Image-Guided Intervention for Symptomatic Tarlov Cysts



Image-Guided Intervention for Symptomatic Tarlov Cysts


Juan Carlos Baez, Gerald M. Wyse and Kieran P.J. Murphy


Symptomatic Tarlov cysts cause chronic pelvic and lower extremity pain. These cysts may be large and can expand the spinal canal or cause erosion of overlying bone. Patel et al. describe a single-needle approach to Tarlov cysts in which they inject fibrin adhesive to treat the cyst.1 This is a three-stage procedure: (1) cyst entry and aspiration, (2) injection of myelographic contrast material to ensure that a wide neck is not present, and (3) injection of tissue adhesive. Many of our initial patients were treated by this standard technique and experienced considerable pain that required significant sedation with fentanyl and midazolam. We believe this pain was caused by a flux in pressure in the cystic cavity during aspiration of the injected substances.


On reflection, it became apparent a two-needle technique was necessary. This method requires access with one needle placed superficially in the cyst and the other at the deepest point of the cyst. The superficial needle is placed to allow venting of any pressure or volume change within the system, and the deeper needle is used as the working lumen. Although the patient’s pain once limited the volume we could aspirate or inject into a Tarlov cyst, we can now drain and fill it completely with minimal patient discomfort.


We have also been able to eliminate the need for myelographic contrast material. If the cyst is wide necked and communicates with the cerebrospinal fluid (CSF) space, it refills after drainage, and we do not inject tissue adhesive. This has allowed us to aspirate large (3- to 6-mL) Tarlov cysts, usually at the S2-S3 level, in a virtually pain-free fashion under computed tomography (CT) fluoroscopic guidance.



Indications


Patients with Tarlov cysts are complex to manage and have innumerable complaints. In our experience, narrow-necked Tarlov cysts may be symptomatic, whereas wide-necked Tarlov cysts are not. They can be differentiated by their T2 signal on magnetic resonance imaging (MRI). Wide-necked cysts have the same signal as the general CSF space around the cord, but narrow-necked cysts have higher signal than the adjacent CSF space. In 1993, Davis et al. published evidence of signal change within symptomatic cysts.2 Their paper demonstrated that in 19 patients with 24 cysts, narrow-necked cysts were consistently more symptomatic than wide-necked cysts. The only patients we have treated with our CT-guided technique (now > 90 patients in the last 2 years) have been symptomatic with narrow-necked cysts. We have also treated patients with symptomatic wide-necked lesions who had previously undergone surgical repair and subsequently developed persistent CSF leaks.


It is not simple political correctness to state that careful patient selection, a multidisciplinary approach, and long-term follow-up and management are necessary in these patients. It is absolutely essential that scientific rigor be applied to this treatment paradigm. All patients are reviewed by both a professor of neurosurgery with an extensive career in spine pathology, and an associate professor of interventional neuroradiology. Patients are categorized into three types:



We switched to the two-needle technique when it became clear the pressure flux in the wall of the cyst induced severe pain in our patients. The two-needle technique not only markedly reduced patient discomfort and requirements for conscious sedation during the procedure, it also increased the amount of fibrin glue we could inject. We are conducting an ongoing study of this technique at our institution with institutional review board approval, and we will be publishing the results in future papers. The two-needle approach to aspiration and injection of any hollow viscus or joint space should be considered, whether it be a Tarlov cyst, a gallbladder, an abscess, an intracranial ventricle, or an arthrogram.




Dec 23, 2015 | Posted by in INTERVENTIONAL RADIOLOGY | Comments Off on Image-Guided Intervention for Symptomatic Tarlov Cysts
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