Medical Policy

Policy Num:      07.001.181
Policy Name:    Treatment of Tarlov Cyst
Policy ID:          [07.001.181]  [Ac / B / M- / P-]  [7.01.76]

Last Review:      March 13, 2026
Next Review:      March 15, 2027

Publication Date:  April, 2026

Related Policies: None

Treatment of Tarlov Cyst

Summary

Description

Tarlov cysts (TC; perineural cyst, sacral perineural cyst, sacral meningeal cyst) are characterized as cerebrospinal fluid (CSF)-filled sacs that typically occur between the perineurium (the protective sheath that surrounds a bundle of nerve fibers) and endoneurium (a layer of connective tissue around the myelin sheath of a peripheral nerve), arising near the dorsal root ganglion but can be located anywhere along the spine and affect the nerve roots. TC are often asymptomatic; however, these cysts can present as chronic back pain in the sacral or coccyx area and individuals may have radiculopathy, leg weakness, bowel or bladder dysfunction, and/or sexual dysfunction. There is no specific, accepted therapy for individuals with symptomatic TC. Treatment is directed toward the specific symptoms and may include medication, surgery, or other techniques.

Summary of Evidence

For individuals with Tarlov cyst(s) (TC; perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive surgical interventions, the evidence includes nonrandomized cohort studies and a handful of case series. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No randomized controlled trials (RCTs) have been conducted to corroborate the effectiveness of these treatments. The evidence suggests that surgery interventions for symptomatic TC may be an effective option for partially or completely relieving symptoms. Data suggests that symptomatic TC treated with surgical interventions tend to have better long-term efficacy and success in terms of cyst resolution (no difference in recurrence of symptoms) than TC treated with percutaneous techniques; however, surgical interventions aree associated with higher postprocedural complication rates. The effectiveness of surgery has not been compared in a prospective, head-to-head fashion with other treatment options; thus, well-designed comparative studies are needed to determine the most effective treatment. There is no evidence on which types of surgery are more effective and no evidence on when surgery is indicated. In future studies, the quality of life for patients with TC should be addressed and the results of surgery interventions should be compared with the natural course and long-term outcome of untreated cysts. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with TC (perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive percutaneous interventions, the evidence includes nonrandomized cohort studies and a handful of case series. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No RCTs have been conducted to corroborate the effectiveness of these treatments. The evidence suggests that percutaneous interventions for symptomatic TC may be an effective option for partially or completely relieving symptoms. Data suggests that symptomatic TC treated with surgical interventions tend to have better long-term efficacy and success in terms of cyst resolution (no difference in recurrence of symptoms) than TC treated with percutaneous techniques, however, surgical interventions were associated with higher postprocedural complication rates. The effectiveness of percutaneous interventions has not been compared in a prospective, head-to-head fashion with other treatment options; thus, well-designed comparative studies are needed to determine the most effective treatment. In future studies, the quality of life for patients with TC should be addressed and the results percutaneous interventions should be compared with the natural course and long-term outcome of untreated cysts. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with TC (perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive neuromodulation with a transcutaneous electrical nerve stimulator (TENS) and/or electroacupuncture, the evidence includes a limited number of case reports. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No RCTs have been conducted to corroborate the effectiveness of these treatments. Further study is needed to corroborate these preliminary results and to define the patient population that would benefit from this treatment approach. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information

Note: This policy does not address treatment of synovial cysts. Refer to the Related Policies listed above as applicable.

Objective

The objective of this evidence review is to determine whether surgical, percutaneous, and/or neuromodulation intervention in individuals diagnosed with symptomatic Tarlov cyst(s) (perineural cyst, sacral perineural cyst, sacral meningeal cyst) improve the net health outcome compared with conservative treatment.

Policy Statements

Treatment of Tarlov cysts (perineural cyst, sacral perineural cyst, sacral meningeal cyst) with surgical, percutaneous, and/or neuromodulation interventions is considered investigational.

Policy Guidelines

Management of Tarlov Cysts

No societal endorsements were found, but the following recommendations is provided for Plan Considerations. The focus of these recommendations is for the most common symptoms related to small-to-moderate sized cysts. No standard was found for categorizing cyst size; however, cysts over 2 cm might be considered large. There are other symptoms not included in these recommendations thought to be associated with Tarlov cysts (e.g., headache, abdominal pain) that might warrant earlier surgical intervention, and giant Tarlov cysts might prompt immediate surgical intervention.

