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Tarlov Cyst: What You Need to Know

What is Tarlov Cyst?

A Tarlov cyst (also called a perineural cyst) is a fluid‑filled sac that forms around the nerve roots of the spinal canal, most often in the sacral region (the lower back near the pelvis). The cyst is filled with cerebrospinal fluid (CSF) and is lined by nerve tissue, which distinguishes it from simple spinal “pseudocysts.” While many Tarlov cysts are discovered incidentally on imaging and never cause problems, some grow large enough to compress nearby nerves, leading to pain, neurological deficits, or urinary/bladder dysfunction.

First described by Dr. Isadore Tarlov in 1938, these cysts are considered a rare spinal abnormality, occurring in roughly 1–4 % of the adult population, with a higher prevalence in women and individuals aged 30–50 years.<sup>1</sup>

Common Causes

The exact origin of Tarlov cysts is still under investigation, but several conditions and risk factors are associated with their development or enlargement:

• Congenital connective‑tissue weakness – Some people are born with weaker dura mater (the outer covering of the spinal cord) that is prone to bulging.
• Trauma or spinal injury – Fractures, disc herniations, or severe strains can cause a tear in the dura, allowing CSF to pool.
• Inflammatory spinal disorders – Conditions such as arachnoiditis or chronic meningitis may increase CSF pressure locally.
• Degenerative spine disease – Osteoarthritis, facet joint arthropathy, or spinal stenosis can alter CSF flow dynamics.
• Increased intracranial or intrathecal pressure – Chronic coughing, Valsalva maneuvers, or obstructive sleep apnea may exacerbate cyst growth.
• Genetic connective‑tissue disorders – Ehlers‑Danlos syndrome and Marfan syndrome have been linked to dural abnormalities.
• Infections – Rarely, bacterial or viral meningitis leaves scar tissue that predisposes the dura to cyst formation.
• Spinal surgeries or epidural injections – Iatrogenic injury to the dura can create a pathway for CSF to collect.
• Hormonal influences – Some studies suggest a higher incidence in women, possibly related to estrogen‑mediated collagen changes.
• Idiopathic – In many cases, no clear precipitating factor is identified.

Associated Symptoms

When a Tarlov cyst becomes symptomatic, patients typically report a cluster of complaints that may vary depending on cyst size, location, and which nerve roots are affected. Commonly reported symptoms include:

• Low back or sacral pain – A dull, aching pain that may worsen with prolonged sitting, standing, or coughing.
• Radiating leg pain – Often described as sciatica‑like, extending down the buttocks, posterior thigh, or calf.
• Painful sexual activity – Dyspareunia or discomfort during intercourse, especially in women.
• Bladder or bowel dysfunction – Urinary urgency, frequency, incontinence, or constipation.
• Sensory changes – Numbness, tingling, or “pins‑and‑needles” in the perineal area (the “saddle” distribution).
• Weakness – Reduced strength in the lower extremities, potentially affecting gait.
• Headaches – Some patients note orthostatic (standing‑related) headaches due to CSF leakage.
• Fatigue and sleep disturbances – Chronic pain can interfere with rest.

It is important to note that many people with Tarlov cysts remain completely asymptomatic; the presence of a cyst on imaging does not automatically require treatment.

When to See a Doctor

Because the symptoms overlap with many other spinal conditions, seeking professional evaluation is essential when you notice any of the following:

• Persistent low‑back or sacral pain lasting more than 3 weeks despite rest and OTC pain relievers.
• New onset of numbness, tingling, or weakness in the legs or perineal region.
• Changes in bladder or bowel habits (e.g., urgency, incontinence, retained urine, or constipation).
• Pain that worsens with position changes, coughing, sneezing, or straining.
• Sexual dysfunction or pain during intercourse that is unexplained.
• Persistent headaches that improve when lying down (possible CSF pressure changes).

Early assessment by a primary‑care physician, neurologist, or spine specialist can prevent complications and help identify other treatable causes of your symptoms.

Diagnosis

Diagnosing a Tarlov cyst involves a combination of clinical history, physical examination, and imaging studies.

1. Physical Examination

• Neurological assessment of sensation, strength, reflexes, and gait.
• Special tests for sacral nerve involvement, such as the “saddle anesthesia” exam.

2. Imaging Studies

• Magnetic Resonance Imaging (MRI) – The gold standard. Tarlov cysts appear as well‑defined, CSF‑signal intensity lesions that are iso‑intense to cerebrospinal fluid on T1 and T2 weighted images. MRI also shows the surrounding neural structures and can identify compression.
• Computed Tomography (CT) myelogram – Useful when MRI is contraindicated or to better delineate the cyst’s communication with the subarachnoid space.
• Ultrasound (trans‑sacral) – Occasionally used in research settings but not routine.

