. 2023 Oct 13;66(1):1–30. doi: 10.1007/s00234-023-03226-6

Table 3.

Treatment outcomes for cyst aspiration and fibrin sealant injection of symptomatic Tarlov cysts

Author, year, country	Study cohort, investigations	Treatment outcomes	Complications, failures
Patel [97] 1997 United States	• Consecutive series 4 patients (3 women, 1 man) with MRI documented sacral cysts, age range 40 to 62 years • Symptomatic for years with severe low back pain (n = 3), back pain and urinary incontinence and urgency (n = 1), severe perineal pain with urinary difficulty (n = 1) • All underwent initial cyst aspiration later followed by fibrin sealant injection on first recurrence	• Treatment successful in all cases within days of the procedure	• No symptom recurrence in follow-up from 7 to 23 months • Presumed cases of aseptic meningitis occurred with low-grade fever, headache, nausea, vomiting, meningismus (neck stiffness) and a lumbar puncture with negative cultures (n = 3)
Hiers [44] 2010 United States	• 130-patient consecutive cohort, retrospective review • Symptomatic Tarlov cysts treated between 2005 and 2010 • Cysts NR • Outcomes assessed by third-party review coupled with medical record reviews	• Treatment success of 75% based on several criteria: improving signs and symptoms, not wanting further treatment, and willingness to undergo another procedure if needed	• Initial 25% failure rate, a 5% failure rate occurred over time and patients not improving within 3 months; did not improve later • No post-operative infections or nerve injuries • Complications (n = 3, 3.8%) • Cutaneous allergic reaction (n = 1) • Substantial worsening of pain lasting 2 weeks then subsiding (n = 4)
Murphy [46] 2011 United States	• 122-patient cohort (102 women, 20 men), mean and median age 54 years • 100 patients treated between April 2004 and November 2007 for symptomatic MRI confirmed Tarlov cysts, 6 were not candidates for aspiration and refused surgery • The majority experienced lower back and buttock pain and sacral dermatome radicular symptoms with pain and burning in the perineal region, buttocks and lower extremities with 9 patients reporting bowel dysfunction • 34% presented with confounding conditions	• Improvement in symptoms (65%) and marked/total improvement (19%) • Those ineligible for cyst aspiration underwent surgical repair (n = 28), 63% improved symptoms	• No postprocedural fevers, or aseptic meningitis • Complication (n = 8, 6.6%) • Transient postprocedural sciatica (n = 6), rectal fullness (n = 1) •Postoperative urticarial resolving during overnight admission and discharged the following morning in good health (n = 1)
Jiang [96] 2015 China	• 42-patient cohort (22 women, 20 men) mean age 34.3 years (range, 22–56 years); mean disease duration, 20.8 months; range, 7–59 months • Treated between June 2009 and August 2012 for symptomatic MRI confirmed sacral Tarlov cysts, evaluated in mean 24-month follow-up • Majority (n = 31) had a solitary cyst located at L5-S1 (n = 5), S1-S2 (n = 21), and S2-S3 (n = 17) • Outcomes assessed pain index (VAS), functional improvement and imaging findings	• ⁺Recovery was rated as excellent (59.5%), good (26.2%), fair recovery (7.1%) and poor recovery (7.1%)— overall excellent/good recovery rating (85.7%) • Post-operatively the majority (85%) of patients had either no pain (n = 25) or mild (n = 11) pain as VAS scores (1–3) • During MRI imaging follow-up, cysts either disappeared (n = 25) or significantly decreased in size (n = 14) and did not increase in follow-up— 3 cysts no change in size during the follow-up	• Failure rate (fair or poor recovery) 14.2% • No symptom or cyst recurrences • No postoperative infection, nerve damage, meningitis or CSF leaks • Sanguineous fluid was aspirated during the procedure (n = 6) but no adverse effects noted • Complications (n = 7, 16.7%) • Headache, low-grade fever, nausea or vomiting without neck stiffness (n = 7) resolving with 2 day treatment of 20% mannitol 250 ml and dexamethasone 10 mg and one day of prophylactic antibiotics in addition to an average of 3 days (range, 2–4 days) of bed rest
