Sacral Tarlov Cysts: Diagnosis and Treatment

Sacral Tarlov Cysts: Diagnosis and Treatment
By Wise Young, Ph.D., M.D.
W. M. Keck Center for Collaborative Neuroscience
Rutgers, State University of New Jersey, Piscataway, NJ 08854-8082
13 December 2008

Someone recently asked for an explanation of Tarlov cysts, what they are, how they are diagnosed, and the best way to treat them. I will describe below the criteria for diagnosis, the prevalence of the cysts, the symptoms, and recommended treatments.

What are Tarlov Cysts?

Tarlov cysts are fluid-filled cysts associated with sacral nerve roots, at the junction of the nerve root and root ganglion. First described by Tarlov [1] in 1938, when he was at the Montreal Institute of Neurology, he was careful to call these cysts perineural and to distinguish them from meningeal cysts, which would be extensions of subarachnoid space.

Computerized tomographic (CT) myelography where dye is injected into the cerebrospinal fluid (CSF) showed that Tarlov cysts are true meningeal cysts that communicate with spinal subarachnoid space [2, 3]. To demonstrate communication of Tarlov cysts with subarachnoid space, CT scans should be obtained 30-60 minutes after injection of subarachnoid dye.

In 1988, Nabors et al. [4] classified Tarlov cysts as a kind of extradural meningeal cyst.  A Tarlov perineural cyst differs from other meningeal cysts in that there are spinal root axons within the cyst walls or the cavity of the cyst. The cysts may surround the nerve or extend into the nerve. For this reason, simple excision of the Tarlov cysts will damage the spinal root.

Prevalence and Symptoms

In his original 1938 communication, Tarlov had found these cysts in 5 of 30 cadavers (17%). In 1994, Paulsen, et al. [5] found 23 patients with perineural cysts out of 500 sequential lumbosacral magnetic resonance scans (4.6%). In 2005, Langdown, et al. [6] in Australia reported that 54 patients out of 3535 MRI scans (1.5%) obtained for lumbosacral symptoms had Tarlov cysts.

Most Tarlov cysts are asymptomatic. Tarlov initially thought that the cysts are innocuous. However, in 1948, he [7] reported a case of sciatica associated with a sacral perineural cyst. Paulsen, et al. [5] found that five of 23 patients with the cysts were symptomatic (22%) and that CT-guided cyst puncture reduced pain. In the Langdown study [6], 7 of 54 patients (13%) had symptoms due to the cyst.

Symptoms are variable, ranging from radicular pain [8] and paresthesia to urinary and bowel dysfunction [9, 10], cauda equina syndrome [11], and even abdominal pain [12], depending on the level of sacral roots involved. Pain is the most common presentation.


Most surgeons agree that asymptomatic Tarlov cysts should not be treated [13] and that symptomatic cysts should be treated. Several treatment options are available:

Lumbar drainage. Bartels & Overbeeke [14] reported that lumbar CSF drainage relieved pain in 2 of 3 patients with symptomatic Tarlov cysts. Subsequently, they did a lumbar-peritoneal shunt in one patient to relieve the pressure. This suggests that CSF pressure contributes to the size of Tarlov cysts and that they are true meningeal cysts.

CT-guided percutaneous decompression. Paulsen, et al. [5] did percutaneous CT-guided decompression of the cysts, reporting rapid reduction in symptoms and relief of pain but the symptoms returned in 3 weeks to 6 months. Patel, et al. [15] used CT-guidance decompression but injected fibrin glue after the decompression, finding no recurrence over 23 months.

Decompressive laminectomy. Siqueira, et al. [16] did decompressive laminectomies in two patients. Sa & Sa [17] treated four cases with a sacral laminectomy, reporting resolution of the pain. However, the pain often recurred. Tanaka, et al. [18] treated 12 consecutive patients with laminectomies and imbrications of the sacral cysts.

