- Hello thank you for of Tarlov cysts their treatment and the underlying fundamental problem of back pain in women. Women get back pain for That might seem like a but in fact it's a
And many women get dismissed as nuts or erratic or unreliable or problematic by physicians because they present with back pain that on an MRI the cause isn't seen. But many women get extra-spinal sciatica
and the causes of that back pain not from a disk not from a It's because of something And in the female pelvis there are many things radicular pain sciatica in women
that will not be visualized So with that in mind it's important to change and broaden how we interpret the Over the last couple of years every Thursday and now
and I see five to seven women a week many of whom have been really mistreated by the medical system as being nuts. But over time when you spend the time to find out what's you find that they have
For example piriformis syndrome where the piriformis become asymmetrically enlarged or traps the sciatic nerve and causes sciatica from a problem occurring
in the posterior aspect of the hip joint. There's the phenomena in women with endometriosis from the deposition of endometriomas on L4/5 S1/2/3 causing cyclical change in the mass effect
and inflammation around that nerve root from the variation in endometrioma size during menses. And after menopause those and cause even further problems. There are issues with
and calcific tendonosis which occur much more commonly in women. Uterine fibroids ovarian hydrosalpinx adnexal masses can compress the pre-sacral or the iliolumbar plexus
or the sciatic nerve as it goes Now we tend not to think of this but these are visible abnormalities on the coronal and sagittal used to acquire and localize so don't blow those off.
Take a look at those something that requires further evaluation with a pelvic ultrasound for example. There's a phenomena involving the ganglion anterior to the sacrococcygeal junction
which is ill-defined but can cause pelvic and And finally there's the involving cystic dilatation that I'm going to spend the
The purpose of this talk is to tell you
about my 10 or 15 years of work on patients with Tarlov cysts. I stumbled into this area because I was referred with severe radiculopathy and sciatica from a sacral Tarlov cyst.
And I have to admit I didn't want to be But as with anything in medicine when there's something and something that's treated badly it is magnetically interesting
and requires further evaluation and you can make a difference. Anything that's done badly you can make a difference And so I've now seen over 400 patients with these abnormalities.
It was Tarlov who reported the dilations of sacral nerve root sleeves as a cause of sciatica in the 1920s. And he published this paper in a journal which stemmed from the
based on his work in 1931. And he published a large text on this. And he described very well and the compression of the nerve on that nerve root sleeve by the cystic dilatations of the
perineural environment. And he found these abnormalities in sacral dissections in cadavers.
Between 2003 and 2013 I was referred 456 patients and of these 410 or 89.9% were female.
10% were male. The age range was 13 to 79 Many of these patients had or kind of genetically of the distal dura which are very dysmorphic
of sacral malformation or dysgenesis. Some of these could be Four hundred and twenty-one were found to have perineural cysts which are what Tarlov described. We divided these into three groups.
Narrow-necked cysts on and these were treated by fibrin Wide-necked cysts on CT or MR which underwent surgical repair. And then a group that we could not define as narrow- or wide-necked
and these were treated in either group.
This is an example of a patient which is a Tarlov cyst and you can see erosion of with this fluid-filled cyst. When you think about the pressure needed for a CSF space to erode a vertebral body
and the duration over that's quite remarkable. Here we see the axial and you can see that the anterior aspect of the cortex overlying So this patient actually could have pain
from sacral mechanical insufficiency. And on the T2 axials you see mass effect on the So not only can this patient have pain from the dural distension and but they can also have mass effect
upon adjacent nerve roots which could cause them to Many of these patients come to me and they're unable to sit. And one of the common presenting problems is a woman unable to sit.
I go out into the waiting room or even sometimes lying on the floor because of the discomfort of sitting. Now naturally when a male physician goes out to the waiting room and finds a patient with
it triggers all their alarm bells about this patient being a lunatic. And of course an aversion reaction occurs and you don't want to or be near them and get But this is a fixable problem.
In this patient we have a in a patient who has On the left side we see On the right side we see some and some contrast entering You see expansion of the adjacent bone
and you see a ball-valve at the point of entry of the Now this patient has clearly what I would call meningeal diverticulum at the S1/2/3/4 level with chronic expansion
and spinal canal in the sacrum. And this is more of a Clearly chronically These are very difficult people to treat and I don't have a good Most of the patients I see
that grow slowly over years at a millimeter or less per year. And here we see a small cyst at S2 and we can see it on the axial images and you can see the measurements there. And then when I followed
there had been a subtle increase in size of three or four with an increase in bony erosion and now resorbtion of the lamina overlying the posterior And that erosion of the lamina
is my point of access into the cyst. You can see too that the signal on the is higher than the signal And this tells me that and the fluid in that cyst
and therefore is saturated as it were. Its protons are saturated and therefore higher in signal on T2 than the subarachnoid space which is pulsating with systole diastole and brain movement.