Murphy [74] 2016 United States	• 213-patient cohort with symptomatic MRI-confirmed Tarlov cysts (n = 289) • Treated between 2003 and 2012 with 90.1% followed for 1 year and 83.1% followed for between 3 and 6 years • Single nerve roots unilaterally (n = 113), single roots bilaterally (n = 78) and more than two roots bilaterally (n = 22) • Cyst locations at S2 (n = 142) and S3 (n = 120) sacral levels, with cyst size (2 to 4 cm) • Outcomes included pain and function assessed by Lumbar Spine Outcomes Questionnaire	• ⁺⁺Treatment overall outcomes were rated as excellent (54.2%) or good/satisfactory (27.6%) and 81% were satisfied at one year with treatment outcomes • Improvements rated as excellent or good for individual presenting symptoms: local pain (75.7%), sciatica/neuropathy (74.8%), perineal pain/sensory loss (74.9%), bladder/sexual function (73.9%), bowel dysfunction (72.6%), plantar flexion weakness (73.6%) or paralysis (0%), dorsiflexion paralysis (0%), and rectal sphincter reduction (73.8%)	• Treatment failures (18.2%) • Symptom recurrence (16.9%) • No documented infections, nerve injuries or aseptic meningitis • Complications (n = 44, 20.7%) • Mild nonspecific allergic reaction with systemic hives leading to overnight hospitalization resolving without incident (n = 1) • Elevated inflammation resolving without treatment (n = 3) • Spinal fluid leak requiring a blood patch for control (n = 7) • Increased sciatica post-operatively resolving within 3 months (n = 20) and increased sciatica persisting for 3 months eventually resolving (n = 1) • Severely increased local pain (n = 7) resolving (n = 6) within 3 months • Increase in symptoms, including bowel and bladder dysfunction, immediately following injection, transient and resolving within 3 months (n = 3)
Jiang [95] 2017 China	• 82-patient cohort (49 women, 33 men) mean age 45.2 years (range 19–74 years), mean symptom duration 35.4 months (range, 6– 360 months) • Treated between June 2003 and August 2015 for symptomatic MRI-confirmed Tarlov cysts • Three treatment approaches over time: aspiration and fibrin sealant injection performed after 2009 (n = 56), open surgery performed before 2009 (n = 14) involving sacral laminectomy microsurgical partial cyst wall fenestration and imbrication followed by 2-day lumbar drainage, and those refusing surgical management were treated with conservative involving physical therapy, anti-inflammatory and neurotropic drugs (n = 12) • Cyst locations at L5-S1 (n = 21), S1-S2 (n = 46), S2-S3 (n = 17) • Outcomes included pain VAS scores, symptom and neurological deficit resolution	Aspiration and fibrin sealant injection after 2009 (n = 56) • Significant reductions in baseline mean pain NRS scores with low postoperative mean pain NRS scores 1.3 ± 1.1 • All symptoms and neurological deficits had been either completely or substantially resolved immediately after operation or during follow-up visits • MRI examinations in most patients showed that the cysts disappeared or decreased in size during follow-up visits	• No postoperative infections, nerve damage, or CSF leaks • No recurrences occurred • Complications (n = 7, 8.5%) • Low-grade fever, nausea, and vomiting without neck stiffness (n = 7) resolving after effective treatments: 20% mannitol 250 mL and dexamethasone 10 mg for 2 days, prophylactic antibiotics for one day, and an average of 3 days bed rest
Open surgery performed before 2009 (n = 14) • Significant reductions in baseline mean pain NRS scores with low postoperative mean pain NRS scores 3.4 ± 2.5 • All symptoms and neurological deficits had been either completely or substantially resolved immediately after operation or during follow-up visits	• MRI-confirmed cyst recurrence (n = 3) with symptom recurrence (n = 3), one received a second operation with no symptom improvement and two others refused a second surgery for unknown reasons • Complications (n = 3, 21.4%) • CSF leakage (n = 3), all undergoing an artificial dural patch in a second operation and postoperative lumbar drainage for about one week
Conservative management (n = 12) • Baseline mean pain VAS scores remained unchanged at follow-up, 5.8 ± 2.1 to 6.1 ± 2.2 • Symptoms were aggravated over time in 9 patients • Three patients achieved substantial relief of preoperative symptoms and neurological deficits	• Treatment failure (75%) • Cysts persisted with MRI follow-up

