European Spine Journal

, Volume 25, Issue 11, pp 3403–3410 | Cite as

Tarlov cysts: long-term follow-up after microsurgical inverted plication and sacroplasty

  • Ralf Weigel
  • Manolis Polemikos
  • Nesrin Uksul
  • Joachim K. KraussEmail author
Original Article



Surgical treatment of Tarlov cysts is still a matter of debate. Published literature thus far includes mainly small case series with retrospective evaluation and short-term follow-up. We present a novel microsurgical technique that combines the decompression of the nerve fibers with the prevention of recurrence. The long-term follow-up is provided.


The indication for surgery was incapacitating pain refractory to medical therapy for at least 6 months. The surgical technique consisted in microsurgical opening of the cyst, relief of CSF followed by secured inverted plication of the cyst wall, packing of remnant space with fat graft, and sacroplasty. Pain and neurological deficits were evaluated according to a modified Barrow National Institute score (BNI score, 0–5) and the Departmental Neuro Score (DNS score, 0–20).


A total of 13 patients (9 women, 4 men) were operated and followed up to 14 years (mean FU 5.3 years). Mean age at surgery was 51.8 (±14) years. Pain and neurological deficits improved significantly in 11/13 patients (BNI score pre-OP 5 vs 3.1 ± 1.2 at 1-year-FU, and 2.8 ± 1.2 at last follow-up visit; DNS score pre-OP 5.5 ± 1.5 vs 2.8 ± 2.1 at 1-year follow-up, and 2.6 ± 2.2 at last follow-up visit. Two patients needed revision surgery due to reoccurrence of the cyst. One patient suffered deterioration of preexisting neurological deficit.


The inverted plication technique combined with sacroplasty is a promising technique. It improves pain and neurological deficits on the long term in the majority of patients with symptomatic Tarlov cysts.


