Case Report

By Dr. Bhagwati Salgotra , Dr. Kunal Kishore , Dr. Murtaza A Calcuttawala , Dr. Hemish Kania
Corresponding Author Dr. Murtaza A Calcuttawala
Ganeral Surgery,Pad Dr D Y Patil Med College and Research Hosp., Building C4,Flat No 902,Bramha Avenue,Near Jyoti Restaurant,Kondwa khurd,Pune 411048 - India 411048
Submitting Author Dr. Murtaza A Calcuttawala
Other Authors Dr. Bhagwati Salgotra
Department of Neurosurgical Sciences, Dhiraj Hospital , Sumandeep Vidyapeeth, Pipari, Vadodara, Dhiraj Hospital , Sumandeep Vidyapeeth, Pipari, Vadodara - India

Dr. Kunal Kishore
Department of Neurosurgical Sciences, Dhiraj Hospital , Sumandeep Vidyapeeth, Pipari, Vadodara, Dhiraj Hospital , Sumandeep Vidyapeeth, Pipari, Vadodara - India

Dr. Hemish Kania
Department of Neurosurgical Sciences, Dhiraj Hospital , Sumandeep Vidyapeeth, Piparia, Vadodara., Dhiraj Hospital , Sumandeep Vidyapeeth, Piparia, Vadodara. - India


Low back pain, sacral perineural cyst, sciatica, tarlov cyst

Salgotra, Kishore, Calcuttawala MA, Kania H. Symptomatic Tarlov Cyst: A Rare Case Report and Its Management. WebmedCentral NEUROSURGERY 2014;5(2):WMC004538
doi: 10.9754/journal.wmc.2014.004538

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Submitted on: 03 Feb 2014 06:09:08 PM GMT
Published on: 04 Feb 2014 04:59:38 AM GMT


Perineural (Tarlov) cysts are meningeal dilatations of the posterior spinal nerve root sheath that most often affect sacral roots and can cause a progressive painful radiculopathy. Tarlov cysts are most commonly diagnosed by lumbosacral magnetic resonance imaging and can often be demonstrated by computerized tomography to communicate with the spinal subarachnoid space. The cyst can enlarge via a net inflow of cerebrospinal fluid, eventually causing symptoms by distorting, compressing, or stretching adjacent nerve roots. It is generally agreed that asymptomatic Tarlov cysts do not require treatment. When symptomatic, the potential surgery-related benefit and the specific surgical intervention remain controversial. We report a case of symptomatic Tarlov cyst, its clinical presentation, treatment, and results of surgical cyst fenestration, partial cyst wall resection, and closure in a case of a symptomatic sacral Tarlov cyst.


Tarlov cysts were first described in 1938 as an incidental finding at autopsy1 Tarlov described a case of symptomatic perineural cyst and recommended its removal. Since then a few cases have been reported in the literature.2–4

Paulsen reported the incidence of Tarlov cysts as 4.6% in back pain patients (n=500). Only 1% of back pain patients (n=500) were symptomatic4 The patient may present as low back pain, sciatica, coccydynia or cauda equina syndrome. The cysts are usually diagnosed on MRI, which reveals the lesion arising from the sacral nerve root near the dorsal root ganglion5

Tarlov advised extensive surgery with sacral laminectomy and excision of the cyst along with the nerve root6 Paulsen reported CT-guided percutaneous aspiration of these perineural cysts for relief of sciatica4 Recently, microsurgical excision of the cyst has been advocated, combined with duroplasty or plication of the cyst wall7

We report a case of symptomatic Tarlov cyst presenting as back pain, to increase the awareness of this rare entity in the neurosurgical and orthopedic community