Author, year, country

Study cohort, investigations

Treatment outcomes

Complications, failures

Patel [97]

1997 United States

• Consecutive series 4 patients (3 women, 1 man) with MRI documented sacral cysts, age range 40 to 62 years

• Symptomatic for years with severe low back pain (n = 3), back pain and urinary incontinence and urgency (n = 1), severe perineal pain with urinary difficulty (n = 1)

• All underwent initial cyst aspiration later followed by fibrin sealant injection on first recurrence

• Treatment successful in all cases within days of the procedure

• No symptom recurrence in follow-up from 7 to 23 months

• Presumed cases of aseptic meningitis occurred with low-grade fever, headache, nausea, vomiting, meningismus (neck stiffness) and a lumbar puncture with negative cultures (n = 3)

Hiers [44]

2010

United States

• 130-patient consecutive cohort, retrospective review

• Symptomatic Tarlov cysts treated between 2005 and 2010

• Cysts NR

• Outcomes assessed by third-party review coupled with medical record reviews

• Treatment success of 75% based on several criteria: improving signs and symptoms, not wanting further treatment, and willingness to undergo another procedure if needed

• Initial 25% failure rate, a 5% failure rate occurred over time and patients not improving within 3 months; did not improve later

• No post-operative infections or nerve injuries

• Complications (n = 3, 3.8%)

• Cutaneous allergic reaction (n = 1)

• Substantial worsening of pain lasting 2 weeks then subsiding (n = 4)

Murphy [46]

2011

United States

• 122-patient cohort (102 women, 20 men), mean and median age 54 years

• 100 patients treated between April 2004 and November 2007 for symptomatic MRI confirmed Tarlov cysts, 6 were not candidates for aspiration and refused surgery

• The majority experienced lower back and buttock pain and sacral dermatome radicular symptoms with pain and burning in the perineal region, buttocks and lower extremities with 9 patients reporting bowel dysfunction

• 34% presented with confounding conditions

• Improvement in symptoms (65%) and marked/total improvement (19%)

• Those ineligible for cyst aspiration underwent surgical repair (n = 28), 63% improved symptoms

• No postprocedural fevers, or aseptic meningitis

• Complication (n = 8, 6.6%)

• Transient postprocedural sciatica (n = 6), rectal fullness (n = 1)

•Postoperative urticarial resolving during overnight admission and discharged the following morning in good health (n = 1)

Jiang [96]

2015

China

• 42-patient cohort (22 women, 20 men) mean age 34.3 years (range, 22–56 years); mean disease duration, 20.8 months; range, 7–59 months

• Treated between June 2009 and August 2012 for symptomatic MRI confirmed sacral Tarlov cysts, evaluated in mean 24-month follow-up

• Majority (n = 31) had a solitary cyst located at L5-S1 (n = 5), S1-S2 (n = 21), and S2-S3 (n = 17)

• Outcomes assessed pain index (VAS), functional improvement and imaging findings

• ⁺Recovery was rated as excellent (59.5%), good (26.2%), fair recovery (7.1%) and poor recovery (7.1%)— overall excellent/good recovery rating (85.7%)

• Post-operatively the majority (85%) of patients had either no pain (n = 25) or mild (n = 11) pain as VAS scores (1–3)

• During MRI imaging follow-up, cysts either disappeared (n = 25) or significantly decreased in size (n = 14) and did not increase in follow-up— 3 cysts no change in size during the follow-up

• Failure rate (fair or poor recovery) 14.2%

• No symptom or cyst recurrences

• No postoperative infection, nerve damage, meningitis or CSF leaks

• Sanguineous fluid was aspirated during the procedure (n = 6) but no adverse effects noted

• Complications (n = 7, 16.7%)

• Headache, low-grade fever, nausea or vomiting without neck stiffness (n = 7) resolving with 2 day treatment of 20% mannitol 250 ml and dexamethasone 10 mg and one day of prophylactic antibiotics in addition to an average of 3 days (range, 2–4 days) of bed rest

Murphy [74]

2016

United States

• 213-patient cohort with symptomatic MRI-confirmed Tarlov cysts (n = 289)

• Treated between 2003 and 2012 with 90.1% followed for 1 year and 83.1% followed for between 3 and 6 years

• Single nerve roots unilaterally (n = 113), single roots bilaterally (n = 78) and more than two roots bilaterally (n = 22)

• Cyst locations at S2 (n = 142) and S3 (n = 120) sacral levels, with cyst size (2 to 4 cm)

• Outcomes included pain and function assessed by Lumbar Spine Outcomes Questionnaire

• ⁺⁺Treatment overall outcomes were rated as excellent (54.2%) or good/satisfactory (27.6%) and 81% were satisfied at one year with treatment outcomes