Tarlov cyst Perineural cyst Microsurgical treatment Pain Outcome 


Compliance with ethical standards

Conflict of interest


Funding statement

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


  1. 1.
    Tarlov IM (1938) Perineural cysts of the spinal nerve roots. Arch Neurol Psychiatry 40:1067–1074CrossRefGoogle Scholar
  2. 2.
    Lucantoni C, Than KD, Wang AC, Valdivia-Valdivia JM, Maher CO, La Marca F, Park P (2011) Tarlov cysts: a controversial lesion of the sacral spine. Neurosurg Focus 31:E14. doi: 10.3171/2011.9.focus11221 CrossRefPubMedGoogle Scholar
  3. 3.
    Marino D, Carluccio MA, Di Donato I, Sicurelli F, Chini E, Mammarella LDT, Rossi F, Rubegni A, Federico A (2013) Tarlov cysts: clinical evaluation of an italian cohort of patients. Neurol Sci Off J Ital Neurol Soc Ital Soc Clin Neurophysiol. doi: 10.1007/s10072-013-1321-0 Google Scholar
  4. 4.
    Tarlov IM (1970) Spinal perineurial and meningeal cysts. J Neurol Neurosurg Psychiatry 33:833–843CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Tarlov IM (1948) Cysts, perineurial, of the sacral roots; another cause, removable, of sciatic pain. JAMA 138:740–744CrossRefGoogle Scholar
  6. 6.
    Araki Y, Tsukaguchi I, Ishida T, Ootani M, Yamamoto T, Tomoda K, Mitomo M (1992) MRI of symptomatic sacral perineural cyst. Radiat Med 10:250–252PubMedGoogle Scholar
  7. 7.
    Plewes JL, Jacobson I (1970) Sciatica caused by sacral-nerve-root cysts. Lancet 2:799–802CrossRefPubMedGoogle Scholar
  8. 8.
    Zhang T, Li Z, Gong W, Sun B, Liu S, Zhang K, Yin D, Xu P, Jia T (2007) Percutaneous fibrin glue therapy for meningeal cysts of the sacral spine with or without aspiration of the cerebrospinal fluid. J Neurosurg Spine 7:145–150. doi: 10.3171/spi-07/08/145 CrossRefPubMedGoogle Scholar
  9. 9.
    Nabors MW, Pait TG, Byrd EB, Karim NO, Davis DO, Kobrine AI, Rizzoli HV (1988) Updated assessment and current classification of spinal meningeal cysts. J Neurosurg 68:366–377. doi: 10.3171/jns.1988.68.3.0366 CrossRefPubMedGoogle Scholar
  10. 10.
    McCrum C, Williams B (1982) Spinal extradural arachnoid pouches. Report of two cases. J Neurosurg 57:849–852. doi: 10.3171/jns.1982.57.6.0849 CrossRefPubMedGoogle Scholar
  11. 11.
    Paulsen RD, Call GA, Murtagh FR (1994) Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts). AJNR Am J Neuroradiol 15:293–297PubMedGoogle Scholar
  12. 12.
    Langdown AJ, Grundy JR, Birch NC (2005) The clinical relevance of Tarlov cysts. J Spinal Disord Tech 18:29–33CrossRefPubMedGoogle Scholar
  13. 13.
    Singh PK, Singh VK, Azam A, Gupta S (2009) Tarlov cyst and infertility. J Spinal Cord Med 32:191–197CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Murphy K, Oaklander AL, Elias G, Kathuria S, Long DM (2016) Treatment of 213 patients with symptomatic Tarlov cysts by CT-guided percutaneous injection of fibrin sealant. AJNR Am J Neuroradiol 37:373–379. doi: 10.3174/ajnr.A4517 CrossRefPubMedGoogle Scholar
  15. 15.
    Cantore G, Bistazzoni S, Esposito V, Tola S, Lenzi J, Passacantilli E, Innocenzi G (2012) Sacral Tarlov cyst: surgical treatment by clipping. World Neurosurg. doi: 10.1016/j.wneu.2012.06.015 Google Scholar
  16. 16.
    Mummaneni PV, Pitts LH, McCormack BM, Corroo JM, Weinstein PR (2000) Microsurgical treatment of symptomatic sacral Tarlov cysts. Neurosurgery 47:74–78PubMedGoogle Scholar
  17. 17.
    Sun JJ, Wang ZY, Teo M, Li ZD, Wu HB, Yen RY, Zheng M, Chang Q, Yisha Liu I (2013) Comparative outcomes of the two types of sacral extradural spinal meningeal cysts using different operation methods: a prospective clinical study. PLoS One 8:e83964. doi: 10.1371/journal.pone.0083964 CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Voyadzis JM, Bhargava P, Henderson FC (2001) Tarlov cysts: a study of ten cases with review of the literature. J Neurosurg 95:25–32PubMedGoogle Scholar