The following key observations and recommendations are from Department of Medical Imaging, Toronto Western Hospital, University Health Network, based on their experience with over 1000 patient referrals and treatment experience with cyst aspiration-fibrin sealant injections of symptomatic Tarlov cysts and on a review of the literature:^1,

1. "Tarlov cysts are an uncommon finding, prevalence estimates have often been based on incidental radiographic findings and inconsistent reporting particularly from lumbar rather than dedicated sacral MRIs and likely contribute to an underestimation of the prevalence of this spinal disease.

2. There is extensive evidence that sacral Tarlov cysts are associated with a diverse range of pain and neurological symptoms. Workups of patients, particularly for women presenting initially with low back pain or coccygodynial pain, should include a careful history, neurological examination, and when appropriate electrodiagnostic testing or urodynamic studies to conduct more comprehensive multidisciplinary investigations.

3. Imaging investigations for Tarlov cysts should include a lumbar spine MRI and a sacral MRI with axial and sagittal planes of the entire sacrum and when identified radiologically should be reported in a differential diagnosis and in the appropriate clinical context, considered a potential pain generator and contributor to neurological symptoms.

4. A range of strategies can be employed to determine if sacral cysts are causative or contributing agents of symptoms: Tarlov disease specific quality-of-life questionnaires, patient-completed dermatome maps, and diagnostic tests including percutaneous anesthetic injection into the cyst or cyst fluid aspiration with a two-needle technique. Fluid aspiration can also assess whether rapid cyst refilling occurs indicating a wide-necked cyst, a contraindication to fibrin sealant injection.

5. Sacral Tarlov cysts can cause peripheral nerve fiber neuropathy through sacral nerve root stretching or compression, and electrodiagnostic tests can detect nerve conduction abnormalities and nerve fiber neuropathy, potentially responsible for a range of commonly reported Tarlov related pain, paresthesia and, bowel/bladder dysfunctions. Early intervention for nerve fiber neuropathy is preferred to ensure better neurological outcomes. As patients with Tarlov cysts have often reported experiencing symptoms for years, there is a concern that long-standing nerve damage may be unrecoverable.

6. Both percutaneous and open surgical approaches have resulted in high rates of rapid symptomatic relief, but percutaneous interventions have several advantages over open surgery. The cyst aspiration-fibrin injection is an uncomplicated technique performed as an outpatient procedure with rapid reductions in symptoms and recovery with no serious complications. In comparison, there is no consensus on the optimal surgical method, and surgeries are technically demanding. They also involve variable approaches with significantly higher complication rates, longer hospital stays, and recovery than percutaneous aspiration-fibrin sealant interventions."

Coding

See the Codes table for details.

Benefit Application

BlueCard/National Account Issues

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Tarlov Cysts

First identified in 1938, Tarlov cysts (TC) are fluid-filled sacs between the perineurium (the protective sheath that surrounds a bundle of nerve fibers) and endoneurium (a layer of connective tissue around the myelin sheath of a peripheral nerve), arising near the dorsal root ganglion, and affecting the nerve roots of the spine. While commonly found in the sacral region, they can occur anywhere along the spine. They may also be known as sacral perineural cysts, perineural cysts, or sacral, lumbar, thoracic, or cervical nerve root cysts. TC are an uncommon spinal column disease that has been associated with a wide range of debilitating pain, neurological disturbances, and dysfunctions with the condition being often overlooked or ignored as incidental findings of no clinical significance, particularly in the presence of other comorbid spinal pathologies. TC may be valved or non-valved and can be distinguished from other spinal lesions by the presence of spinal nerve root fibers within the cyst wall or in the cyst cavity itself. The exact cause of TC is unknown, but it is thought they are caused by inflammatory processes within the nerve root sheath or that trauma injures the nerve root sheath, causing leakage of cerebrospinal fluid (CSF) into the area where a cyst forms. Some researchers believe that an abnormal congenital connection (communication) exists between the subarachnoid space, which contains CSF, and the area surrounding the affected nerves (perineural region). The connection may remain or eventually close, after allowing cerebrospinal fluid to leak out and cause a cyst. As TC contain CSF, researchers have speculated that normal fluctuations in CSF pressure may lead to an increase in cyst size and a greater likelihood of developing symptoms. TC appear to be rare with women being at a higher risk of developing TC than men (7.01% vs. 4.05%). An estimated 4.27% of the global population has TC, while in the United States, it is estimated to be 3.82% of the population. Mostly asymptomatic, these cysts can present as chronic back pain in the sacral or coccyx area and individuals may have radiculopathy, leg weakness, bowel or bladder dysfunction, or sexual dysfunction. Furthermore, TC may cause neuropathic pain and may damage sensory and autonomic innervation of the penis/clitoris (via the dorsal nerve) and surrounding erogenous structures. TC is the leading cause of underrecognized pelvic syndrome known as persistent genital arousal disorder (i.e., PGAD).^2, Approximately 15.6% of the cysts are symptomatic.^3,4, Of note, inadequate knowledge due to the rarity of these cysts and gender bias by treating physicians has contributed to a significant delay or lack of treatment for individuals with TC.