Some of these patients in other areas. And this person has a at the thoracolumbar junction. So I look on the images in a patient with perineural
or Tarlov cysts in the sacrum and the words are interchangeable for perineural cysts on the sagittal T2 images. And the more that there are the more likely in my mind
that they have an underlying So here we see this in the thoracic spine and clearly this could cause an intercostal nerve radiculopathy by compression of the exiting nerve root
which runs along that rib. This patient has presacral meningoceles. In other words expansion in the presacral space from with bony erosion. This would fall into a category
These are very difficult to treat. You can go trans-sacral you can go through the sciatic It is hard to make these people better. Sometimes these patients... This patient's name is clearly
We have to edit this slide okay? Sometimes these patients because a perineural and there will be a CSF And you see we see descent of the brain down into the foramen magnum
tonsillar herniation loss and evidence of intercranial hypotension from a CSF leak from a tear in a dural cyst and loss of CSF. Here again we see effacement
of the quadrigeminal plate cistern of the perimesencephalic cistern with brain descent from CSF leak. And the cause in this patient were these thoracal lumbar which are treated by
Sometimes sacral can cause intercranial I've seen this a couple of where the valsalva of pregnancy results in a rupture of the cyst. Now when you look at this
design of cysts in the sacrum it looks kind of like a This is clearly a patient with a congenital cause and these are expansile which are a component
for this person to have And these can be symptomatic but they're just not possible and the surgical outcomes are not good. This poor young woman and she has a deficiency
We see the bladder compressed we see the Foley catheter in the bladder and we see this huge presacral meningocele with a very wide neck and unfortunately there In the past some folks have done
retroperitoneal laparoscopic and fenestrated the cysts. But what happens is the patient gets the worst and intercranial hypotension We need some kind of
where we can use some kind of
the dehiscent anterior and rebuild the dura Of the patients treated surgically the results were tough. Some of them got post-operative leaks.
Some people were referred 34 patients in fact and they had a combination post-operative infections It wasn't an ideal outcome. A hundred and seventy-four of
We didn't feel that their symptoms were related to their Tarlov cysts and they declined treatment or they sought treatment elsewhere. It's very important to go to ensure that the cysts are symptomatic.
In the women I've seen from an inflammatory spondyloarthropathy. Some have had facet joint Some have had fibroids and have done well after hysterectomy. Some have had endometriosis
or complications of endometriosis surgery. And so we weed out these other causes before we treat the cyst. Of the 289 cysts that were 144 were unilateral 69 patients were bilateral
16 cysts were on S1 142 were on S2 120 were on S3. For some reason these cysts
Rarely are the cysts at S4 or S5. One patient had cysts involving L4 and L5.
The technique is simple. I use conscious sedation. An IV is placed 22-gauge IV. The patient gets IV fluids And they lie head-first on their tummy in the gantry of the CT scanner.
And I use strict sterile technique. I've developed a number of approaches. The single-needle technique. This can cause pain during the procedure. The double-needle technique where I put in two needles
I aspirate the fluid with the deep needle and air goes in through and the cyst decompresses easily that way. Sometimes if the lamina is very dense I will put a vertebroplasty and then an 18-gauge needle
and I get that two-needle Occasionally I've gone I prefer not to have to do that. This is an example of a classic two-needle Here we see an S2-level
with erosion of the lamina and this large cyst. So I put in two needles and you can pass them through the lamina just by twisting your fingertips and the needle descends
You can feel it give. One goes deep and one goes superficial. So you take the stylets out of both you aspirate the fluid and then air goes in through You develop an air-fluid level.
You aspirate some more fluid the air-fluid level gets bigger. And then you wait. You wait for four five minutes and see if there's refilling of the cyst. If there's a wide neck
you can't get an air-fluid level at all you're not going to inject fibrin because the fibrin will get in the subarachnoid space You would get a If you get an air-fluid level like this you wait four or five minutes. You see if it refills. If it doesn't refill and then you inject fibrin glue Baxter TISSEEL fibrin glue.
It's simple stuff to handle just make sure you and the mixing instructions before you try and use I inject about 80% of the I try not to fill the cyst
a lot of pain and inflammation afterwards. And really the objective of the fibrin is to block the ball valve to This person had a myelo CT. You can see on the myelogram non-filling of the Tarlov cyst.