Case Report

A 47-year-old man presented with a 1-year history of progressive, intractable pain and numbness as well as dysesthesias of left leg. Pain aggravated on walking. At the time, he was becoming increasingly incapacitated, although he was still able to work . He rated his pain as 8 of 10 possible points on a visual analog scale. Pain was rapidly relieved in recumbent position. He had no bowel or bladder dysfunction, and sensation for urination and defecation was normal. The pain was not associated with specific time, posture and it used to get relieved by non steroidal antiinflammatory drugs (NSAID). For last three months, the intensity and duration of pain had increased, which was now unrelieved by taking NSAID. The pain had progressed to the lower back and bilateral upper thigh up to the ankle. The pain was aggravated by activity and prolonged standing and was more bothersome in the evening. On physical examination, a grade of 4/5 strength was demonstrated in left lower limb. Other all limbs had 5/5 strength. Heel and toe walking and knee bends were well performed. Sensory examination showed diminished sensory perception to pinprick on the soles of his feet and in S1 distribution. There was no sensory deficit over the perineum. Anal sphincter tone and constriction were normal. Knee jerks were normal.Left ankle jerk was grade +.

Examination showed no spinal tenderness. Straight leg raising was 30° on the left side and normal on the right side. There was mild blunting of sensations along the S1 dermatome on the left side, no motor deficit in both lower limbs.

Preoperative MR imaging(Fig 1) demonstrated a large sacral cyst arising within the thecal sac at S-1,of around 3*2*2cm  with expansion of the osseous sacral central canal and enlargement of L-5 and S-1 neural foramina causing compression of all adjacent nerve roots. The cyst did not fill with contrast material and appeared to have no communication with the spinal subarachnoid space. X-ray of the lumbosacral spine did not reveal any abnormality

Fig 1: MRI Lumbosacral Spine shows Tarlov’s Cyst at T5-S1 level.


To relieve progressively incapacitating symptoms, surgery was recommended. After sacral laminectomy, microsurgical cyst fenestration was performed. Briefly, after exposure of the L5-S1 sacral nerve roots, a large  cyst was identified at S1 level of cord. The thin transparent cyst wall membrane was widely fenestrated with a scalpel and microscissors. Clear fluid contents of the cyst drained spontaneously. The posterolateral wall of the cyst was resected after electrical stimulation verified that no motor nerve fibers were present. Fibrin glue was then applied to fill the cyst cavity. To prevent cyst recurrence or CSF leakage, Although the cyst wall specimen was sent to the laboratory for pathological examination, its volume was inadequate to determine whether nerve root fibers were present.

Fig 2 A.B- Intraoperative photograph of excision of Tarlov’s cyst.


Tarlov cysts are rare causes of low back pain. They are more common in females4,7 Clinical presentation of Tarlov cysts is variable. The cysts may cause local and/or radicular pain. The dominant syndrome is referable to the caudal nerve roots, either sciatica, sacral or buttocks pain, vaginal or penile paraesthesia or sensory changes over the buttocks, perineal area and lower extremity. Depending on their location, size and relationship to the nerve roots, they may cause sensory disturbances or motor deficits to the point of bladder dysfunction. Tenderness on firm pressure over the sacrum may be present. Commonly, the symptomatology is intermittent at its onset and is most frequently exacerbated by standing, walking and coughing. Bed rest alleviates the discomfort8

Plain X-rays are usually normal. However, they may reveal characteristic bone erosion of the spinal canal or anterior or posterior neural foramina9 A CT scan can demonstrate cystic masses isodense with CSF located at the foramina. Bony changes may also be present10 An MRI gives a much better soft tissue contrast and is currently the investigation of choice for perineural cysts. The cysts demonstrate low signal on T-1 weighted images and high signal on T-2 weighted images, similar to CSF5 Myelography showing the filling of the meningocele sac 1h after injection of contrast medium is highly suggestive of a perineural cyst11

Microscopic features of the cyst were described by Tarlov. The early stage in cyst formation is that of a space between the arachnoid which covers the root or the perineurium and the outer layer of the pia cover of the root or the endoneurium. It usually begins in one portion of the circumference of the perineural space, the larger cysts compressing the nerve root to one side. The cyst occupies the posterior root abutting the proximal portion of the dorsal ganglion. Its main part is bordered by reticulum or by nerve fibers1