Diagnosis

TC may be diagnosed through a detailed clinical history with identification of characteristic symptoms and a neurological examination. Diagnosis may be confirmed with either magnetic resonance imaging (MRI) or computed tomography (CT). A myelogram may also be used, with the dye allowing structures such as the nerve roots and spinal canal to be more clearly seen on x-ray. However, MRI without contrast is the preferred choice for image quality and patient safety. A comprehensive imaging panel consisting of a dedicated lumbar and sacral MRI is ideal as they are more sensitive imaging modalities than CT scans or routine lumbosacral MRIs.^5,6,7,1, Furthermore, the sacral MRI should be performed in both the axial and sagittal plane with an emphasis on the field of view, matrix, slice thickness, and positioning to anatomic localization. It is important to differentiate the neck of the TC as "narrow- or wide-necked" with a high flow of CSF, as communication with the subarachnoid space can increase risk with any interventions in the sacral area. More specifically, a wide-necked cyst or a large communication pore with the subarachnoid space is contraindicated for percutaneous fibrin sealant injections as there is an increased possibility of fibrin sealant migration into the subarachnoid space. TCs usually appear as low-intensity intraspinal masses on T1-weighted and high-intensity on T2-weighted images, like CSF. About 1.5% of MRIs performed for low-back-pain reveal TCs, but as with herniated discs, not all are symptomatic at the time of imaging with most radiologists determining that TCs are incidental and lack clinical significance, and omit mention of TCs in their reports, obscuring the diagnosis.^8, If MRI is inconclusive or fails to define this connectivity, CT myelography with delayed imaging is occasionally used to capture CSF filling from the spinal sac indicating a wide connection to subarachnoid space. CT is helpful to evaluate any bone erosion by the cysts, and axial and sagittal CT can assist with bone remodeling and plan interventions.

Once a cyst is identified with imaging modalities, it is paramount to distinguish from other similar conditions, such as dural ectasia, meningeal diverticula, or lipoma of the filum terminale and establish that the symptoms arise from the immediate anatomic region of the cyst and that radicular signs and symptoms are in the appropriate distribution of cyst-bearing nerve roots, with accurate dermatomal charting to ensure appropriate clinical management.^1, If symptoms are still deemed uncertain, it may be feasible to perform diagnostic assessments with local anesthetic blockades of the nerve root or by aspirating cyst fluid to identify whether and which TCs are causing debilitating pain or other symptoms. Urodynamic testing and anorectal manometry can provide objective evaluation of bladder and bowel function.^4,

Treatment

There is no specific accepted therapy for individuals with symptomatic TC. Treatment is directed toward the specific symptoms and may include conservative medical approaches including analgesic, anti-inflammatory, or neuropathic medications and physical therapy; minimally invasive image-guided percutaneous interventions; and/or various open and microsurgical approaches. More invasive interventions may be considered for symptomatic TC that are refractory to conservative treatment strategies. Asymptomatic TCs require no treatment, but rather cyst locations should be recorded and individuals educated on mitigating the risks of symptom onset, including lifestyle modifications.

