Management of Spinal Arachnoid and Perineural Cysts

Spinal arachnoid and perineural (Tarlov) cysts comprise cerebrospinal fluid-filled lesions that arise within or adjacent to the dural and nerve root sheaths of the spinal canal. Although often incidental findings on routine magnetic resonance imaging, a subset of cysts produce radicular pain, sensory disturbance, motor weakness or autonomic dysfunction. Management spans watchful waiting for asymptomatic lesions, image-guided percutaneous interventions and definitive surgery. Percutaneous options include cyst aspiration and fibrin sealant injection guided by computed tomography or fluoroscopy. Surgical techniques focus on cyst fenestration, dural repair to eliminate check-valve mechanisms, root sheath reconstruction and minimally invasive approaches such as epiduroscopic laser decompression. Decision-making integrates symptom severity, cyst anatomy and patient comorbidity, with multidisciplinary input from neurosurgery, neuroradiology and pain specialists. Global experience underscores the importance of algorithmic selection of candidates for intervention to optimise long-term relief and minimise complications.

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Management of Spinal Arachnoid and Perineural Cysts publication trend

The graph below shows the total number of articles in management of spinal arachnoid and perineural cysts across all publications each year (not limited to Nature Index journals).

Technical terms

Arachnoid cyst: A cerebrospinal fluid-filled sac formed within the arachnoid membrane, often intradural and capable of compressing neural elements.

Perineural (Tarlov) cyst: A cystic dilatation between the perineurium and endoneurium at the dorsal root ganglion, typically in the sacral canal.

Cyst fenestration: Surgical creation of an opening in the cyst wall to allow continuous drainage into the subarachnoid space or epidural compartment.

Check-valve mechanism: A unidirectional flow phenomenon whereby cerebrospinal fluid enters a cyst through a dural defect but cannot return, leading to progressive enlargement.

Epiduroscopic neural laser decompression: A percutaneous technique using a flexible endoscope and Holmium:YAG laser to decompress nerve-compressing cysts under direct vision.

Fibrin sealant injection: Percutaneous instillation of a biocompatible glue into a cyst cavity to obliterate the lumen and promote wall adhesion.

References

1. Treatment of 213 Patients with Symptomatic Tarlov Cysts by CT-Guided Percutaneous Injection of Fibrin Sealant. American Journal of Neuroradiology (2015).
2. Percutaneous Fibrin Gel Injection under C-Arm Fluoroscopy Guidance: A New Minimally Invasive Choice for Symptomatic Sacral Perineural Cysts. PLOS ONE (2015).
3. Diagnosis and surgical strategy for sacral meningeal cysts with check-valve mechanism: technical note. Acta Neurochirurgica (2012).
4. Reconstruction of nerve root sheaths for sacral extradural spinal meningeal cysts with spinal nerve root fibers. Science China Life Sciences (2013).
5. A novel technique for managing symptomatic spinal cysts using epiduroscopic neural laser decompression: technical note and preliminary results. Journal of Orthopaedic Surgery and Research (2018).
6. Management of Tarlov cysts: an uncommon but potentially serious spinal column disease—review of the literature and experience with over 1000 referrals. Neuroradiology (2023).
7. Management of perineural (Tarlov) cysts: a population-based cohort study and algorithm for the selection of surgical candidates. Acta Neurochirurgica (2019).
8. Utilizing real-time contrast medium to detect the fistula of giant spinal arachnoid cyst and treat with minimal invasive surgery. BMC Surgery (2019).