WHAT ARE THE COMMON TYPES OF SPINAL OR NEURAL CYSTS?
A Tarlov Cyst (TC) or Perineural Cyst is a dilated nerve root sheaths filled with cerebrospinal in the spinal column. Tarlov cysts (Perineural Cysts) are found most commonly in the dorsal root ganglion of the sacral region of the spinal column. The most common place for these fluid-filled cerebrospinal fluid sac is in the nerve root sheets of the S2-S3 level of the sacrum or tailbone. Nevertheless, you can get a Perineural Cyst (Tarlov Cysts or TC) in other areas of the spine. Also, it could be present in multiple areas.
The vast majority of Tarlov cysts diagnosed are not the cause pain in patients with neck pain, upper back pain, mid back pain, low back pain or extremity pain. In fact, 98% of diagnosed cases, the cyst is not the source of pain. However, a small cyst can aggravate an existing disorder. But, the large cysts can be the cause of symptoms or pain, especially when there are no other clinical findings are present. If the TC (Tarlov Cyst or Perineural Cyst) is too big, it can pinch and irritate neural structures; causing neurological damage, chronic pain, and sexual dysfunction. Severely enlarged and symptomatic cysts can be removed, and we will discuss this procedure later. To start with, let’s provide you a basic definition of a cyst.
What is a Cyst?
In the most basic terms, a cyst is a thin sac that is filled with fluids. They can occur in any tissue and vary in size. Regardless of where they are found, these are abnormal sac-like structures that can cause discomfort, chronic pain, and malfunction. However, cysts, in general, do not cause pain. But, can become painful when enlarged, infected or irritated. In this article, we will pay attention to the types of cysts in the spine. Now that we have defined what a cyst is let’s see if there are different types of spinal cysts.
Are There Different Types of Spinal Cysts?
Yes, there is a verity of cysts found in or around the spinal column. In the spine, there can be small or large cysts. The most common and least understood type is the Tarlov or Perineural cyst, which were first described some 70 years ago. They are called perineural cysts (PC) because of their proximity to spinal nerves.
These PC or neural cysts can occur anywhere in the spine, but are most common in the lowest portions; the tailbone or sacrum. Researchers have the incidence of occurrences in 1-2% of the population and more common in males. In this article, we will concentrate on the Tarlov cyst, but before getting too in-depth, it might be helpful to define other types of cysts such as the Meningeal Cysts, Meningeal Diverticula, and Arachnoid Diverticula.
Is there any Difference between TC and Meningeal Cysts in the Spine?
The cysts are often multiple, extending around the circumference of the nerve, and can enlarge over time to compress neighboring nerve roots, to cause bone erosion.
It is rare to have just one TC. Often, multiple TCs extend around the entire circumference of a nerve. Contrary to the common belief, they can enlarge over time, and larger cysts cause symptoms. Large TCs are known to cause bony erosions. But before we get too in-depth, we must differentiate a TC from other spinal Meningeal Cysts.
For ease of understating we provided the main descriptive criteria for TC and other Meningeal Cysts in the spine. Please keep in mind that the topic in regards to differentiation of meningeal cysts from is still relatively new, and as such; remains somewhat controversial. However, both can cause symptoms, when enlarged. None-the-less, let take a closer look at them, starting with the Tarlov first:
What are the Basic Characteristics of a Tarlov (TC)?
- They have the potential communicate with spinal subarachnoid space.
- Often found just beyond from the point where the posterior nerve root and dorsal root ganglion lies in the sacral spinal region
- The walls of a TC always contain nerve fibers If you see one, there are more. In other words, there are more than one TC
How is a TC Differentiated from other Neural cysts such as Meningeal Cysts, Meningeal Diverticula, and Arachnoid Diverticula?
- Meningeal Cysts are the communicating cysts. In other words, they have free access to the spinal subarachnoid space
- Meningeal Cysts are typically found proximal to dorsal root ganglion (DRG) throughout vertebral column (TC was distal or just after the DRG)
- The walls of the Meningeal Cysts, Meningeal Diverticula, and Arachnoid Diverticula are all lined by arachnoid mater.
- Unlike the TC, there are no neural element or components Unlike TC; there can be only one. Multiplicity isn’t documented as it is for TC.
We have spoken quite a bit about cysts (Tarlov) and other meningeal cysts, but have not covered other types of cysts found near the spine. We have mentioned numerous times that TCs are often asymptomatic. But, there is a type of cyst that is. A synovial cyst cause symptoms 100% of the time. Unlike the TCs, they are not classified as a neural cyst, but rather one that arises from spinal joints.
What are Synovial Cysts?
As mentioned earlier, Tarlov cysts are fluid-filled sacs that are not well understood. But, Synovial cysts are the second most common type of spinal cyst. They too can be small or large cysts, that results from premature wear and tear or degenerative changes in the spine. Synovial cysts are the type of fluid-filled sacs common in patients with spinal instability or congenital malformations such as spondylolisthesis. Spinal instability and conditions such as spondylolisthesis place exorbitant amounts of stresses upon the spinal joint. The cumulative impact of these stresses is said to be the leading cause of synovial cysts. Let’s see how.