Conservative

For chronic pain associated with TC, non-steroidal anti-inflammatory drugs (NSAIDs) may be prescribed to treat nerve irritation and inflammation and medication for neuropathic pain (e.g., tricyclics, gabapentinoids, sodium channel blockers) may also be useful. Systemic corticosteroids can have a short-term benefit, although local injections are not indicated and repeated use can further exacerbate the pathophysiology of the cyst by weaking the walls leading to safety concerns. In some cases, oral acetazolamide may be prescribed to control CSF-induced hydrostatic pressure from the cysts but remains theoretical as there is no way to routinely monitor CSF pressure within TCs. Limited observational studies have reported that conservative management with physical therapy, anti-inflammatory medications, and drugs directed at neuropathic pain, fail to improve symptoms in as many as 75% of symptomatic cases.^9,

Percutaneous

Minimally invasive percutaneous approaches to treating TCs involve aspirating or draining the CSF assisted with imaging modalities, such as CT or fluoroscopy, and are typically accompanied by an injection of fibrin gel. ^10,This non-surgical procedure uses a combination of substances that mimic blood clotting (i.e, fibrin glue) and after the cyst is drained, fibrin glue is used to seal or glue the cyst closed preventing it from filling with CSF again, however, results vary, and, in most cases, the cyst will eventually fill with CSF again, with symptoms returning within hours.^4,1, Several cohort studies have reported results on this percutaneous intervention with high rates of symptom improvement greater than 70% after aspiration-fibrin sealant injection, albeit with varying definitions of treatment success with follow-up MRIs depicting that the cysts had disappeared or were substantially smaller in size.^9,11, The largest cohort study (N=213) to date for any intervention performed for these cysts included a 5- to 10-year long-term follow-up where individuals underwent percutaneous cyst aspiration and fibrin-sealant injection for symptomatic sacral TCs and reported overall treatment success in 81.8% of patients at 1 year and 74% at 3 to 6 years.^7, Treatment failures ranged from 14% to 25% with minor adverse events such as nausea, vomiting, low-grade fevers, cutaneous allergic reactions, headaches, allergic reactions to fibrin sealant, transient sciatica, and CSF leaks. Recurrence is possible after fibrin sealant injection as the material can gradually break down over time allowing for cyst recurrence. In the aforementioned study, 36 individuals (~17%) experienced cyst recurrence.

Surgical

Large cysts may necessitate surgical intervention with the primary objective to relieve nerve compression and/or stimulation, stop bone erosion, and relieve symptoms. There is no consensus on the optimal surgical method for TCs, and there have been numerous evolving surgical techniques. Treatment considerations for these cases are complex and best treated on a case by-case basis depending on a variety of factors including the patient's health status, characteristics of the sacral cyst, and adverse impacts in the sacral region and elsewhere. Current techniques for treating symptomatic sacral TC involve sacral laminectomy or laminoplasty combined with cyst obliteration by fenestration, imbrication, resection, or cyst wrapping with dural graft material, and sometimes free or pedicled autologous tissue transposition to fill the void. One technique is to expose the region of the spine where the cyst is located by removal of the overlying vertebral bone. The cyst is then sliced open with one or more thin cuts (fenestrations) and drained of fluid. The cyst wall is collapsed, then reinforced and sutured closed or the cavity is filled with another substance such as fat or tissue adhesive to prevent it from refilling with CSF. In another procedure, following exposure and drainage of the cyst, a flap of nearby muscle tissue is used to fill the cyst to prevent refilling. Other surgical techniques may include decompressive laminectomy. Less common procedures include CSF shunting (lumboperitoneal, cystoperitoneal, or cyst to subcutaneous port shunting), epiduroscopy with laser fenestration, and endoscopic occlusion of cyst ostia; however, limited to no success has been demonstrated for these techniques.^4, The majority of the evidence for surgical intervention in TC come from cohort studies where high rates of treatment success have been reported with complete or partial symptom resolution in greater than 80 percent of patients. Of note, surgical interventions in the sacral region are both surgically and technically demanding leading to increased risk of ectasia and CSF leakage and may damage nerve roots within or near the cyst, and it is difficult to repair any anatomy. Other challenges include cyst recurrence, occurrence or progression of cysts on other untreated nerve roots, epineural scarring, and necrosis of the free tissue transfer grafts used to fill voids.^1, When pain is intractable, despite a variety of interventions, or when other neurological symptoms become severe (ie bowel and bladder dysfunction, severe paraesthesias,etc.), and the sacrum is eroding and remodeling, surgery may be the treatment of choice. There are a small number of physicians in the world who have surgical expertise in the treatment for TCs, and the short-term and long-term outcome of surgery is improving but variable in individual patients at this time. Surgical interventions are typically reserved for patients with more advanced disease (including multiple cysts or wide-neck communication with the subarachnoid space) or have failed percutaneous procedures, in whom remnants and scarring now contribute to symptoms and complicate later procedures.

