Hi everyone i discovered earlier when I tried to copy and paste paragraphs from the article about Tarlov Cyst and Infertility, than when I copied and pasted to share instead of numbers to the references of Drs the explanation of their reference were there to read , This article I shared earlier through the link, I took time and deleted the numbers of references It makes for interesting reading and offers a lot more insight into the various Drs Opinions,and more insight in this rare disease its from 2009 when reading through the lines and numbers you get more information, right under this Im going to Post the sentences and words I deleted, so you will understand what I mean, also the Link to the article itself Love Sharon xx soft hugs xx Its a long post but valuable information make yourself a cuppa
J Spinal Cord Med. 2009 April; 32(2): 191–197.
PMCID: PMC2678291
Tarlov Cyst and Infertility
Pankaj Kumar Singh, MBBS, MS,1 Vinay Kumar Singh, D Orth, MRCS,2 Amir Azam, MS, MRCS,3 and Sanjeev Gupta, MS, MCh4DISCUSSION
The first methodical description of perineurial cysts of the spinal region is credited to Isadore M. Tarlov during his postmortem study of filum terminale Tarlov initially thought these cysts were entirely incidental and asymptomatic, but a decade later in 1948, he realized the causal relationship between the sacral perineurial cysts and sciatica after operating on a woman with this condition. The most common location in the spine is the sacral region, with the S2/S3 nerve roots most commonly affected The symptomatic Tarlov cysts are exceedingly rare and only one fifth present clinically . Depending on size and location, Tarlov cysts may cause a variety of symptoms ranging from backache, perineal pain or sciatica to frank cauda equina syndrome Symptoms are mostly exacerbated by maneuvers that elevate CSF pressure, such as coughing, walking, changing posture, and the Valsalva maneuver Exacerbation of symptoms after these maneuvers can be explained on the basis of CSF being forced into the cysts with increased spinal subarachnoid pressure Because of close proximity to the dorsal root ganglion, they mostly produce sensory sign symptoms with normal motor nerve conduction A number of urologic symptoms are also described including dysuria, incontinence, and neurogenic bladderThe absence of urinary incontinence in this patient can be explained on the basis of normal bladder anatomy and physiology. Urinary continence depends on a functioning of bladder neck, as well as the external urinary sphincter. The bladder neck is under sympathetic control delivered through the inferior hypogastric plexus, whereas the external urinary sphincter is parasympathetically controlled, supplied by the pudendal nerve. The ejaculatory ducts open in the prostatic urethra, lying between the bladder neck and the external sphincter . If pathology selectively involves the inferior hypogastric nerves interfering with the normal bladder neck integrity but leaving the external urinary sphincter intact, retrograde ejaculation can occur without urinary incontinenceSpinal perineurial cysts warrant a thorough work-up to determine the exact location, size, relationship with spinal nerve roots, and multiplicity. Plain radiographs and CT scans can be useful in picking up the underlying bony erosions. Contrast-enhanced myelograms give a characteristic appearance of delayed filling of Tarlov cysts with contrast medium and can be particularly useful in differentiating Tarlov cysts from other meningeal diverticula Because of better soft tissue resolution, MRI is the preferred imaging method In MRI, Tarlov cysts show CSF-like characteristics and therefore are hypointense in T1-weighted images and hyperintense in T2-weighted sequencesThe natural history of symptomatic Tarlov cysts is progressive enlargement and eventually clinical deterioration. The ball-valve mechanism has been proposed as an underlying factor responsible for the enlargement of these cysts Mummaneni et al lone. Medical management should consist of analgesics, anti-inflammatory medications, and physiotherapy. Surgery can be avoided in individuals who respond to conservative measures. Active management should be offered to patients who fail to respond to medical management or who develop new symptoms. The active management plan can broadly be divided into nonsurgical and surgical methods. Drainage of CSF either by a permanent lumboperitoneal shunt or percutaneous CT-guided aspiration ) have been tried with variable results but have not been approved universally. Recurrence within a few months remains the rule in most patients after CT-guided aspiration Mixed results were obtained with CT-guided instillation of fibrin glue into recurrent cysts. However, because of high rates of aseptic meningitis associated with the procedure, it is not usually recommended Appropriate patient selection remains the mainstay of surgical treatment in sacral perineurial cysts. To choose the right surgical candidate, the basic approach is to decide whether the symptoms can be attributed to the cyst in the first place. The chances of cure will obviously be higher when a definitive causal relationship can be established. The neurosurgical techniques used for the treatment of Tarlov cysts include bony decompression alone, cautery of the cyst wall, complete excision of the cyst along with the nerve root involved, cyst fenestration, and imbrication or oversewing of the cyst wall . Tarlov proposed the excision of cysts along with the involved nerve root. The morbidity produced by the procedure, however, is high enough not to justify its use . Simple decompressive laminectomy has a low success rate It has been observed that some symptoms respond better to surgical excision than others. Coccydynia, dyspareunia, perineal pain, and urinary symptoms are claimed to be specifically curable by Tanaka et al In contrast, they found sciatica and lumbago poorly relieved by surgery. However, quite the contrary, some authors including Tarlov himself found backache and sciatica resolving quickly after surgery, whereas urinary symptoms showing only partial improvement. Voyadzis et al suggested that the surgical excision of symptomatic Tarlov cysts more than 1.5 cm in diameter carries a favorable prognosis. Tanaka