Laminectomy and cyst resection. Voyadzis, et al. [9] operated on 10 patients, carrying out sacral laminectomies and resections of the cysts. Seven of 10 patients had complete resolution of their pain but 3 (30%) showed no benefit. These three all had cysts smaller than 1.5 cm in diameter. Histology revealed nerve fibers in 75% of the cases, ganglion cells in 25%, and evidence of old hemorrhage in half.

Laminectomy, partial cyst excision, duroplasty or plication of the cyst walls. Total cyst resection is unnecessary [19]. Caspar, et al. [20] excised the cysts with duroplasty or plication of cyst wall in 15 patients with no complications and relief of pain in 13 (87%).

Laminectomy, fenestration of cyst wall, partial resectio, and myofascial flap. Acosta, et al. [13] stimulated the cyst wall to find motor axons, resected parts did not have nerves, and then used a muscle flap to close the cyst. Guo, et al. [21] used a similar approach to resect the cyst wall, imbricated the remaining sheath, and repaired the defect with muscle and Gelfoam.

Summary and Conclusions

Tarlov cysts are fluid-filled meningeal cysts on spinal roots.  Although present in 1-5% of the population, only 10% to 20% of cysts are symptomatic, manifesting as sciatica or other radicular pains, bowel and bladder problems, and other complaints. Lumbar CSF drainage and percutaneous CT-guided drainage of the cysts will relieve the symptoms temporarily. Injecting fibrin glue postpones recurrence. Resection of the cyst resolves the pain but histology revealed nerve fibers and sensory ganglion in the cyst walls. Laminectomy, fenestration and partial resection with careful neurophysiological testing to avoid motor fibers, and closure with a muscle flap is the preferred approach.


1. Tarlov I (1938). Perineural cysts of the spinal nerve roots. Arch Neurol Psychiatry. 40: 1067-1074.

2. Goyal RN, Russell NA, Belanger JM, Benoit BG and Rawa M (1987). Metrizamide CT scanning in spinal nerve root cysts. Can J Neurol Sci. 14: 149-52.

3. Goyal RN, Russell NA, Benoit BG and Belanger JM (1987). Intraspinal cysts: a classification and literature review. Spine. 12: 209-13.

4. Nabors MW, Pait TG, Byrd EB, Karim NO, Davis DO, Kobrine AI and Rizzoli HV (1988). Updated assessment and current classification of spinal meningeal cysts. J Neurosurg. 68: 366-77.

5. Paulsen RD, Call GA and Murtagh FR (1994). Prevalence and percutaneous drainage of cysts of the sacral nerve root sheath (Tarlov cysts). AJNR Am J Neuroradiol. 15: 293-7; discussion 298-9.

6. Langdown AJ, Grundy JR and Birch NC (2005). The clinical relevance of Tarlov cysts. J Spinal Disord Tech. 18: 29-33.

7. Tarlov IM (1948). Cysts, perineurial, of the sacral roots; another cause, removable, of sciatic pain. J Am Med Assoc. 138: 740-4.

8. Chaiyabud P and Suwanpratheep K (2006). Symptomatic Tarlov cyst: report and review. J Med Assoc Thai. 89: 1047-50.

9. Voyadzis JM, Bhargava P and Henderson FC (2001). Tarlov cysts: a study of 10 cases with review of the literature. J Neurosurg. 95: 25-32.

10. Kumpers P, Wiesemann E, Becker H, Haubitz B, Dengler R and Zermann DH (2006). [Sacral nerve root cysts–a rare cause of bladder dysfunction. Case report and review of the literature]. Aktuelle Urol. 37: 372-5.

11. Nicpon KW, Lasek W and Chyczewska A (2002). [Cauda equina syndrome caused by Tarlov’s cysts–case report]. Neurol Neurochir Pol. 36: 181-9.

12. Slipman CW, Bhat AL, Bhagia SM, Issac Z, Gilchrist RV and Lenrow DA (2003). Abdominal pain secondary to a sacral perineural cyst. Spine J. 3: 317-20.