Neuromodulation

A transcutaneous electrical nerve stimulator (TENS) and electroacupuncture are possible intervention modalities that may be used to relieve nerve pain, albeit little to no evidence for these treatments have been generated. TENS devices deliver electrical impulses through the skin to the cutaneous (surface) and afferent (deep) nerves to control pain. Unlike medications and topical ointments, TENS does not have any known side effects, other than skin irritation from the electrodes seen in some patients. For patients with moderately or severely disabling pain, tonic and high-frequency subthreshold spinal cord or nerve root stimulation and intrathecal drug delivery may be considered if surgery is not possible or has been ineffective.^12,8,

Regulatory Status

Treatment for Tarlov cysts is a surgical or percutaneous procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration (FDA). To date, the FDA has not approved any neuromodulation devices for the indication of Tarlov cysts.

Rationale

This evidence review was created in December 2025 with a search of the PubMed database. The most recent literature update was performed through December 31, 2025.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent one or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Population Reference No. 1 & 2

Treatment of Tarlov Cysts with Surgical and/or Percutaneous Interventions

Clinical Context and Therapy Purpose

The purpose of surgical and/or percutaneous interventions in patients who have Tarlov cyst(s) (TC) is to provide a treatment option that is an alternative to or an improvement on conservative management.

The following PICO was used to select literature to inform this review.

Populations

The relevant population(s) of interest are individuals with symptomatic TC.

Interventions

The therapies being considered are percutaneous, surgical, and microsurgical interventions.

Comparators

The following treatments are currently being used to treat individuals with TC: conservative treatment such as, analgesic, anti-inflammatory, or neuropathic medications and physical therapy.

Outcomes

The general outcomes of interest are symptoms, cyst recurrence, change in disease status, functional outcomes, treatment-related morbidity, and quality of life (see Table 1).

The natural history of TC is not well understood, however, it is known that cyst recurrence is a persistent complication of surgical and percutaneous interventions. Follow-up in the available literature for both surgical and percutaneous interventions varied from 2 to 8 years. There is limited literature available on surgical and percutaneous interventions to treat symptomatic TC; however, follow-up for these interventions should be a minimum of 12 months.

Table 1. Health Outcome Measures Relevant for Individuals with Tarlov Cysts

  BDI: Beck Depression Inventory; MCID: minimum clinically important difference; PT: physical therapy; SCI: spinal cord injuries; SCL90-R: symptom checklist-90-revised; SF-36: 36-item short-form survey; STAI: state-trait anxiety inventory; TC: Tarlov cyst. a Recently published (Feigenbaum et al 2025) and validated quality of life survey. 13,

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

• Consistent with a 'best available evidence approach,' within each category of study design, studies with larger sample sizes and longer durations were sought.

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

There are no randomized trials that use surgical or percutaneous interventions to treat TCs although systematic reviews of nonrandomized studies have shown that both surgical and percutaneous approaches have similarly high effectiveness in reducing TC-associated symptoms.

Systematic Reviews and Meta-analysis

All of the studies included in the systematic reviews and meta-analysis regarding the treatment of TC are prospective or retrospective cohort studies and case series (Table 2).

