This website aims to provide information about the Tarlov Cyst disease, and it is designed for educational and informational purposes. Here you will find news and personal experiences about this medical condition.

Tarlov cysts, also known as perineurial cysts or sacral nerve root cysts. They are named for neurologist Isadore M. Tarlov, who described them in 1938.

They are dilations of the nerve root sheaths and are abnormal sacs filled with cerebrospinal fluid (hereafter referred to as CSF) that can cause a progressively painful radiculopathy (nerve pain). The fluid in the cyst can put pressure on the nerve inside and on the adjacent nerve roots, and it causes debilitating symptoms.

Tarlov cysts differ in structure; they might incorporate nerve elements or be free of them. A cyst can be valved or non-valved. A valved cyst has a structure in its neck that makes it easier for cerebrospinal fluid (CSF) to enter the cyst than to leave it. In a non-valved cyst, CSF flows between the cyst and the dural tube.

They are located most prevalently in the spinal canal of the S1 to S4 region of vertebrae and can be distinguished from other meningeal cysts by nerve-fibre-filled walls. Perineural cysts can form in any section of the spine; some patients have cysts at more than one location of the spine, including cervical, thoracic, lumbar, and sacral. Multiple Tarlov cysts are not uncommon.

The cyst is in the nerve and therefore cannot be cut out.

These cysts are often detected incidentally during MRI, CT and Myelogram scans for other medical conditions. Tarlov Cysts are relatively common when compared to other neurological cysts.. Although originally believed by Tarlov 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.

The annual incidence of perineural cysts is estimated at approximately 5%, although large cysts that cause symptoms are relatively rare, with an annual incidence estimated at less than 1/2,000. Women are affected more frequently than men.

Causes of Tarlov Cyst

The cause of these cysts is still unknown; there are several hypotheses proposed regarding the formation of Tarlov Cysts, including: inflammation within the nerve root cysts followed by inoculation of fluids (epidurals), developmental or congenital origin, and trauma. Some incidents or conditions that might potentially cause the asymptomatic cysts to become symptomatic are traumatic injuries such as falls, automobile accidents, heavy lifting, and childbirth. Trauma to the spinal cord, an increase in the CSF pressure, or a blockage of the CSF can result in cyst formation.

Symptoms

Symptoms can vary depending on the location of the cysts, size and the section of the spine they occur:

Pain with sitting. May feel like you are sitting on a rock or an object.

Pain with standing

Pain or numbness in the buttocks or between the legs

Leg weakness or numbness

Pulling and burning sensation in the coccyx (tailbone) area, especially when bending

Pain in the legs and feet, especially in the back of the thighs

Pain in the chest, upper back, neck, arms and hands

Pain with sexual intercourse

Inability to empty the bladder or, in extreme cases, to urinate at all

Bowel or bladder changes, including incontinence

Headaches and sometimes accompanied by blurred vision, double vision, pressure behind the eyes and optic nerve pressure causing papilledema (optic nerve swelling)

Dizziness and feeling of loss of balance or equilibrium, especially with a change of position,vaginal, rectal, pelvic and/or abdominal pain

Diagnosis and treatment

Effective examination methods for Tarlov Cysts are MRI and CT. Both of them are good imaging procedures that allow the detection of extradural spinal masses such as Tarlov cysts. The best imaging study to image the Tarlov/perineural cyst is a spine MRI, and since the vast majority of the perineural cysts are on the sacral spine, then the order should be for a "full sacral spine MRI (S1-S5) all the way to the coccyx/tailbone".

A CT with Myelography is a diagnostic tool that uses radiographic contrast media (dye) that is injected into the spinal canal’s fluid (cerebrospinal fluid, CSF). After the dye is injected, the contrast dye serves to illuminate the spinal canal, cord, and nerve roots during imaging. Thus, when a CT scan and myelography are combined, images are produced that clearly show both the bony structures of the spine and the nerve structures. These images are invaluable to physicians as they diagnose a patient’s spine problem.