The pathogenesis of perineural cysts is uncertain. Tarlov felt that hemorrhage into the subarachnoid space caused accumulations of red cells which impeded the drainage of the veins in the perineurium and epineurium, leading to rupture with subsequent cyst formation. Four out of the seven patients in Tarlov's 1970 article had a history of trauma8 Schreiber and Haddad also supported this posttraumatic cause of cyst formation12 Because many of the patients with perineural cyst in their series did not have histories of trauma, Fortuna et al. believed that the perineural cysts were congenital, caused by arachnoidal proliferations within the root sleeve13

There is no consensus on a single method of treatment. Various methods have been advocated. Tarlov advised that symptomatic, single perineural cysts should be completely excised together with the posterior root and ganglion from which they arise8 Paulsen reported CT-guided percutaneous aspiration of these perineural cysts in two patients for the relief of sciatica caused by compression4 According to Caspar microsurgical excision of the cyst combined with duroplasty or plication of the cyst wall is an effective and safe treatment of symptomatic sacral cysts. The parent nerve root is always left intact7

Tarlov cysts are a documented cause of sacral radiculopathy and other radicular pain syndromes. They must be considered in the differential diagnosis of patients presenting with these clinical presentations and appropriately treated by cyst excision


Patient appreciated relief of pain immediately after the surgery. Postoperative period was uneventful and the patient made prompt recovery. On nine months followup, the patient had no pain in lower limbs and back. The patient is back at his job and is asymptomatic. Postoperative MRI taken at nine month did not show any evidence of recurrence of the cyst. Tarlov cyst are well treatable entity and significant symptomatic relief is achievable


1. Tarlov IM. Perineural cysts of the spinal nerve roots. Arch Neural Psychiatry. 1938;40:1067–74.
2. Chaiyabud P, Suwanpratheep K. Symptomatic Tarlov cyst: Report and review. J Med Assoc Thai. 2006;89:1047–50
3. Acosta FL, Jr, Quinones-Hinojosa A, Schmidt MH, Weinstein PR. Diagnosis and management of sacral Tarlov cysts Case report and review of the literature. Neurosurg Focus. 2003;15:E15.
4. Paulsen RD, Call GA, Murtagh FR. Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts) AJNR Am J Neuroradiol. 1994;15:293–9
5. Rodziewicz GS, Kaufman B, Spetzler RF. Diagnosis of sacral perineural cysts by nuclear magnetic resonance. Surg Neurol. 1984;22:50–2.
6. Tarlov IM. Cysts (perineurial) of the sacral roots. J Am Med Assoc. 1948;138:740–4.
7. Caspar W, Papavero L, Nabhan A, Loew C, Ahlhelm F. Microsurgical excision of symptomatic sacral perineurial cysts: A study of 15 cases. Surg Neurol. 2003;59:101–6.
8. Tarlov IM. Spinal perineurial and meningeal cysts. J Neural Neurosurg Psychiatry. 1970;33:833–43.
9. Taveras JM, Wood EH. Diagnostic neuroradiology. 2nd ed. Vol 2. Williams and Wilkins: Baltimore; 1976. pp. 1139–45
10. Tabas JH, Deeb ZL. Diagnosis of sacral perineural cysts by computed tomography. J Comput Tomogr. 1986;10:255–9
11. Nishiura I, Koyama T, Handa J. Intrasacral perineurial cyst. Surg Neurol. 1985;23:265–9
12. Schreiber F, Haddad B. Lumbar and sacral cysts causing pain. J Neurosurg. 1951;8:504–9
13. Fortuna A, La Torre E, Ciappetta P. Arachnoid diverticula: A unitary approach to spinal cysts communicating with the subarachnoid space. Acta Neurochir (Wien) 1977;39:259–68

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3 reviews posted so far

Critical Appraisal of a Case of Sacral Nerve Root Sheath Cyst
Posted by Dr. Sanjoy Sanyal on 17 Mar 2014 04:43:47 AM GMT Reviewed by WMC Editors

Symptomatic Tarlov cyst: case report and management
Posted by Prof. Angelo Lavano on 19 Feb 2014 07:19:50 PM GMT Reviewed by WMC Editors

Tarlov Cyst
Posted by Dr. William J Maloney on 13 Feb 2014 05:22:05 PM GMT Reviewed by Interested Peers

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