In the spinal column, the synovial cysts are located adjacent to the joint or facets. Poor posture, injuries and spinal instabilities are the leading causative factors. The facets or spinal joints bear the weight of the body. When stressed they get inflamed or swell-up. This inflammatory process is initiated to protect the joint, but often backfires; causing greater issues for the long haul.
So, increased stresses on your spinal joints can lead to increased production of the normal fluids the spinal joint needs. The increased production of these fluids (synovial fluids) is needed to protect your joint by providing additional lubrication. However, continued stresses can lead to an excessive buildup of these fluids. As the fluid levels increase, they can get trapped in the joint lining (synovial lining) and produce sac-like projections of varying sizes.
What is the Significance of a Synovial Cyst?
The clinical significance of synovial cysts is that they can compress nerves, cuase sexual dysfunction or chronic pain. Nerve compression can occur when the synovial cyst is projected from the facet into the neural foramina. The neural foramina or intervertebral foramina are the openings through which the spinal nerves exit from the spinal canal. Conservative treatment is the best means of approach. Yes, there are several surgical methods, but the long-term outlook of spine surgery for synovial cyst is not favorable.
Most surgical intervention requires removal of joints or encapsulating ligaments. These procedures may reduce pain, but render the spine unstable. Therefore, if you are diagnosed with a Synovial Cysts, the most effective treatment options include targeted research-based chiropractic backed by clinical physiotherapy. In short, you need us for targeted pain management. So, visit one of our centers today.
Chiropractic Specialty Center® has the breakthrough technology, knowledge, and skills needed to target and treat synovial cysts effectively. Key to successful pain management are our research-based methods, integrative solutions, and advanced technology. For our synovial cyst patients, we offer targeted advanced spinal decompression therapy, shockwave therapy, ultrasound therapy, interferential current therapy along with several other chiropractic and physiotherapy procedures and methods that target it comprehensively. Let our clinical non-surgical spine experts provide you the care you need today.
How is Neural Cyst Diagnosed?
The only acceptable means of diagnosing cyst in the spine is through an MRI. As mentioned, cysts are fluid-filled sacs. Synovial cysts contain synovial fluids (joint fluids), while the Tarlov cysts are fluid-filled sacs with cerebral spinal fluid. The most researched and best-proven method of assessing fluid-filled sacs (whether from synovial fluids or cerebral fluids) is through the MRI. CT scans are helpful but rather outdated as they don’t show the fluids as well as the MRI.
The Magnetic Resonance Imaging (MRI) is the gold standard for diagnosing a spine-related condition. And, when it comes to a Tarlov cyst, there is nothing better. The best MRI view of a Tarlov cyst is the T2-weighted MRI images. The T2-weighted images enhance fluid levels as such making the diagnosis of a Tarlov cyst relatively easy. On a T2-weighted MRI, a Tarlov Cyst will appear to be a white ballooned/dilated area of the sheath that covers the exiting sacral nerve roots.
As mentioned, dilation of the nerve root sheaths is the source of a perineural cyst. The dilation is the result of excessive accumulation of CSF (cerebrospinal fluid) within the nerve sheath. Now, let’s look into the layers of nerve sheaths where these fluid collections occur. Three meningeal layers cover the brain and the spinal cord; the outer most and the toughest layer would be the dura mater, followed by the arachnoid and the innermost layer is called the pia mater. Subarachnoid space is the space between the pia and arachnoid mater.
What are the Signs and Symptoms of a Neural Cyst (Perineural or Tarlov)?
The presence of a Perineural Cyst (PC) may or may not be accompanied by neurologic symptoms. However, living with an asymptomatic Tarlov cyst could lead to remodeling and erosions of the sacral bone. This, in turn, may lead to increased spinal fluid pressure causing the cyst to fill-up with CSF and cause neurological damage, sexual dysfunction, and chronic pain. The larger cysts can compress nerves and cause symptoms. Patients with large cysts may experience pain in the legs or spine. In short, cysts cause symptoms when they grow. Yes, if you have a PC or TC, it can and will grow over time. Injuries such as falls can dramatically increase the chance for growth and keep in mind the growing or large cyst cause symptoms.
Traumatic accidents, infections, falls, childbirth or epidurals can transform asymptomatic Tarlov cysts to become symptomatic. Symptoms of an enlarging Tarlov Cyst or Perineural Cyst would be similar to sciatica or slip-disc. Patients would experience either localized or radiating pain, numbness, paresthesia, and tingling. A patient with a Perineural Cyst, however, would also complain of pain, symptoms include soreness or pain in the sacral region. Bowel and bladder changes may also occur. Pain may increase with a cough or sneeze, and they may have headaches or dizziness.
What are the Links Between Traumatic Events, Childbirth, Epidural Injections and TC?
If you are wondering what caused the TC (Tarlov Cyst), there is no clinical data that definitively report the actual causes. A possible cause or enlargement of a smaller cyst into a large one as related to published medical research is an increase in the Cerebral Spinal Fluid (CSF) pressure. To enhance your understanding, it might be better to explain what Cerebral Spinal Fluids are first.
