgical Fenestration and Decompression: A surgical procedure involving the creation of a small window in the cyst wall to allow continuous drainage of CSF into the epidural space, thereby reducing cyst pressure and nerve compression.
  4. Laminectomy with Cyst Excision: Involves the surgical removal of part of the vertebra (lamina) to access and excise the cyst. This is considered in cases where other treatments have failed or when the cyst is causing significant neurological deficits.
  5. Radiofrequency Ablation (RFA): An emerging technique where radiofrequency energy is used to ablate the cyst wall, promoting collapse and sclerosis of the cyst. This method is still under investigation but shows promise for long-term symptom relief.
  6. Spinal Cord Stimulation (SCS): For patients with chronic, intractable pain not relieved by other interventions, SCS can be used to modulate pain signals and provide symptomatic relief. Electrodes are implanted near the spinal cord, delivering electrical impulses to interfere with pain transmission.
  7. Fib-Glue Closure: A novel treatment conducted at my alma mater, Johns Hopkins Hospital, between 2003 and 2013 where 289 cysts were treated with aspiration and injection of fibrin-glue (Tisseel VH) in 213 consecutive patients. At 3-6 years following procedure, 74.0% of patients followed were satisfied with treatment. There were no clinically significant complications.


Tarlov cysts, though often asymptomatic, can lead to significant discomfort and neurological impairments when symptomatic. Accurate diagnosis through clinical evaluation and imaging is crucial for effective management. While conservative treatments may suffice for many patients, interventional modalities offer advanced solutions for those with persistent or severe symptoms. By targeting the underlying cyst pathology, these treatments can significantly enhance pain management and improve quality of life.


  1. Lucantoni C, Than KD, Wang AC, et al. “Tarlov cysts: a controversial lesion of the sacral spine.” Neurosurgical Focus. 2011.
  2. Voyadzis JM, Bhargava P, Henderson FC. “Tarlov cysts: a study of 10 cases with review of the literature.” Journal of Neurosurgery: Spine. 2001.
  3. Hiers RH, Long D, North RB. “Surgical treatment of symptomatic sacral Tarlov cysts.” Neurosurgery. 2003.
  4. Langdown AJ, Grundy JR, Birch NC. “The clinical relevance of Tarlov cysts.” Journal of Spinal Disorders & Techniques. 2005.
  5. Marino D, Carluccio MA, Benedetti A, et al. “Percutaneous CT-guided treatment of symptomatic sacral Tarlov cysts.” Journal of Vascular and Interventional Radiology. 2013.
  6. Shao Z, Wang B, Wu Y, Zhang Z, Wu Q, Yang S. CT-guided percutaneous injection of fibrin glue for the therapy of symptomatic arachnoid cysts. AJNR Am J Neuroradiol. 2011 Sep;32(8):1469-73. doi: 10.3174/ajnr.A2595. Epub 2011 Aug 11. PMID: 21835944; PMCID: PMC7964360.
  7. Murphy K, Oaklander AL, Elias G, Kathuria S, Long DM. Treatment of 213 Patients with Symptomatic Tarlov Cysts by CT-Guided Percutaneous Injection of Fibrin Sealant. AJNR Am J Neuroradiol. 2016 Feb;37(2):373-9. doi: 10.3174/ajnr.A4517. Epub 2015 Sep 24. PMID: 26405086; PMCID: PMC4752851.

These references provide further insights into the anatomy, clinical presentation, and advanced treatment modalities for Tarlov cysts.

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