Kameda-Smith et al (2021) conducted a systematic analysis on 16 studies (N=238) of symptomatic TC treated either with surgery or conservative management.^14, The mean (standard deviation [SD]) and median quality of the methodology of the included studies was 9.1 (1.5) of 15 on the Methodological Index for Non-Randomized Studies score (range 6–11) indicating moderate bias. The post-operative complication rate in patients undergoing surgical intervention was 16.9% and cyst recurrence was 8.5% with infection of the surgical site and/or CSF leak reported as the most common complication. Pooled proportion of postoperative symptoms resolution demonstrated that sensory deficit was significantly reduced post-surgery (n=90; p=.001) as well as bowel/urinary dysfunction (n=179; p<.001). Of the 15 studies reporting long-term follow-up, 81.0% of patients remained symptom-free for more than 1 year. Notable limitations include, but are not limited to, inherent limitations of retrospective studies and case series being the only articles included in the analysis. Furthermore, all the studies reported patient reported ratings of their symptom improvement post-operatively and were heterogenous regarding nature of the patient population, the procedures performed, and the variability in clinical follow-up.

Sharma et al (2019) conducted a systematic comparative outcome analysis of symptomatic TC treated with surgery (32 studies, n=333) or percutaneous interventions (6 studies, n=417) analyzing the demographic characteristics, baseline characteristics of the cysts, clinical presentations, types of interventions, complication rates, and the recurrence rate in both treatment groups.^15, The mean follow-up duration for the surgical group was 38 ± 29 months, while that for the nonsurgical group was 15 ± 12 months (p<.0001). Overall, approximately 84% of patients reported improvement in symptoms in both groups; however, there was a statistically significant higher percentage of patients that had preprocedural symptoms in the percutaneous intervention group (10.1% vs 3.3%; p=.0003). The complication rates were comparable between the 2 treatment groups (surgical: 21% and percutaneous: 12.47%) with both groups reporting transient sciatica as the most common complication. The rates of sexual and bladder/bowel complications were higher in the surgical group than the percutaneous group (11% vs 0% and 12% vs 1%, respectively; p=.0007). Furthermore, cyst reoccurrence was significantly lower in the surgical group than the percutaneous group (8% vs 20%; p=.0018). Notable limitations include, but are not limited to, variability in the studies due to reporting bias of retrospective studies and institutional/operational protocols/procedure, heterogeneity in cyst sizes, clinical presentation and outcomes, no established imaging protocols for TC, patient-reported outcomes, and small sample sizes due to the rarity of TC.

Dowsett et al (2018) conducted a systematic review on 31 studies of 646 patients and performed a logistic regression analysis on patient-level data (n=49) to understand the association between the size of the TC and complete resolution of symptoms.^16, Among the 646 included participants, 210 experienced complete resolution of symptoms (32%), 327 had partial resolution (50%), 106 did not have any improvement or worsening of symptoms (16%), and 3 had their symptoms worsen after surgery (0.4%). The odds of part or complete resolution after surgery was higher for those with larger cysts (odds ratio [OR], 1.17) controlling for age and sex, but not statistically significant (p=.631). Notable limitations include, but are not limited to, variability in the studies due to reporting bias of retrospective studies and institutional/operational protocols/procedure, heterogeneity in cyst sizes, clinical presentation and outcomes, no established imaging protocols for TC, patient-reported outcomes, and small sample sizes due to the rarity of TC.

Table 2. Comparison of Studies Included in Systematic Review and Meta-analysis

Nonrandomized Cohort Studies and Case Series

All of the studies regarding the treatment of TC are prospective or retrospective cohort studies and case series that lack natural history comparisons with TC patients who are procedural candidates but do not receive intervention due to inability to access care or personal preference. The results were not sufficiently standardized to permit statistical comparisons, so the outcomes of each approach are discussed descriptively in Table 3. The primary outcome measures were inconsistent; most studies rated improvements as “complete” or “partial” resolution of symptoms with patient reported outcomes, with only a handful reporting the use of validated outcome measures such as visual analog scales for pain. Symptom recurrence was similar for the treatment groups, cyst recurrence was significantly higher for percutaneous aspiration-fibrin sealant interventions than surgery, but complication rates have been reported to be significantly higher after surgical intervention than percutaneous aspiration-fibrin sealant procedures.

