Perineural “Tarlov” Spinal Nerve Outlet Cyst Pains – Overlooked and Treatable

I have a patient with multiple level cysts where the nerves exit the spine in the neck. He also has some mild foraminal stenosis. He is symptomatic with arm and referred upper back pain. Getting his problem taken seriously has been an issue. Now it appears these perineural cysts do indeed cause trouble and can be treated. 

 Epidemiological study of Tarlov Nerve – Root cysts (TC) An Overlooked, Treatable Cause of Chronic Pain and Dysfunction
A. Oaklander1, R. H. Hiers2, P. Devan1, D. S. Klein1, 1Neurology, Harvard Med. Sch., Boston, MA, USA, 2Tarlov Cyst Disease Fndn., Knoxville, TN, USA
IASP Poster PM 105 Montreal 2010

•  cerebrospinal fluid gets trapped in spinal nerve-root sleeves and creates cysts
• Despite published cases, “medical lore is that they are always clinically insignificant”
•  prevalence of 0.012% (1.2/10,000)
• 3/4 were women, and 12 times more likely over 65
• Symptoms:
  – chronic pelvic pain (abdomen, pelvis, hip, genitalia) 74% – in women
  – leg pain and difficulty sitting 91%
  – bladder and bowel symptoms if severe
• Location
  -91%  sacral cysts,
  -11%  lumbar cysts,
  -6% thoracic cysts, and
  -3%  cervical cysts.
•  Collagen mutations more common – Ehler Danlos and Marfan’s mentioned – what they don’t mention is idiopathic hypermobility which is commonly associated with a Fibromyalgia subgroup…
• “Symptoms can often be treated and sometimes cured, by one of two procedures with satisfactory published results”
  – Surgery – cyst exposure, careful opening and cyst obliteration by packing, collapsing or imbrication
  Surg Neurol. 2003 Feb;59(2):101-5; discussion 105-6
  Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases
  Caspar W, Papavero L, Nabhan A, Loew C, Ahlhelm F. abstract here
  – Controlled injection – “Other procedure is CT controlled cyst obliteration by injecting blood, fibrin sealant or fat”
  Vasc Interv Radiol. 2008 May;19(5):771-3. Epub 2008 Mar 28.
  Two-needle technique for the treatment of symptomatic Tarlov cysts.
  Murphy K, Wyse G, Schnupp S, Gailloud P, Woodworth GF, Sciubba DM, Oka M, Sasson  AD, Long D.

• Another treatment I came across was steroid – oral and epidural:
  Spine (Phila Pa 1976). 2008 Jul 15;33(16):E565-8
  Conservative management of perineural cysts.
  Mitra R, Kirpalani D, Wedemeyer M.
  One case was  “L5–S1 right sided intralaminar epidural steroid injection.”(no mention of dose or agent)
  Other case was  “The patient was treated with a 6-day course of oral steroids, tapering from 24 to 0 mg.” – no mention of what agent – (gd’ doesn’t SPINE monitor the stuff they publish…) – these cases were big and inflamed and the steroid might have helped the inflammation and they were much small subsequently….

Comment – though they make a case for particularly sacral ones being symptomatic, they don’t actually give info on how to tell if symptomatic – particularly if in a double crunch situation both it and foraminal stenosis)… Does suggest to me that a steroid epidural injection might be worth trying..