• Improvements rated as excellent or good for individual presenting symptoms: local pain (75.7%), sciatica/neuropathy (74.8%), perineal pain/sensory loss (74.9%), bladder/sexual function (73.9%), bowel dysfunction (72.6%), plantar flexion weakness (73.6%) or paralysis (0%), dorsiflexion paralysis (0%), and rectal sphincter reduction (73.8%)

• Treatment failures (18.2%)

• Symptom recurrence (16.9%)

• No documented infections, nerve injuries or aseptic meningitis

• Complications (n = 44, 20.7%)

• Mild nonspecific allergic reaction with systemic hives leading to overnight hospitalization resolving without incident (n = 1)

• Elevated inflammation resolving without treatment (n = 3)

• Spinal fluid leak requiring a blood patch for control (n = 7)

• Increased sciatica post-operatively resolving within 3 months (n = 20) and increased sciatica persisting for 3 months eventually resolving (n = 1)

• Severely increased local pain (n = 7) resolving (n = 6) within 3 months

• Increase in symptoms, including bowel and bladder dysfunction, immediately following injection, transient and resolving within 3 months (n = 3)

Jiang [95]

2017

China

• 82-patient cohort (49 women, 33 men) mean age 45.2 years (range 19–74 years), mean symptom duration 35.4 months (range, 6– 360 months)

• Treated between June 2003 and August 2015 for symptomatic MRI-confirmed Tarlov cysts

• Three treatment approaches over time: aspiration and fibrin sealant injection performed after 2009 (n = 56), open surgery performed before 2009 (n = 14) involving sacral laminectomy microsurgical partial cyst wall fenestration and imbrication followed by 2-day lumbar drainage, and those refusing surgical management were treated with conservative involving physical therapy, anti-inflammatory and neurotropic drugs (n = 12)

• Cyst locations at L5-S1 (n = 21), S1-S2 (n = 46), S2-S3 (n = 17)

• Outcomes included pain VAS scores, symptom and neurological deficit resolution

Aspiration and fibrin sealant injection after 2009 (n = 56)

• Significant reductions in baseline mean pain NRS scores with low postoperative mean pain NRS scores 1.3 ± 1.1

• All symptoms and neurological deficits had been either completely or substantially resolved immediately after operation or during follow-up visits

• MRI examinations in most patients showed that the cysts disappeared or decreased in size during follow-up visits

• No postoperative infections, nerve damage, or CSF leaks

• No recurrences occurred

• Complications (n = 7, 8.5%)

• Low-grade fever, nausea, and vomiting without neck stiffness (n = 7) resolving after effective treatments: 20% mannitol 250 mL and dexamethasone 10 mg for 2 days, prophylactic antibiotics for one day, and an average of 3 days bed rest

Open surgery performed before 2009 (n = 14)

• Significant reductions in baseline mean pain NRS scores with low postoperative mean pain NRS scores 3.4 ± 2.5

• All symptoms and neurological deficits had been either completely or substantially resolved immediately after operation or during follow-up visits

• MRI-confirmed cyst recurrence (n = 3) with symptom recurrence (n = 3), one received a second operation with no symptom improvement and two others refused a second surgery for unknown reasons

• Complications (n = 3, 21.4%)

• CSF leakage (n = 3), all undergoing an artificial dural patch in a second operation and postoperative lumbar drainage for about one week

Conservative management (n = 12)

• Baseline mean pain VAS scores remained unchanged at follow-up, 5.8 ± 2.1 to 6.1 ± 2.2

• Symptoms were aggravated over time in 9 patients

• Three patients achieved substantial relief of preoperative symptoms and neurological deficits

• Treatment failure (75%)

• Cysts persisted with MRI follow-up

NR not reported

⁺Jiang et al. treatment recovery categories: excellent (returning to regular employment without any signs or symptoms), good (partial resolution of symptoms that did not interfere with return to work), fair (no improvement in pain or function but shrinkage of cyst), and poor recovery (no improvement in symptoms or cyst shrinkage)

⁺⁺Murphy et al. treatment success categories: excellent outcome (complete pain relief, discontinuation of all pain medications, improvement or stabilization of cyst related neurological signs and symptoms, not requiring further treatment, satisfaction with results, and willingness to undergo another procedure if required, good/satisfactory outcome (pain improved on the Lumbar Spine Outcomes Questionnaire scale, discontinuation of narcotic analgesics, neurologic deficits commensurate with adequate function or no further progression, satisfied with treatment results, and not seeking further treatment. Treatment failures included all outcomes other than excellent or good/satisfactory even if some improvement was noted