The Cerebral Spinal Fluids or CSF is produced in the brain. The primary function of CSF is to provide nutrients and remove waste products from the brain and spinal cord. Also, it protects the brain and spinal cord by cushioning them from traumatic events.
Increased CSF pressure or blockage of CSF flow is a known causative factor. Furthermore, increased CSF pressure or blocked CSF flow can undoubtedly enlarge a smaller asymptomatic TC into a large symptomatic one. So, it is not unusual for a patient who had an asymptomatic Tarlov Cyst (TC) become symptomatic following an incident such as sports injuries, car accidents, falls, childbirth or heavy lifting.
Aside from traumatic events and childbirth, Epidural Injections are known causes or at least, aggravating factors in TC. An epidural injection is an invasive procedure that delivers steroids to block spinal pain or pain in arms and legs caused by inflamed spinal nerves. Epidural injections given during childbirth are referred to as epidural anesthesia injected into the lumbar spine to block the pain felt during delivery.
Are There Any Side Effects to Epidural Injections?
Generally speaking, anytime you inject a chemical into the body there are side effects. The severity of side effects is dependent on the chemical injected and the patient’s tolerances. Although epidural injections are considered minimally invasive procures, they can have severe side effects. One of the known side effects as it pertains to our topic is the increase in CSF pressure. Epidural injected into the spinal column can engorge veins, leading to increased CSF pressure. In fact, epidural are known causes of increased intracranial pressures that result from changes in CSF pressure or flow. As mentioned earlier, a change in CSF pressure is the leading causes of TC.
What Should You Do if You Have a Spinal Cyst?
As mentioned earlier, a Tarlov cyst is often not the cause of pain. Medical research has established the fact the 98% of Perineural Cyst cases is not the source of pain. In fact, in the majority patients diagnosed with a Tarlov cyst are those that suffer from spinal disc disorders such as a herniated disc (slip-disc or slipped disc). Therefore, clinical expertise and judgment are needed when it comes to treating patients that present with a Tarlov cyst. In our centers, we have treated thousands of patients with Tarlov cysts. In almost all cases, the pain was not due to their cyst.
Tarlov cysts are often a complicating or aggravating factor. Much like when you cut your finger while cooking and not feeling the pain until you touch slat or an acidic liquid like lemon juice. Similarly, the Tarlov cyst is an aggravating factor, especially when you have a spinal disc disorder or a joint malfunction. In other words, the spinal disc or spinal joint is the source of pain rather than the cyst. Just like the pain, you feel when your cut finger comes in contact with salt or lemon juice.
Surgical Intervention Through the Two-Needle Fibrin Glue Approach for the Symptomatic Tarlov Cyst
Diagnosis and identification of a perineural or TC start with an MRI, which is more sensitive than CT. Cysts are always visualized, but not always reported seldom. As mentioned earlier, most are in the sacral area and asymptomatic. Symptomatic Tarlov Cyst is rare. If the cause of neck pain, back pain or pain in the sacral area is related to symptomatic Tarlov cyst, surgery is an option. Surgery can provide temporary relief or a lasting relief depending on the procedure. A minimally invasive procedure is often recommended for the symptomatic Tarlov cyst. These procedures are relatively new and as such long-term impacts are still being studied.
In one study, Dr. Paulsen reported immediate symptom relief lasting up to 3 months following single-needle aspiration of symptomatic TC in five individuals. To date, the most promising and least invasive procedures is one that Dr. Zhang published. The fibrin glue injection has been refined with help from Dr. Murphy and his colleagues. They innovated a new method with two-needle fibrin glue technique. The good doctors stated that their two-needle method of fibrin glue for the symptomatic Tarlov cyst best as it minimizes the risks associated with a single needle method. Our advice for TC patients is to obtain multiple surgical consultations from Neurosurgeons when deciding on a surgical intervention.
Non-Invasive Therapy and Treatment Options for this Cyst
While traditional methods of chiropractic or physiotherapy provide temporary relief: our systems of care fix and repairs the root-causes. The clinical teams of Chiropractic Specialty Center are experts in the spine and joint conditions. We are not one of those centers that offer a temporary relief. Our expertise and successes achieved are the results of our research-based clinical treatment we provide. Our Chiros are the expert you need in identifying the causes of your pain. Too often, patients with a Tarlov Cyst or Synovial Cysts receive improper therapeutic procedures. The absence of an accurate diagnosis is the primary factor of ineffective treatment. Diagnosis is the most challenging aspect of your care. As such, our clinical teams will carefully assess you to ensure a speedy recovery.
Our methods of treatment for the spinal column have improved the lives of thousands of our patients. In fact, we have helped many that others could not. Our successes in the area of the spine and joint care are due to our commitment to research and understanding of causes. If you have a Tarlov cyst or a Synovial cyst, your best hope of recovering from pain through non-invasive manner is us. Our methods of integrative treatments coupled with advanced spine technology allow us to deliver for you a world-class level of pain management, unmatched by others. Visit us today and discover your non-surgical treatment options for a Tarlov Cyst, Perineural Cyst, and Synovial Cyst today.