13. Acosta FL, Jr., Quinones-Hinojosa A, Schmidt MH and Weinstein PR (2003). Diagnosis and management of sacral Tarlov cysts. Case report and review of the literature. Neurosurg Focus. 15: E15.

14. Bartels RH and 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: 861-4; discussion 864-5.

15. Patel MR, Louie W and Rachlin J (1997). Percutaneous fibrin glue therapy of meningeal cysts of the sacral spine. AJR Am J Roentgenol. 168: 367-70.

16. Siqueira EB, Schaffer L, Kranzler LI and Gan J (1984). CT characteristics of sacral perineural cysts. Report of two cases. J Neurosurg. 61: 596-8.

17. Sa MC and Sa RC (2004). [Tarlov cysts: report of four cases]. Arq Neuropsiquiatr. 62: 689-94.

18. Tanaka M, Nakahara S, Ito Y, Nakanishi K, Sugimoto Y, Ikuma H and Ozaki T (2006). Surgical results of sacral perineural (Tarlov) cysts. Acta Med Okayama. 60: 65-70.

19. Yucesoy K, Naderi S, Ozer H and Arda MN (1999). Surgical treatment of sacral perineural cysts. A case report. Kobe J Med Sci. 45: 245-50.

20. Caspar W, Papavero L, Nabhan A, Loew C and Ahlhelm F (2003). Microsurgical excision of symptomatic sacral perineurial cysts: a study of 15 cases. Surg Neurol. 59: 101-5; discussion 105-6.

21. Guo D, Shu K, Chen R, Ke C, Zhu Y and Lei T (2007). Microsurgical treatment of symptomatic sacral perineurial cysts. Neurosurgery. 60: 1059-65; discussion 1065-6.

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7 Responses to “Sacral Tarlov Cysts: Diagnosis and Treatment”

  1. Thomas Says:

    Thank you for this excellent review!

    Thomas S

  2. Doenene Says:

    I have been experiencing moderate to severe lower back pain for 4-5 months. I have on and off loss of feeling in my left ring and pinky finger, pain down my left leg and tingling in my left foot. I went to Physical therapy, primary care, and chiropractor. The Chiropractor thought I probably had a herniated diska and finally he ordered an MRI – the MRI showed I did have 2 bulging and one protruding disk – but also revealed Perineural sheath cysts on my sacrum. Could this be the main source of pain?

  3. Tess Mathis Says:

    Hello there,

    Well, I was diagnosed with multiple tarlov cysts last February. Looked for a neurosurgeon that works on these cysts. Long story – so I will save you from the details, other than to say that the so-called neurosurgeon in my area has not responded to me regarding my latest CT Scan or any thing else. Below are the results of the latest CT Scan and Myelogram along with the notes from the MRI I had last February.

    I’ve received so much information and he refuses to contact me. He also noted back in August that I may have Von Hippels disease after I waited for two hours pass my appointment time and quickly needed to leave because of responsbilities to my children. I had 5 minutes left with him, the doctor before he – stated they thought I had neurofibromatosis – what a disaster this is and not knowing or understanding reports is absolutely frustrating.

    I have a CT Scan and Myelogram and have not a clue what it means, I am really frustrated with this neurosurgeon, he said he would call me two months ago and answer any questions I had because he had been so late and is quite far from my home. Nothing – nothing at all.

    Meanwhile I would really appreciate someone helping me understand the results of the last tests:

    Omnipague myelogram lumbar

    The thecal sac is patulous. Images were obtained in the semierect position with the attempt at filling the Tarlov cysts. There is cystic dilatation to the L5, S1 and S2 nerve root sheaths, but the Tarlov Cysts are not filled with contrast on the routine images. There is no evidence for central spinal stenosis or thecal sac distortion. Minimal anterior extradural impression on the thecal sac is present at L3-L4, L4-L5, L5-S1 by annular bulging.
    There is a patulous thecal sac with minimal cystic dilatation to the L5, S1 and S2 nerve roots.

    See additionally dictacted Lumbar spine CT Report.

