Tarlov cyst

[clubdeac]

So I got a 35 y/o woman with two VERY large S2/S3 tarlov cysts. She's got a lot of hypersensitivity and central sensitization. Can't touch her or perform any PE maneuvers whatsoever. Her pain is across her LS junction/sacral area with referral into her bilateral posterior hips and proximal thighs. I always thought that tarlov cysts were typically asymptomatic and if they did cause pain it was more of a sacral radicular type. My initial impression of her was a lot of pscyhological overlay. Then I got online and started reading more about tarlov cysts. They describe very low back/sacral pain as a common complaint. They also say that asymptomatic ones often become symptomatic after a traumatic event. Well her pain all started after she fell down a flight of stairs 10 yrs ago. So..... what can I do for this lady? Caudals and meds? Just send out to a neurosurgeon who specializes in this?

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[PMR 4 MSK]

Get her pain down before considering surgery, except as a last resort. Oral meds or injections, whatever works. As you describe her, most surgeons will either write her off as crazy and/or operate and when she is still having problems, then write her off as crazy.

 

[101N]

Get her pain down before considering surgery, except as a last resort. Oral meds or injections, whatever works. As you describe her, most surgeons will either write her off as crazy and/or operate and when she is still having problems, then write her off as crazy.

In the vast majority of cases you should read Tarlov's as normal variants like spina bifida occulta, Bertolotti segments, and vertebral hemangioma's.

 

[facets]

I hope this does not start any more flame wars like the US thread, BUT, try a caudal, you may be surprised how well this works for sacral pain. You are at the VA right? Good, you won't get paid anyway, but you may help the patient

 

[specepic]

I hope this does not start any more flame wars like the US thread, BUT, try a caudal, you may be surprised how well this works for sacral pain. You are at the VA right? Good, you won't get paid anyway, but you may help the patient

I would be more inclined to do a L5/1 ILESI personally rather than stick a needle anywhere near those cysts. I have sent a few folks to surgeons very similar to this pt. No surgeon has bitten whatsoever.

 

[101N]

I hope this does not start any more flame wars like the US thread, BUT, try a caudal, you may be surprised how well this works for sacral pain. You are at the VA right? Good, you won't get paid anyway, but you may help the patient

What's the inflammatory component?

You seem to be quick on the needle. $

 

[clubdeac]

Yeah I was thinking a caudal would be the best approach...

 

[caedmon]

I'll try to attach the MRI images on a word document. Very large cyst that looks like it is filling the right S2 foramen (versus erosion) and extending somewhat anteriorly. Just tried a right L5 ESI (given the distribution of pain). Some literature mentions draining and filling with fibrin glue or other substances. Any experience?

Difference would be, this is a young guy, with no psychosocial overlay with spontaneous onset of pain and right leg dyesthesias.

 

[SSdoc33]

I'll try to attach the MRI images on a word document. Very large cyst that looks like it is filling the right S2 foramen (versus erosion) and extending somewhat anteriorly. Just tried a right L5 ESI (given the distribution of pain). Some literature mentions draining and filling with fibrin glue or other substances. Any experience?

Difference would be, this is a young guy, with no psychosocial overlay with spontaneous onset of pain and right leg dyesthesias.

draining it IS an option. and you'd be a hero if it worked. even if it refilled (which it will), you'd be able to make a good diagnosis as the patient SHOULD have immediate pain relief right after the aspiration.

BUT, you'd be risking a PDPH, and an infection. i personally wouldnt do it, but let us know if you try. doubt any epidural would help out all that much if indeed the pain is due to the cyst....

 

[101N]

draining it IS an option. and you'd be a hero if it worked. even if it refilled (which it will), you'd be able to make a good diagnosis as the patient SHOULD have immediate pain relief right after the aspiration.

BUT, you'd be risking a PDPH, and an infection. i personally wouldnt do it, but let us know if you try. doubt any epidural would help out all that much if indeed the pain is due to the cyst....

Disagree, draining it isn't an option as it's a Tarlov, not an arachnoid cyst. You'd have to exanguinate all of the CSF to get rid of it because they arn't compartmentalized but contiguous with the rest of the subarachnoid space. Imbrication is possible but not many NS will take it on because it doesn't work very well.

