Neurology Perspectives (Apr 2024)
Symptomatic Tarlov cysts: A case series and effectiveness of multimodal rehabilitation plus pharmacological treatment
Abstract
Background: Tarlov cysts, or perineural cysts, are nerve root lesions most frequently found in the sacral region, and are generally asymptomatic. They are usually detected incidentally and their association with sexual, bladder, or bowel dysfunction is frequently ruled out. Aims: We describe the management of a series of patients with symptomatic Tarlov cysts using a protocol that combines multimodal rehabilitation (biofeedback+posterior tibial nerve stimulation+INDIBA® radiofrequency) and pharmacological treatment (Tiobec Dol® dietary supplement and/or acetazolamide) and evaluate the effect of this programme on pain and pelvic floor muscle strength. Material and methods: Retrospective study of 5 patients with urinary or faecal incontinence and pelvic pain or dyspareunia, who presented Tarlov cysts.The outcome variables were: (1) pain as measured with the visual analogue scale (0–10) and (2) maximal and mean pelvic floor muscle strength (in mm Hg) at baseline and after treatment completion. Results: Treatment improved mean pelvic floor muscle contraction from 9.2±6.01 mmHg to 10.6±5.2 mmHg (P=.3111) and maximal pelvic floor muscle contraction from 41.2±21.98 mmHg to 45.8±17.51 mmHg (P=.4430), and decreased pain from 8±1.26 points to 4.6±2.65 points (P=.0343). Conclusions: Tarlov cysts may cause pain and radiculopathy, although they are usually asymptomatic and, consequently, underdiagnosed. More rarely, they cause urinary, bowel, and sexual dysfunction. We describe the cases of 5 patients with Tarlov cysts presenting with incontinence and pain who were managed with multimodal rehabilitation plus pharmacological treatment. Cases of Tarlov cysts should be reported and studied; this will help to expand our understanding of their pathophysiology and to standardise effective multimodal treatment. Resumen: Contexto: Los quistes perineurales de Tarlov son lesiones de las raíces nerviosas sobre todo sacras, generalmente asintomáticos. Su hallazgo es incidental y muchas veces la disfunción sexual, vesical e intestinal es desestimada. Objetivo: Presentar el manejo en una serie de casos con quistes de Tarlov sintomáticos utilizando un protocolo de Rehabilitación multimodal (biofeedback + neuromodulación del tibial posterior + radiofrecuencia [INDIBA®]) más farmacoterapia (Tiobec-dol y/o Acetazolamida) y evaluar su efecto sobre la fuerza de la musculatura de suelo pélvico y sobre el dolor. Material y Métodos: Estudio retrospectivo a 5 pacientes con Incontinencia urinaria o faecal más dolor pélvico o dispareunia y quistes de Tarlov sacros.Variables de resultado: a) dolor medido por escala EVA (0–10) y b) fuerza máxima y media de la musculatura de suelo pélvico (medida en mm Hg) al inicio y al término del tratamiento. Resultado: Los pacientes mejoraron la fuerza media de 9.2 ± 6.01 a 10.6 ± 5.2 mmHg (p = .3111) y máxima de 41.2 ± 21.98 a 45.8 ± 17.51 mmHg (p = .4430); el dolor disminuyó de 8 ± 1.26 a 4.6 ± 2.65 puntos (p = .0343). Conclusiones: Los quistes de Tarlov causan dolor y síndrome radicular, aunque generalmente se consideren asintomáticos y por tanto infradiagnosticados. Con menos frecuencia producen disfunción vesical, intestinal y sexual. Hemos documentado cinco pacientes con quiste de Tarlov, incontinencia y dolor y pautado simultáneamente tratamiento rehabilitador multimodal y farmacológico. Se precisa reportar y estudiar los quistes de Tarlov para entender su fisiopatología y establecer manejo multimodal estandarizado y efectivo.