et al also proposed large cyst size and a positive filling defect on myelography as indicators of good surgical outcome. Mummaneni et al proposed that patients whose symptoms are exacerbated by postural changes or Valsalva maneuvers are more likely to benefit from microsurgery. However, there is some controversy regarding the surgical results for different symptoms. We found that, as cysts have an the inherent property of enlargement with time it is reasonable to operate on patients presenting with progressive symptoms. Surgical indications are obviously less clear in cases such as cauda equina. Because some authors report partial resolution of urologic symptoms with time , we suggest that these cases should have a surgical consultation sooner than later. Retrograde ejaculation and infertility may be the rare presentations of sacral Tarlov cyst of the cauda equina region; it is difficult to draw conclusions regarding outcomes based on a single case. Even after surgery, the sperm count and the seminal volume remained far lower than the optimal values required for natural conception ultimately necessitating assisted fertilization Two techniques of laminectomy have been described by Tanaka et al recapping laminectomy and simple laminectomy. Mummaneni et al recommended microsurgical cyst fenestration and imbrication as effective treatment. Imbrication of cyst wall is preferred over a total excision because the latter has a high risk of neural damage After exposing the sacral nerve roots by laminectomy, the cysts can be fenestrated with a scalpel to drain the fluid contents. It has been observed that the nerve roots are mostly located ventrally or laterally to cyst rather than dorsally within the cyst. Microdissection should be used to push any dorsally positioned nerve root fibers into the floor of the foramen Intraoperative physiologic monitoring can be a useful adjunct at this stage in minimizing damage to the neural tissue The nerve root sleeve can be imbricated, followed by a watertight dural closure. The need for a watertight dural closure is emphasized by most authors. It can be achieved by a primary dural closure using a fine non absorbable suture, as in our case, or by dural grafts. The closure can further be reinforced with epidural fat or muscle grafts and fibrin glue application The muscle or fat graft can also prevent CSF reaccumulation within the cysts by creating a mechanical pressure Mummaneni et al recommended the use of postoperative lumber drains in patients who showed communication between the cyst and spinal subarachnoid space in CT myelograms. Tanaka et al achieved very good results with a success rate of 83% by using imbrication and resection of cysts. Radicular pain was markedly improved in 50% of the patients in the series of Mummaneni et al . The remainder of the patients also showed moderate symptomatic relief but still needed analgesics for pain control Whereas a spinal perineurial cyst predominantly remains an incidental finding, because of its tendency to enlarge with time, patients should be informed of the possibility of developing symptoms later in life. However, that does not mean that all Tarlov cysts should be monitored; if the patient becomes symptomatic, imaging should be repeated at appropriate intervals. After an MRI, a CT myelogram should be performed to confirm the communication between the cyst and subarachnoid space and the filling-defect sign. In the light of good surgical results, early microsurgical resection should be considered, especially in patients with progressive symptoms. A surgical decision should be based on symptomatic progression, cyst size of more than 1.5 cm, and a positive filling-defect sign in myelography. Patients showing exacerbation of symptoms after Valsalva maneuver are also good surgical candidates. Electrophysiologic monitoring is imperative in minimizing the damage to sacral nerve roots.
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CONCLUSION
Most Tarlov cysts are discovered incidentally and are asymptomatic in nature. However, because of their natural tendency to increase in size with time, they may become symptomatic later in life. . Microsurgical excision may benefit patients with progressive symptoms caused by Tarlov cysts.
DISCUSSION
The first methodical description of perineurial cysts of the spinal region is credited to Isadore M. Tarlov during his postmortem study of filum terminale. At the time of initial discovery, the main differential diagnosis of these cysts remained meningeal diverticula and long arachnoid prolongations. Tarlov (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control1,The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control4,The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control5) distinguished among these lesions on the basis of 3 main features: (a) communication with the spinal subarachnoid space, (b) location in relation with dorsal root ganglion, and (c) histopathologic composition. Whereas meningeal diverticula and long arachnoid diverticula communicate freely with the spinal subarachnoid space, Tarlov cysts have only a potential communication. This difference in communication explains the delayed filling of Tarlov cysts in myelograms contrary to the rapid filling of the other 2 lesions. The second differentiating point was the location of these cysts (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control4). Tarlov cysts are mostly found at/or distal to the junction of the posterior nerve root and dorsal root ganglion in the sacral region. Meningeal diverticula, on the other hand, develop proximal to the dorsal root ganglion throughout the vertebral column. The third distinguishing feature was the histologic composition of these cysts. The wall of Tarlov cyst contains nerve fibers, whereas the meningeal diverticula have a wall lined by arachnoid mater with no evidence of a neural element. Most authors including Tarlov himself (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control1,The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control4–The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control9) agreed that the most important distinguishing feature of the perineurial cyst is the presence of nerve root fibers in the cyst wall.