These things tend to be procedural tar babies, the more you mess with them the more iatrogenic complications you cause.

 

[clubdeac]

Disagree, draining it isn't an option as it's a Tarlov, not an arachnoid cyst. You'd have to exanguinate all of the CSF to get rid of it because they arn't compartmentalized but contiguous with the rest of the subarachnoid space. Imbrication is possible but not many NS will take it on because it doesn't work very well.

These things tend to be procedural tar babies, the more you mess with them the more iatrogenic complications you cause.

So how do you treat them?!!! Same way you treat arachnoiditis, CRPS etc.

 

[jsaul]

Disagree, draining it isn't an option as it's a Tarlov, not an arachnoid cyst. You'd have to exanguinate all of the CSF to get rid of it because they arn't compartmentalized but contiguous with the rest of the subarachnoid space. Imbrication is possible but not many NS will take it on because it doesn't work very well.

These things tend to be procedural tar babies, the more you mess with them the more iatrogenic complications you cause.

This is exactly my opionion as well

 

[101N]

So how do you treat them?!!! Same way you treat arachnoiditis, CRPS etc.

In the vast majority of cases they aren't painful and don't need treatment. If you think you have one that does then send it to a NS with a question of imbrication or no.

You haven't convinced me that this Tarlov isn't just an innocent bystander in a hypochondriac.

 

[SSdoc33]

Disagree, draining it isn't an option as it's a Tarlov, not an arachnoid cyst. You'd have to exanguinate all of the CSF to get rid of it because they arn't compartmentalized but contiguous with the rest of the subarachnoid space. Imbrication is possible but not many NS will take it on because it doesn't work very well.

These things tend to be procedural tar babies, the more you mess with them the more iatrogenic complications you cause.

doing some reading on this. you can aspirate if you shoot the fibrin glue up there to seal off neck of the cyst. sounds like a recipe for disaster to me. interesting page

http://www.tarlovcystfoundation.org/TarlovCystInformation.asp

 

[db36jp78]

My tarlov cyst experience-N of 1

had a younger woman, 35, active with almost coccyx like pain after a day at a football game and 6 hours of driving. Present for 4-6 months before I see her.

Sent her for pt, tried cushioned seats, active release, oral meds, compounded meds, etc. No relief, MRI with 2 tarlov cysts-S1 and S2 one right and one left. I do a caudal (no other options at this point) and get some relief but not nothing great, try a gangion impar through and through the coccyx-no relief

Sit down and talk with her, decide to do an S1 and S2 carefully in an attempt to avoid puncturing the the cysts and what do you know she's better off all meds and happy, no idea why she's better but sometimes thats how it goes.

 

[Finally M3]

These things tend to be procedural tar babies, the more you mess with them the more iatrogenic complications you cause.

Procedural tar baby. I like that

I've heard from a neurosurgeon that messing with a Tarlov cyst is like trying to throw a series of stiches into a water balloon.

 

[epidural man]

So I got a 35 y/o woman with two VERY large S2/S3 tarlov cysts. She's got a lot of hypersensitivity and central sensitization. Can't touch her or perform any PE maneuvers whatsoever. Her pain is across her LS junction/sacral area with referral into her bilateral posterior hips and proximal thighs. I always thought that tarlov cysts were typically asymptomatic and if they did cause pain it was more of a sacral radicular type. My initial impression of her was a lot of pscyhological overlay. Then I got online and started reading more about tarlov cysts. They describe very low back/sacral pain as a common complaint. They also say that asymptomatic ones often become symptomatic after a traumatic event. Well her pain all started after she fell down a flight of stairs 10 yrs ago. So..... what can I do for this lady? Caudals and meds? Just send out to a neurosurgeon who specializes in this?

Menno Sluitjer would say try pulsed RF in the caudal space.

I'm not sure this book is even obtainable any more. Great read though.

 

[Jcm800]

What's the inflammatory component?

You seem to be quick on the needle. $

tsk tsk. an honest suggestion, just cuz you dont agree, doesnt mean you should make bold generalizations about someones character who you dont know, on the interweb no less...

 

[101N]

tsk tsk. an honest suggestion, just cuz you dont agree, doesnt mean you should make bold generalizations about someones character who you dont know, on the interweb no less...