When faced with a patient asking about an MRI report that indicates a possible Tarlov Cyst, the specialist may consult a neuroscience textbook and find there the initial mistaken supposition of Mr Tarlov that these cysts would not cause pain. This notion was contradicted by clinical experience and corrected in journal articles by Tarlov and others, but misinformation on this aspect of Tarlov Cysts persists in medical books and this results in denial of pain management, disability status and treatment. Untold numbers of persons with this disease suffer for a long period without diagnosis or treatment.

Despite advancements in diagnosis, there remains a great deal of controversy regarding the optimal treatment of symptomatic Tarlov Cysts. There are some treatments available for alleviating the symptoms caused by these cysts. Their effectiveness is “personal”. Every case is different; it depends on the number of cysts, size, location, age of the patient and more.

There is no compelling evidence that chiropractic, physical therapy or any other conservative manual or physical treatment is effective in treating symptomatic TCs.

Non-surgical treatment options include using a needle to aspirate CSF from the cysts can temporarily relieve symptoms. Eventually, the cysts will refill and the symptoms will recur, usually within hours.

Pain may be temporarily controlled by aspiration of the cysts and then injecting the cysts with fibrin glue (a substance produced from blood chemicals involved in the clotting mechanism).

The aspiration of CSF and injection of fibrin glue procedure theoretically is designed to remove the CSF from the cyst, and to block the entrance or the neck of the cyst with the sealant glue, to prevent the return of the flow of CSF into the cyst. Some patients have found immediate relief after the procedure, while others have reported a delayed benefit from the procedure when the nerve irritation has subsided. After the procedure, there are outcomes of both short-term relief as well as longer-term relief reported. However, it is considered to be a temporary relief procedure.

Surgery may be the treatment of choice when the pain is intractable, the sacrum is eroding and remodelling , and the neurological symptoms become severe. Before referring to a spine surgeon, find out in advance if the surgeon dismisses TCs as asymptomatic or not surgically treatable. This could save you time, money and aggravation. There are a small number of physicians in the world who have surgical expertise in the treatment of TCs, and the short-term and long-term outcome of surgery is improving but variable in individual patients at this time.

The usual surgical procedure consists of fenestration and imbrication of the cysts and then packing all the dead space around the cysts with fat, glue, and/or muscle. The body does not like dead spaces, and new cysts will possibly develop in the dead spaces around the old cysts if not filled. Due to the potential risks for further nerve damage or spinal fluid leaks, there might be increased symptoms postoperatively, including more bowel and bladder problems, when the cysts are located in the S2-S3 nerve location.

However, the neurosurgeons are perfecting surgical techniques and including intra-operative nerve monitoring to decrease the risks of further nerve damage. Due to the long-term nerve compression causing irritation and inflammation to the nerves, it may take months to a year to determine the full benefit of the surgery.

For more detailed information, please visit the Tarlov Cyst Disease Foundation.

Treatment in the UK and abroad

Few surgeons in the world can operate on a Tarlov Cyst. The world’s specialist is Dr Feigenbaum from Dallas, Texas, USA.

Dr Feigenbaum's practice routinely treats patients with giant meningeal cysts from all over the United States and other countries(Cyprus).

DR Casey from London uses a similar technique to Dr Feigenbaum, and this is available in the UK.

Dr Dorte Clemmensen is available in Denmark for treatments.

The treatment is not available under the NHS, either routinely or through specialised commissioning, and they do not routinely commission the treatment because of a lack of evidence for its effectiveness. The NHS’s responsible commissioner.

This is the reason Ms Beathrice Viviani, from Bournemouth, was given when her application for a state-funded treatment in another European Economic Area (S2), was rejected by the Border Healthcare Team (NHS England) after travelling to Cyprus to have her Tarlov Cyst treated privately by Dr Feigenbaum at the AIMIS Spine Centre.

Ms Viviani had to use all her savings (£30.000) to pay for the surgery that saved her from being bedridden and in a wheelchair for the rest of her life.

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