This literature review sought to consolidate and discuss the diagnostic workup of symptomatic Tarlov cysts, as well as compare the risks, benefits and reported patient outcomes of various approaches to treatment: conservative management, minimally-invasive percutaneous procedures (MIPPs) and surgical intervention.

Tarlov cysts, also known as perineural cysts, have been reported in 1.5% to 4.6% of patients receiving an MRI for lumbosacral symptoms [Chia]. However, a recent study suggests they may be more prevalent than thought, with an incidence of up to 13.2% [Kuhn].

The cysts are benign, but can present with symptoms including abdominal, perineal, and sacro-coccygeal pain, as well as bowel/bladder dysfunction, dyspareunia and cauda equina syndrome. Additional clinical findings may include reflex changes and motor loss.

The relevance of Tarlov cysts may be under-appreciated, and it is necessary to reconsider their role in spinal and lower extremity symptoms.

Searches of PubMed were performed in December 2018 and September 2019, with 97 papers originally identified for inclusion. After reviewing each paper for the criteria detailed below, 64 remained.

Papers included were those in English and involving case reports/retrospective studies of management modalities and treatment outcomes for patients with symptomatic Tarlov (perineural) cysts.

MRI was a consistently-used imaging modality across nearly all studies. Surgery, including cyst fenestration and excision, offered the most favorable results (75-80% rate of symptom resolution across 43 papers). MIPPs demonstrated an average 50-60% rate of complete symptom resolution, per results from 18 papers. Nearly all patients undergoing such procedures reported some degree of relief. Conservative therapy had the lowest rate of symptom resolution.

Surgery appears to offer the most reliably favorable outcomes. MIPPs likewise offered a favorable prognosis, although not as uniformly successful. Conservative therapy was the least reliable approach to treatment, although certain conservative modalities may offer value to patients who are not surgical candidates.