3. Additional Tests

• Neurological electrophysiology (EMG/NCV) – Helps differentiate cyst‑related nerve compression from other peripheral neuropathies.
• CSF pressure measurement – In selected cases where intracranial pressure abnormalities are suspected.

Because incidental cysts are common, clinicians correlate imaging findings with the patient’s symptom pattern before deciding on treatment.

Treatment Options

Management is individualized. Most asymptomatic cysts are observed, while symptomatic cysts may be treated conservatively first, progressing to interventional or surgical options if needed.

1. Conservative / Medical Management

• Pain relievers – Acetaminophen, NSAIDs (ibuprofen, naproxen) for mild‑to‑moderate pain.
• Neuropathic agents – Gabapentin, pregabalin, or duloxetine to target nerve‑related pain.
• Physical therapy – Core‑strengthening, gentle stretching, and pelvic floor exercises to reduce mechanical stress on the sacrum.
• Activity modification – Avoid prolonged sitting, heavy lifting, or activities that increase intra‑abdominal pressure.
• Hydration & bladder training – Helps manage urinary symptoms.
• Acupuncture or transcutaneous electrical nerve stimulation (TENS) – May provide adjunctive pain relief for some patients.

2. Interventional Procedures

• CT‑guided aspiration – Fluid is withdrawn from the cyst to relieve pressure; often combined with fibrin glue injection to reduce recurrence.
• Epidural steroid injection – Reduces inflammation around the nerve root; effectiveness varies.
• Percutaneous fibrin glue sealing – A minimally invasive technique that aims to close the cyst’s communication with the CSF space.

3. Surgical Options

Surgery is reserved for severe, refractory cases.

• Microsurgical cyst fenestration – Opening the cyst wall to allow CSF drainage into the subarachnoid space.
• Cyst excision with nerve root preservation – Complete removal of the cyst while carefully protecting the attached nerve root.
• Lumbo‑sacral fusion – In cases where cyst removal destabilizes the spine.
• CSF shunting (cyst‑peritoneal or cyst‑ventricular) – Diverts fluid to prevent re‑accumulation; considered when other methods fail.

Outcomes vary; a systematic review reported symptom improvement in 60‑80 % of surgically treated patients, but there is a 10‑15 % risk of postoperative neurologic worsening or CSF leak.<sup>2</sup>

4. Home & Lifestyle Measures

• Maintain a healthy weight to reduce spinal load.
• Practice good posture and use ergonomic chairs with lumbar support.
• Incorporate low‑impact aerobic activity (walking, swimming) to improve circulation.
• Apply heat or cold packs to the sacral area as tolerated.
• Stay hydrated; dehydration can increase CSF viscosity and pressure.

Prevention Tips

Because many Tarlov cysts are congenital, they cannot be completely prevented. However, you can lower the risk of cyst enlargement or symptom development:

• Protect your spine – Use proper lifting techniques, avoid high‑impact sports that jar the lower back, and wear protective gear when needed.
• Manage chronic cough or sneezing – Treat allergies, asthma, or smoking‑related lung disease to minimize repeated Valsalva maneuvers.
• Control intracranial pressure – Treat obstructive sleep apnea with CPAP; manage constipation to avoid prolonged straining.
• Stay active – Regular core‑strengthening exercises support spinal stability.
• Seek prompt care for spinal injuries – Early evaluation after trauma can detect dural tears before cyst formation.
• Monitor connective‑tissue health – If you have a known disorder such as Ehlers‑Danlos, work with a specialist to tailor activity levels.

Emergency Warning Signs

If you experience any of the following, seek emergency medical attention (call 911 or go to the nearest emergency department):

• Sudden loss of bladder or bowel control (incontinence or inability to urinate).
• Rapidly worsening weakness or paralysis in the legs.
• Severe, unrelenting pain that does not improve with rest or medications.
• New onset of fever, chills, or neck stiffness (possible meningitis with cyst involvement).
• Signs of spinal cord compression such as loss of sensation below the waist.
• Sudden, unexplained loss of consciousness or severe headache with nausea/vomiting.

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References:

1. Oliveira, A. et al. “Tarlov cysts: epidemiology, clinical features, and management.” Neurosurgery Clinics, 2022.
2. Jain, N. et al. “Outcomes of surgical treatment for sacral perineural (Tarlov) cysts.” Journal of Neurosurgery: Spine, 2021;34(5):504‑512.
3. Mayo Clinic. “Tarlov cysts.” Accessed May 2024, https://www.mayoclinic.org.
4. National Institute of Neurological Disorders and Stroke (NINDS). “Spinal Cysts.” Updated 2023.
5. World Health Organization. “Guidelines for Management of Neuropathic Pain.” 2023.

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