Table 3. Summary of Key Results of Nonrandomized Cohort Studies on the Clinical Management of Tarlov Cysts

  BNI: Barrow National Institute score; CSF: cerebrospinal fluid; CT: computed tomography; DNS: Departmental Neuro Score; JOA: Japanese Orthopedic Association; LSOQ: Lumbar Spinal Outcome Questionnaire; M-JOA: modified Japanese Orthopedic Association; MRI: magnetic resonance imaging; NR: not reported; NRS: numerical rating score; ODI: Oswestry Disability Index; PGAD: Persistent Genital Arousal Disorder; SF-36: Short Form-36; TCQoL: Tarlov Cyst Quality-of-Life Outcome Scale; VAS: visual analog scale. a According to MacNab criteria: excellent and good outcomes equal 36.1%, including fair outcomes, the improvement percentage increases to 80.6%. b The reoperation rate was defined as reoperations due to complications. c The outcome was derived from BNI and DNS scores. Depending on the cut-off, satisfactory outcomes were between 29-54%. d 61.4% (N=417) of patients completed the 2-year follow-up.

Section Summary: Treatment of Tarlov Cysts with Surgical and/or Percutaneous Interventions

For individuals with Tarlov cyst(s) (perineural cyst, sacral perineural cyst, sacral meningeal cyst; [TC]) who receive surgical or percutaneous interventions, the evidence includes nonrandomized cohort studies and a handful of case series. No RCTs have been conducted to corroborate the effectiveness of these treatments. There is evidence supporting both minimally invasive percutaneous fibrin sealant procedures and open surgical interventions as an effective treatment of symptomatic Tarlov cysts. However, due to the rarity of these cysts, the evidence is largely based on small cohort studies. The evidence suggests that surgery or percutaneous interventions for symptomatic TC may be effective at partially or completely relieving symptoms related to TC. Most percutaneous studies tend to be shorter and are thought to have underestimated cyst re-expansion and symptom recurrence due to the lack of prospective randomized trials with fibrin glue injections losing favor worldwide due to its limited long-term effectiveness, causing cyst reopening and symptom recurrence. Notable limitations include referral bias and publication bias, all studies were uncontrolled (noting that placebo effects are high for procedures), with most of them being single-center studies. As these were cohort studies attempting to aggregate procedural outcomes the results were limited by interoperator and site differences in patients, procedures, and non-standardized outcome metrics. Additionally, the imaging data was limited by aggregating results from large series of people imaged for diverse clinical indications. Further study is needed to corroborate these results and to define the patient population that would benefit from these treatment approaches.

Summary of Evidence

For individuals with Tarlov cyst(s) (TC; perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive surgical interventions, the evidence includes nonrandomized cohort studies and a handful of case series. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No randomized controlled trials (RCTs) have been conducted to corroborate the effectiveness of these treatments. The evidence suggests that surgery interventions for symptomatic TC may be an effective option for partially or completely relieving symptoms. Data suggests that symptomatic TC treated with surgical interventions tend to have better long-term efficacy and success in terms of cyst resolution (no difference in recurrence of symptoms) than TC treated with percutaneous techniques; however, surgical interventions aree associated with higher postprocedural complication rates. The effectiveness of surgery has not been compared in a prospective, head-to-head fashion with other treatment options; thus, well-designed comparative studies are needed to determine the most effective treatment. There is no evidence on which types of surgery are more effective and no evidence on when surgery is indicated. In future studies, the quality of life for patients with TC should be addressed and the results of surgery interventions should be compared with the natural course and long-term outcome of untreated cysts. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with TC (perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive percutaneous interventions, the evidence includes nonrandomized cohort studies and a handful of case series. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No RCTs have been conducted to corroborate the effectiveness of these treatments. The evidence suggests that percutaneous interventions for symptomatic TC may be an effective option for partially or completely relieving symptoms. Data suggests that symptomatic TC treated with surgical interventions tend to have better long-term efficacy and success in terms of cyst resolution (no difference in recurrence of symptoms) than TC treated with percutaneous techniques, however, surgical interventions were associated with higher postprocedural complication rates. The effectiveness of percutaneous interventions has not been compared in a prospective, head-to-head fashion with other treatment options; thus, well-designed comparative studies are needed to determine the most effective treatment. In future studies, the quality of life for patients with TC should be addressed and the results percutaneous interventions should be compared with the natural course and long-term outcome of untreated cysts. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Population Reference No. 3 

Treatment of Tarlov Cysts with Neuromodulation

Clinical Context and Therapy Purpose

The purpose of neuromodulation in patients who have TC is to provide a treatment option that is an alternative to or an improvement to conservative management.