Fair enough, but are we chef's or doctors. Do we do this work to help patients or to make money. I adhere to the theme of doing well by doing good, but some of the crap I read on this forum makes me cringe.

 

[SSdoc33]

i find that a lot of what i read on this forum is way better than what i see in practice. this at least gives us a medium to be thoughtful and discuss methods, rather than dealing with the charlatans of the pain world in the real world

 

[jj337]

Not saying it was a good thing (actually maybe even crazy) but during fellowship, saw a patient with Tarlov at L5/S1 or maybe L4/5. Attending put RFA needle in it and drained it and then we burned the capsule. I didn't have enough follow up with the patient to find out if she had a terrible headache or if it actually worked.

 

[101N]

Not saying it was a good thing (actually maybe even crazy) but during fellowship, saw a patient with Tarlov at L5/S1 or maybe L4/5. Attending put RFA needle in it and drained it and then we burned the capsule. I didn't have enough follow up with the patient to find out if she had a terrible headache or if it actually worked.

Sometimes the cyst capsule IS the nerve root.

 

[ParaVert]

"You haven't convinced me that this Tarlov isn't just an innocent bystander in a hypochondriac."

Couldn't agree more.

"Do we do this work to help patients or to make money?"

Maybe you're independently wealthy, but I've got a mortgage.

"I find that a lot of what i read on this forum is way better than what i see in practice."

This forum remains the most current and relavent resource for my post-training education.

 

[lobelsteve]

US guided caudal.

S1 TFESI too high.
Ganglion impar reasonable.
Caudal reasonable to finish.
Off-load, topical NSAID, Cymbalta/Savella/Lyrica (pick one)
Surgeon to say it's not causing any pain.

 

[Tenesma]

Talk to Tarlov and Son at Lahey -- they will tell you they are sorry they even have their name associated with it.

Tarlov cysts are not uncommon --- and have been there since birth...

I have seen larger cysts than that...

doubt it is the cause of her pain - just look at her behavioral issues...

 

[Jcm800]

i find that a lot of what i read on this forum is way better than what i see in practice. this at least gives us a medium to be thoughtful and discuss methods, rather than dealing with the charlatans of the pain world in the real world

Ditto. My point is we are discussing options, he won't make a penny on his hypothetical suggestion to this question...

 

[clubdeac]

I step away for a few days and look at what I missed. I love this forum. You guys crack me up.

So you're telling me there are no good treatments for tarlovs and there are no good diagnostic tests to tell me whether her pain is even from the Tarlov. Well just great! There's no denying she's a poor coper. But is it the pain from her Tarlov that she is having problems coping with? That my friends is the question....

 

[lobelsteve]

I step away for a few days and look at what I missed. I love this forum. You guys crack me up.

So you're telling me there are no good treatments for tarlovs and there are no good diagnostic tests to tell me whether her pain is even from the Tarlov. Well just great! There's no denying she's a poor coper. But is it the pain from her Tarlov that she is having problems coping with? That my friends is the question....

n=1 study and it's yours. No diagnostic test, no known therapy.
Rule out things you can. TTP? coccygiodynia. No TTP? Pelvic/GI- CT to assess, Gyn consult (we do NOT examine the hoohoo). You list LS and butt/posterior thigh pain- with inability to perform exam and centralization. Throw out some more history, PQRST, agg/rel factors, prior treatments, etc. Retroperitoneal seeding of ovarian CA sounds like it fits the bill with data provided.

 

[Jcm800]

n=1 study and it's yours. No diagnostic test, no known therapy.
Rule out things you can. TTP? coccygiodynia. No TTP? Pelvic/GI- CT to assess, Gyn consult (we do NOT examine the hoohoo). You list LS and butt/posterior thigh pain- with inability to perform exam and centralization. Throw out some more history, PQRST, agg/rel factors, prior treatments, etc. Retroperitoneal seeding of ovarian CA sounds like it fits the bill with data provided.

i def draw line at getting near the hoohoo...i try not examine the anoose and the pee pee and balzack either...

 

[epidural man]

(we do NOT examine the hoohoo).

I try to as much as I can....(just not in the pain clinic. )

Unforutnately, I see a ton of groin pain - and even though I know it makes no difference, I always feel like I should examine the balzack.

