P052: RADIOGRAPHIC FINDINGS OF A SYMPTOMATIC TARLOV CYST IN A PATIENT PRESENTING WITH BILATERAL LOWER EXTREMITY RADICULOPATHY
Hisham Kassem, MD1; Ivan Urits, MD2; Omar Viswanath, MD3; Alan D Kaye, MD, PhD4; Jonathan P Eskander, MD5; 1Mount Sinai Medical Center, Department of Anesthesiology, Miami Beach, FL; 2Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA; 3Valley Anesthesiology and Pain Consultants, Phoenix, AZ; 4Louisiana State University Health Sciences Center, Department of Anesthesiology, New Orleans, LA; 5Portsmouth Anesthesia Associates, Anesthesiology and Pain Medicine, Portsmouth, VA
Tarlov cysts are rare perineural fluid-filled sacs most commonly found in the lower spine, at the junction of peripheral nerve roots and the respective dorsal root ganglia (1). These lesions can be found in approximately 5% of the general population, are often asymptomatic, and incidentally noted on radiographic imaging (1). As these cysts increase in size, they can compress the respective nerve root leading to patients presenting with pain or neurological deficits. While the exact cause is unknown, it is thought to be the result of cerebrospinal fluid (CSF) entering the nerve root sheath which can moreover be exacerbated by increases in hydrostatic pressure (1). Women are at a greater risk for developing this pathology as well as those patients with genetic disorders of connective tissue (2).
These images are of a 49-year-old patient who presented with a history of chronic intermittent bilateral lower extremity radicular symptoms radiating into the buttocks, down the posterior thighs and terminating at the calves. Magnetic resonance imaging (MRI) performed of the lumbar spine without contrast showed a 1.6 cm thin-walled, CSF intensity perineural cyst within the right lateral recess at the L5-S1 intervertebral level with effacement of the S1 nerve root (Figure 1A). Additionally, there were multiple similarly visualized perineural cysts at the S1-S2 level measuring up to 1.2 cm on the right and 1.3 cm on the left with effacement of the S2 nerve roots (Figure 1B,1C).
Though patients with Tarlov cysts frequently remain asymptomatic for extended periods, they may progressively develop symptoms. Various treatment modalities may be employed which include conservative therapy, minimally invasive, or open surgical intervention. The utilization of fluoroscopy guided percutaneous cyst aspiration with fibrin gel injection has been shown to provide complete or substantial long-term resolution of symptoms (3). While some patients who choose to undergo surgical intervention can show improvement, surgery is not widely recommended as the patients’ symptoms may not be relieved or in some instances worsened. In addition, the potential for complications remains higher with surgery, such as CSF leaks and the need for repeat intervention. Tarlov cysts have been thought to be a controversial incidental finding in the general population. Further large observational studies may elucidate the incidence of low back pain and lumbar radiculopathy in patients who present with Tarlov cysts on imaging.