    CT Lumbar Spine PostMyelogram

    Findings: Verebral body alignment and height are normal

    L5-S1 – There is minimal cystic dilatation of the promixal L5, S1 and S2 nerve root sheaths. The right Tarlov Cyst contains a faint amount of contrast. A faint amount of contrast is also present in the S4 Tarlov Cyst bilaterally image 122 with the Hounsfield numbers in the dependent part of the cyst measuring a mean between 30 and 50 compared with a mean of -1 in the more nondependent portion of the cysts.

    MRI Evalulation of the Lumbar Spine

    Findings: At the L5-S1 disc space, there is no disk herniation or significant bulge of the annulus. There is evidence of a 1.2 cm right L5 perineural cyst seen in the lumbar sacral plexus.

    At the remainder of the lumbar disck spaces, there are no focal herniations with only a 2 mm bulge in the L4-L5 annulus being present. There is no spinal stenosis. A quite capacious spinal canal is present.The conus medullaris is normally positioned. There is no intrathecal mass. Multiple nerve root diverticula or Tarlov cysts are present arising from the left S3 nerve root a 1.9 cm cyst, at the S4 level on the right and on the left 2.4 cm. There is no compression fracture derformity of the lumbar vertebrae.

    1. Multiple root sleeve diverticula arising from the S3 and S4 nerve roots as described above.
    2. At the L5-S1 disk space there is no disc herniation or significant buldge of the annulus. There is evidence of a 1.2 cm right L5 perineural cyst seen in the lumbosacral plexus.

    DOCTORS Summary August 09 (still hasn’t called as of today)

    part of

    Her MRI demonstrates a very large cyst at her scarl area at S3, S4 area with significant remodeling of her sacral bone and lamina, thereare also evidence of multiple cysts seen at the root sleeves in multiple levels present. There is evidence that there is compression on the sacral thecal sac from the large one as described above.

    EMG – Also noted – Compressed nerve L5

    I am hopeful that someone can help me understand what in the world this all is. I have spent weeks trying to figure out what a hounsfield unit in a perineural cyst related to me or if it means it is some other kind of tumor. Also, I can see that the bulging seems to have increased between my February MRI and September CT Scan –

  4. Jean McCann Says:

    I have just been diagnosed by an exellent neurosurgeon, Dr. Wayne
    Villanueva. I have a sacral Turlov Cyst. I can feel the cyst when I
    sit (unless I sit forward). I have pain going now both legs now. I’ve
    read the mateial I could get off the internet. Dr. Villanueva said he
    has never done this type of surgery and we need to find someone who
    has. I had one such surgery in 2003 performed by a Dr. Marsutti who
    has since left the country. Dr. Villanueva knows no one in Louisville,
    Kentucky who performs this surgery. He said I may have to travel to
    get this surgery performed. My questions to you are as follows:
    1. Where and who performs this surgery?
    2. Immediate risks to my body. I’m 71, but am very active with bowling
    golf. Tried to play golf the other day but was very painful.
    3. What’s the percentage of successful surgery with no residual side
    side affects? Help! please if you can!

  5. Jean McCann Says:

    I have just been diagnosed with “sacral Turlov Cyst”. The neurosurgeon that diagnosed me, Dr. Wayne Villanueva, informed me
    he had never performed such surgery and didn’t know of anyone in
    Louisville, Kentucky who has. I did have a like surgery in 2003. Dr.
    Villanueva said we may have to leave the state to have this surgery.
    I have pain sitting (unless I sit up). I have pain going down both legs.
    I am 71! I’m very active. I play golf, I bowl, but now the pain has kept
    me from doing either of these things. I have had an MRI!
    1. Do you know of who, or,where they do this surgery?
    2. What’s the success percentage?
    3. What are the residual side effects, if any?
    4. What is the recovery time?

  6. Kirty Says:

    Thank you! Very informative.

  7. bersihwajah Says:

    thank you
    I still learn more about cysts and the best treatment for that.
    🙂 ..

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