On the CT you see there's some Here we see axial images and you can see down the right side there is laminar erosion with erosion of the posterior Here's an image from the CT fluoro
showing that thin lamina Here are images from the procedure where two needles have and you see the air-fluid
And after the achievement the injection of TISSEEL
filling about 80% of the Here's a case of a 12-year-old girl with urinary incontinence These are S2/S3/S4 problems. Tingling sensation in the sacral area not a lot of pain and very
Here is the MRI demonstrating the high signal by comparison to the subarachnoid space around the spinal canal indicating a narrow-necked cyst. Axial images showing
And here's the procedure a Two needles again achieving In fact a beautiful empty cyst. And then injection of fibrin. This is a more difficult procedure. Here you clearly have a large
multiple small other-sited cysts. Again erosion of the anterior You have to wonder how of sacral stability is functioning given the erosion of the compressible cyst.
It's a fundamental undermining of the engineering of the sacrum. So large cyst very thinned lamina very thin anterior cortical very easy to treat. You see the lamina is dehiscent.
You could put two needles So in go both needles
You achieve an air-fluid level. You wait and see if it refills. It doesn't refill and then Post-procedurally I keep the
depending on how they are. I tell them to do that they wouldn't have I tell them to maintain do nothing unusual just keep and over time taper
I only ever had to admit one patient who developed a rash
I only ever had to admit one patient who developed a rash after the fibrin injection. It's a very safe very simple procedure.
Remember you can always do All right so in terms of the results excellent results in 106 patients 49.7%. Satisfactory results in 53 patients 25%. So in total 159 patients giving us about a 75% success rate.
I tell patients that in proportion to the If they've had pain for 10 or 15 years it's going to take a few months. If they've had pain for 3 months we can do a better job of
But those chronically stretched unhappy dysfunctional nerves in that cyst in a chronically painful Tarlov cyst are going to take longer than a person who's had In seven patients aspiration
And in 40 patients they and that may have been we hadn't found the true
61.4% of patients were satisfied with the at the three- and six-year followup.
This is remarkable for a either impossible to in women who are really suffering. Let's just talk a little bit and my theory for this. This is related to CSF circulation.
It's a pathology of CSF flow. And we know that arachnoid granulations in the region of the transverse sinuses are And these illustrations made by one of my
demonstrates the role of in CSF resorbtion and its reintroduction of that fluid back into the venous cyst. Everywhere that there there are arachnoid granulations.
For some reason we think that CSF resorbtion and we're educated and we remember that the superior sagittal are the areas where CSF is resorbed. In fact all the way
down to the sacrum and there are arachnoid granulations. And the number of arachnoid granulations increase as we go further distally. And this has to be the case because really when you think of it
the CSF in our sacrum couldn't possibly circulate So these arachnoid granulations are passing from the subarachnoid into the fat in the epidural space into adjacent veins directly
and on every nerve root sleeve. We published a paper about this in the European journal Neuroradiology and if you're an insomniac but it's actually a very So here we see an illustration
of the relationship of to the dorsal root ganglion So everywhere there's there are arachnoid granulations and this is the key zone for the development of Tarlov cysts.
We believe that there is in the acquired cases in this region and that it may be an inflammatory or post-infective phenomena or related to endometriosis Now we're not the first to think this
and in fact in the I found a paper from the saying that arachnoid is found in spinal nerve or men after cadaveric dissection. So about two years ago
we did a series of sacral anatomic dissections in the anatomy lab at to look at the arachnoid as these have never been studied. We also studied our patients genetically
and I was able to get funding from the National Organization through the support of the Tarlov Help Tarlov Talk population and we studied our patients. And we found that some 21 of 24 in Canada
were found to have mutations and I was very excited about this but this may have been a false result. We have repeated this work at John Hopkins and it appears that this may based on a problem with the chip
that we did the genetic work on here. Hal Dietz and Dave Valle at have been working on this and we haven't been able but we have found other with arachnoid cysts
with Marfan syndrome and other We've scanned everything in this analysis looking for relationships with any of the connective So I'm going to skip through this and in terms of the future research
we've been fortunate to from the state of Maryland and from a previous to fund this research to try or series of mutations that of cystic dilatation
I'd like to thank my Don Long Dr. Kathuria Dr. Chen and then the folks who Dr. Bojan Dr. Fasel in
and Abby Skanda who was involved in this work. I'd like to thank Reta Honey Hiers
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