  19. 19.
    Sonntag VK (2016) Flap the cyst. World Neurosurg 87:659–660. doi: 10.1016/j.wneu.2015.10.047 CrossRefPubMedGoogle Scholar
  20. 20.
    Burke JF, Thawani JP, Berger I, Nayak NR, Stephen JH, Farkas T, Aschyan HJ, Pierce J, Kanchwala S, Long DM, Welch WC (2016) Microsurgical treatment of sacral perineural (Tarlov) cysts: case series and review of the literature. J Neurosurg Spine 24:700–707. doi: 10.3171/2015.9.spine153 CrossRefPubMedGoogle Scholar
  21. 21.
    Caspar W, Papavero L, Nabhan A, Loew C, Ahlhelm F (2003) Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases. Surg Neurol 59:101–105CrossRefPubMedGoogle Scholar
  22. 22.
    Freidenstein J, Aldrete JA, Ness T (2012) Minimally invasive interventional therapy for Tarlov cysts causing symptoms of interstitial cystitis. Pain Phys 15:141–146Google Scholar
  23. 23.
    Guest JD, Silbert L, Casas CE (2005) Use of percutaneous endoscopy to place syringopleural or cystoperitoneal cerebrospinal fluid shunts: technical note. J Neurosurg Spine 2:498–504. doi: 10.3171/spi.2005.2.4.0498 CrossRefPubMedGoogle Scholar
  24. 24.
    Guo D, Shu K, Chen R, Ke C, Zhu Y, Lei T (2007) Microsurgical treatment of symptomatic sacral perineurial cysts. Neurosurgery 60:1059–1065. doi: 10.1227/01.neu.0000255457.12978.78 (discussion 1065–1056) CrossRefPubMedGoogle Scholar
  25. 25.
    Neulen A, Kantelhardt SR, Pilgram-Pastor SM, Metz I, Rohde V, Giese A (2011) Microsurgical fenestration of perineural cysts to the thecal sac at the level of the distal dural sleeve. Acta Neurochir (Wien) 153:1427–1434. doi: 10.1007/s00701-011-1043-0 (discussion 1434) CrossRefGoogle Scholar
  26. 26.
    Tanaka M, Nakahara S, Ito Y, Nakanishi K, Sugimoto Y, Ikuma H, Ozaki T (2006) Surgical results of sacral perineural (Tarlov) cysts. Acta Med Okayama 60:65–70PubMedGoogle Scholar
  27. 27.
    Xu J, Sun Y, Huang X, Luan W (2012) Management of symptomatic sacral perineural cysts. PLoS One 7:e39958. doi: 10.1371/journal.pone.0039958 CrossRefPubMedPubMedCentralGoogle Scholar
  28. 28.
    Lee JY, Impekoven P, Stenzel W, Lohr M, Ernestus RI, Klug N (2004) CT-guided percutaneous aspiration of Tarlov cyst as a useful diagnostic procedure prior to operative intervention. Acta Neurochir (Wien) 146:667–670. doi: 10.1007/s00701-004-0274-8 CrossRefGoogle Scholar
  29. 29.
    Murphy K, Wyse G, Schnupp S, Gailloud P, Woodworth GF, Sciubba DM, Oka M, Sasson AD, Long D (2008) Two-needle technique for the treatment of symptomatic Tarlov cysts. J Vasc Interv Radiol JVIR 19:771–773. doi: 10.1016/j.jvir.2008.02.001 CrossRefPubMedGoogle Scholar
  30. 30.
    Patel MR, Louie W, Rachlin J (1997) Percutaneous fibrin glue therapy of meningeal cysts of the sacral spine. AJR Am J Roentgenol 168:367–370. doi: 10.2214/ajr.168.2.9016209 CrossRefPubMedGoogle Scholar
  31. 31.
    Hayashi K, Nagano J, Hattori S (2014) Adhesive arachnoiditis after percutaneous fibrin glue treatment of a sacral meningeal cyst. J Neurosurg Spine 20:763–766. doi: 10.3171/2014.2.spine13763 CrossRefPubMedGoogle Scholar
  32. 32.
    Rogers CL, Shetter AG, Fiedler JA, Smith KA, Han PP, Speiser BL (2000) Gamma knife radiosurgery for trigeminal neuralgia: the initial experience of The Barrow Neurological Institute. Int J Radiat Oncol Biol Phys 47:1013–1019CrossRefPubMedGoogle Scholar
  33. 33.
    Mezzadri J, Abbati SG, Jalon P (2014) Tarlov cysts: endoscope-assisted obliteration of the communication with the spinal subarachnoid space. J Neurol Surg A Cent Eur Neurosurg 75:462–466. doi: 10.1055/s-0033-1361836 CrossRefPubMedGoogle Scholar