In an attempt to clarify the matter further, Goyal et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control7) and Nabros et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control8) presented 2 simplified classification systems of spinal cysts. According to Goyal et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control7), Tarlov cysts or perineurial cysts are defined as cysts formed within the nerve root sheath at dorsal root ganglion. Nabros et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control8) classified spinal cysts in 3 types. Type I are extradural meningeal cysts without nerve root fibers. Type II lesions correspond to Tarlov cysts and are defined as extradural meningeal cysts with nerve fibers. Type III contains intradural meningeal cysts.
The exact etiology of sacral perineurial cysts remains a matter of debate, and different theories have been proposed. Tarlov himself believed that hemosiderin deposition caused by blockage of venous drainage of the perineurium and epineurium after local trauma leads to the development of these cysts (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control5). Fortura et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control10) proposed congenital arachnoid proliferation along the exiting nerve roots resulting in the formation of sacral perineurial cysts. Paulson et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control3) suggested the ball-valve mechanism whereby the cerebrospinal fluid (CSF) enters the cyst with systolic pulsations but is unable to exit through the same portal during diastole. The same theory is supported by Tanaka et al (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control6) and is thought to be the basis of positive filling defects in computed tomography (CT) myelograms and the increase in size of Tarlov cysts with time. The cyst wall is usually composed of dense, paucicellular collagenous bundles along with well-vascularized loose fibrous tissues. The cysts are often multiple, extending around the circumference of the nerve root. Because of inherent tendency to enlarge with time, the cysts may compress the neighboring nerve roots and may cause bony erosion (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control6).
Tarlov (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control1) initially thought these cysts were entirely incidental and asymptomatic, but a decade later in 1948, he realized the causal relationship between the sacral perineurial cysts and sciatica after operating on a woman with this condition. The most common location in the spine is the sacral region, with the S2/S3 nerve roots most commonly affected (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control11). The symptomatic Tarlov cysts are exceedingly rare (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control3), and only one fifth present clinically (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control3). Depending on size and location, Tarlov cysts may cause a variety of symptoms ranging from backache, perineal pain or sciatica (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control6), to frank cauda equina syndrome (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control12). Symptoms are mostly exacerbated by maneuvers that elevate CSF pressure, such as coughing, walking, changing posture, and the Valsalva maneuver (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control13). Exacerbation of symptoms after these maneuvers can be explained on the basis of CSF being forced into the cysts with increased spinal subarachnoid pressure (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control13). Because of close proximity to the dorsal root ganglion, they mostly produce sensory sign symptoms with normal motor nerve conduction (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control6). A number of urologic symptoms are also described including dysuria, incontinence, and neurogenic bladder (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control2,The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control6,The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control14).
Retrograde ejaculation and infertility, never described before in relation to Tarlov cysts, nonetheless can be viewed in conjunction with the urologic symptoms. Normal antegrade ejaculation (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control15) requires coordinated contractions of the vas deferens and seminal vesicles to propel the semen into the prostatic urethra and closure of bladder neck to prevent backflow of semen. These 2 events occur under sympathetic control. Ejaculation is further assisted by parasympathetically (S2–S4) induced rhythmic contractions of the bulbospongiosus and ischiocavernosus muscles, which expel the semen through the urethral meatus. Common causes of retrograde ejaculation include prostatic surgeries and neuropathies in the elderly and retroperitoneal lymph node dissection (RLND) and spinal cord injury in young fertile men (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control15) (Table 1). Apparently, successful antegrade ejaculation is largely dependent on both sympathetic and parasympathetic drives. Sympathetic efferent nerves, which are responsible for maintaining the integrity of bladder neck, emerge from the T12 to Tl3 segments and pass to the bladder neck through the inferior hypogastric plexus (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control15). Any space-occupying lesion in the sacral region that involves this plexus may impair the bladder neck mechanism. The most common cause of retrograde ejaculation in RPLD is damage to these sympathetic efferent nerves (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control15). The parasympathetic component, which is responsible for contractions of the bulbospongiosus and ischiocavernosus muscles, stems from the S2 to S4 segments (The following popper user interface control may not be accessible. Tab to the next button to revert the control to an accessible version.Destroy user interface control15) The entire article is below,