 

[olafa]

What's the inflammatory component?

You seem to be quick on the needle. $

Typically guys at the VA aren't in it for the money. By the way, on the MRI that's a huge cyst!
Hopkins has a clinic via Int Radiologists for the fibrin gluing of the cysts, sometimes it seems the cysts calcify and then it seems the patients pain is more difficult to control.

 

[Ligament]

I have a patient who gets outstanding short term relief from low volume caudal epidurals from her Tarlov's cyst. I have not found a long term solution for her unfortunately. I was considering placing stim leads nearby/on the cyst itself.

I have absolutely no doubt Tarlov's can be pain generators. I also think they are more often than not red-herrings.

BTW, I do agree there is a role for caudal epidurals in pain management. Pudendal neuralgia patients, post lami patients, horrible severe multi-level lumbar stenosis patients, doing "reverse" transforaminal epidurals with a catheter (thread catheter to neuroforamen and out the neuroforamen laterally)...I rarely need them but they are a great option to have.

 

[Pain Applicant1]

http://www.painphysicianjournal.com/2012/march/2012;15;141-146.pdf

 

[Tenesma]

dumb article... just because the case reports improved w/ local injection does not mean that the Tarlov Cyst is the cause of the pain.... idiots...

 

[lobelsteve]

I see a Tarlov cyst every day.

I might have a symptmatic one (but more likely subarchnoid cyst due to size and configuration). I have never seen one cause pain before.

 

[clubdeac]

So I ended up injecting this lady. She had three large cysts just medial to S1, S2 and S3. I stuck a needle in each foramen and aspirated. I was only able to aspirate one which produced 6 cc's clear fluid. I then did TFESIs at each level. After getting off the table she said she felt amazing! Then.... a week later she's presenting with urinary incontinence and terrible pelvic pain. I was a little worried. Called my neurosurgery buddy. He took a look at her and got a new MRI. No change. He dismissed it as "crazy lady" syndrome and I haven't heard from her since. Probably won't be doing that again.......

 

[lobelsteve]

So I ended up injecting this lady. She had three large cysts just medial to S1, S2 and S3. I stuck a needle in each foramen and aspirated. I was only able to aspirate one which produced 6 cc's clear fluid. I then did TFESIs at each level. After getting off the table she said she felt amazing! Then.... a week later she's presenting with urinary incontinence and terrible pelvic pain. I was a little worried. Called my neurosurgery buddy. He took a look at her and got a new MRI. No change. He dismissed it as "crazy lady" syndrome and I haven't heard from her since. Probably won't be doing that again.......

Only 2 years of fingers crossed. You need to call her and see her back in to re-assess.
Lost to follow up with patient conceived complication is a recipe for disaster.

 

[lillianna07]

I have a question, I am not a Doctor nor a student I am a Mom with an 11yr old with a perineural cyst on the T10 of her spine. First developed migraines 2 to 3x a week treatment from her neurosurgeon was Topamex 75mg 2x a day fixed the migraines. for the past 6 wks shes been complaining of her back hurting when she bends or lifts something heavy, feet and hands falling asleep and her backing out of activities like the water park on days when her back is really bothering her. Now i understand that you guys say they dont cause any pain and if so then they are crazy, if that is the case then please explain to me how an 11yr old can be in pain in the same area who happens to be very pain tolerant considering past medical history is 16 surgeries to date none on her spine and not related to this issue. also what im getting out of what im reading is there is no actual treatment just give them the push off and call them crazy because a neurosurgeon is to scared to treat it or just wont. so what really are a mothers options?

 

[lobelsteve]

Sorry, not a medical advice forum. Bye bye post. Violates terms of service.

 

[myrandom2003]

saw an article in fellowship out of a radiology journal where they did a Ct guided TFESI for a cervical tarlov cyst which reduced pain and also reduced the size of the cyst after a few weeks. Not sure of how it worked as they offered no incite into that.
I will try to find the article and post it.

 

[myrandom2003]

ha ha just kidding, it wasn't Ct guided but fluoro.
For what it's worth here is the article.

 

[GoSpursGo]

SDN is not for medical advice. Please consult with your physician. Since this thread appears to have run its course a while ago, thread closed.