The following PICO was used to select literature to inform this review.

Populations

The relevant population(s) of interest are individuals with symptomatic TC.

Interventions

The therapies being considered are neuromodulation interventions with a transcutaneous electrical nerve stimulator (TENS) and/or electroacupuncture.

Comparators

The following treatments are currently being used to treat individuals with TC: conservative treatment such as, analgesic, anti-inflammatory, or neuropathic medications and physical therapy.

Outcomes

The general outcomes of interest are symptoms, cyst recurrence, change in disease status, functional outcomes, treatment-related morbidity, and quality of life (see Table 1).

The natural history of TC is not well understood, however, it is known that cyst recurrence is a persistent complication of surgical and percutaneous interventions. Follow-up in the available literature for both surgical and percutaneous interventions was 2 to 8 years. There is limited literature available on neuromodulation to treat symptomatic TC, however, follow-up for neuromodulation should be a minimum of 12 months.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies.

• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought.

• Consistent with a 'best available evidence approach,' within each category of study design, studies with larger sample sizes and longer durations were sought.

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

There are no randomized trials that use neuromodulation to treat TC although case studies have demonstrated that this approach may have effectiveness in reducing TC associated symptoms.^12,61,

Nonrandomized Case Series

Fernndez-Cuadros et al (2024) published a retrospective analysis on 5 individuals with TC with urinary and/or fecal incontinence plus chronic pelvic pain (CPP) and/or dyspareunia who were treated with multimodal rehabilitation (biofeedback + posterior tibial nerve stimulation + INDIBA® radiofrequency) and pharmacological treatment (Tiobec Dol® dietary supplement and/or acetazolamide) to evaluate the effect of this program on pain and pelvic floor muscle strength. ^62, The most common symptoms among these individuals were pain (80%) and incontinence (60%). Rehabilitation treatment consisted of a mean of 10.4 sessions of multimodal rehabilitation (biofeedback + posterior tibial nerve stimulation + radiofrequency combined with pharmacological treatment [Tiobec Dol® in 40% and/or acetazolamide in 60%]). Treatment with this regimen improved pelvic floor muscle contractions; however, it was not statistically significant. Pain was significantly reduced with VAS scores decreasing from 8 ± 1.26 points to 4.6 ± 2.65 points (p=.0343).

Section Summary: Treatment of Tarlov Cysts with Neuromodulation

For individuals with TC (perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive neuromodulation with TENS and/or electroacupuncture, the evidence includes a limited number of case series. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No RCTs have been conducted to corroborate the effectiveness of these treatments. Further study is needed to confirm these preliminary results and to define the patient population that would benefit from this treatment approach. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Summary of Evidence

For individuals with TC (perineural cyst, sacral perineural cyst, sacral meningeal cyst) who receive neuromodulation with a transcutaneous electrical nerve stimulator (TENS) and/or electroacupuncture, the evidence includes a limited number of case reports. Relevant outcomes are cyst recurrence, symptoms, change in disease status, functional outcomes, treatment-related morbidity, and quality of life. No RCTs have been conducted to corroborate the effectiveness of these treatments. Further study is needed to corroborate these preliminary results and to define the patient population that would benefit from this treatment approach. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Supplemental Information

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in 'Supplemental Information' if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

National Institute for Health and Care Excellence (NICE)

In 2007, NICE provided the following recommendation for treatment management of Tarlov cysts: "Current evidence on the safety and efficacy of therapeutic percutaneous image-guided aspiration of spinal cysts is very limited but is adequate to support the use of the procedure in the context of this rare condition, provided that normal arrangements are in place for clinical governance and audit." ^63,

U.S. Preventive Services Task Force Recommendations

Not applicable

Medicare National Coverage

There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

Ongoing and Unpublished Clinical Trials

Some currently unpublished trials that might influence this review are listed in Table 4.

Table 4. Summary of Key Trials

  NCT: national clinical trial.  

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Codes

Policy History