  34. 34.
    Naderi S (2016) Surgical approaches in symptomatic Tarlov cysts. World Neurosurg 86:20–21. doi: 10.1016/j.wneu.2015.10.044 CrossRefPubMedGoogle Scholar
  35. 35.
    Seo DH, Yoon KW, Lee SK, Kim YJ (2014) Microsurgical excision of symptomatic sacral perineurial cyst with sacral recapping laminectomy: a case report in technical aspects. J Korean Neurosurg Soc 55:110–113. doi: 10.3340/jkns.2014.55.2.110 CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Smith ZA, Li Z, Raphael D, Khoo LT (2011) Sacral laminoplasty and cystic fenestration in the treatment of symptomatic sacral perineural (Tarlov) cysts: technical case report. Surg Neurol Int 2:129. doi: 10.4103/2152-7806.85469 CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Takemori T, Kakutani K, Maeno K, Akisue T, Kurosaka M, Nishida K (2014) Symptomatic perineural cyst: report of two cases treated with cyst-subarachnoid shunts. Eur Spine J 23(Suppl 2):267–270. doi: 10.1007/s00586-014-3259-1 CrossRefPubMedGoogle Scholar
  38. 38.
    Bartels RH, van Overbeeke JJ (1997) Lumbar cerebrospinal fluid drainage for symptomatic sacral nerve root cysts: an adjuvant diagnostic procedure and/or alternative treatment? Technical case report. Neurosurgery 40:861–864CrossRefPubMedGoogle Scholar
  39. 39.
    Nadler SF, Bartoli LM, Stitik TP, Chen B (2001) Tarlov cyst as a rare cause of S1 radiculopathy: a case report. Arch Phys Med Rehabil 82:689–690. doi: 10.1053/apmr.2001.22353 CrossRefPubMedGoogle Scholar
  40. 40.
    Murphy KJ, Nussbaum DA, Schnupp S, Long D (2011) Tarlov cysts: an overlooked clinical problem. Semin Musculoskelet Radiol 15:163–167. doi: 10.1055/s-0031-1275599 CrossRefPubMedGoogle Scholar
  41. 41.
    Peh WC, Evans NS (1992) Tarlov cysts—another cause of sacral insufficiency fractures? Clin Radiol 46:329–330CrossRefPubMedGoogle Scholar
  42. 42.
    Yucesoy K, Naderi S, Ozer H, Arda MN (1999) Surgical treatment of sacral perineural cysts. A case report. Kobe J Med Sci 45:245–250PubMedGoogle Scholar
  43. 43.
    Stewart DH Jr, Red DE (1971) Spinal arachnoid diverticula. J Neurosurg 35:65–70. doi: 10.3171/jns.1971.35.1.0065 CrossRefPubMedGoogle Scholar
  44. 44.
    Wilkins RH (1996) Intraspinal cysts. In: Wilkins RH, Rengachary SS (eds) Neurosurgery. McGraw-Hill, New York, pp 2061–2070Google Scholar
  45. 45.
    Elsawaf A, Awad TE, Fesal SS (2016) Surgical excision of symptomatic sacral perineurial Tarlov cyst: case series and review of the literature. Eur Spine J. doi: 10.1007/s00586-016-4584-3 PubMedGoogle Scholar
  46. 46.
    Acosta FL Jr, Quinones-Hinojosa A, Schmidt MH, Weinstein PR (2003) Diagnosis and management of sacral Tarlov cysts. Case report and review of the literature. Neurosurg Focus 15:E15CrossRefPubMedGoogle Scholar
  47. 47.
    Potts MB, McGrath MH, Chin CT, Garcia RM, Weinstein PR (2016) Microsurgical fenestration and paraspinal muscle pedicle flaps for the treatment of symptomatic sacral Tarlov cysts. World Neurosurg 86:233–242. doi: 10.1016/j.wneu.2015.09.055 CrossRefPubMedGoogle Scholar
  48. 48.
    Tan CF, Wong HF, Ng KK, Wai YY, Wan YL (2001) The fate of epidural autologous free fat grafts; longitudinal MRI surveillance. Transpl Proc 33:631–632CrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Ralf Weigel
    • 1
    • 2
  • Manolis Polemikos
    • 1
  • Nesrin Uksul
    • 1
  • Joachim K. Krauss
    • 1
    Email author
  1. 1.Department of NeurosurgeryMedical School HannoverHannoverGermany
  2. 2.Neurosurgical DepartmentSt. Katharinen HospitalFrankfurt Am MainGermany

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