Understanding Cervical Tarlov Cyst (Perineural Cyst): A Hidden Cause of Neck and Upper Limb Pain

When patients present with unexplained neck pain, upper limb radicular symptoms, or even vague neurological complaints, one of the less commonly considered diagnoses is a Tarlov cyst, especially in the cervical region. Though more frequently observed in the sacral spine, these fluid-filled sacs—also known as perineural cysts—can occasionally appear in the cervical region and become symptomatic.

What is a Tarlov Cyst?

A Tarlov cyst is a cerebrospinal fluid (CSF)-filled sac that arises at the junction of the dorsal nerve root and dorsal root ganglion. These cysts are lined by nerve fibers and typically develop due to weakness or ballooning of the nerve root sheath. Most commonly found in the sacral spine, they are usually incidental findings on MRI and asymptomatic. However, in rare cases, they can occur in the cervical spine, and their symptoms can overlap with other common conditions such as cervical radiculopathy or myelopathy.

How Do Cervical Tarlov Cysts Present?

Cervical perineural cysts may remain asymptomatic, but when symptomatic, they can produce a wide variety of symptoms depending on their size, location, and the degree of nerve involvement:

• Neck pain

• Shoulder or arm pain

• Paresthesia or numbness in the arms or fingers

• Weakness of upper limb muscles

• Occipital headache if the cyst affects upper cervical nerves

• Imbalance or gait issues (if there’s cord compression)

These symptoms can mimic disc herniation, cervical spondylosis, or brachial plexus neuropathy, making diagnosis challenging.

Diagnosis: The Role of MRI

The gold standard for diagnosing a cervical Tarlov cyst is MRI (Magnetic Resonance Imaging). Tarlov cysts appear as well-defined, fluid-filled lesions at the nerve root sleeves. High-resolution MRI can differentiate them from other intradural or extradural cysts.

In rare cases, CT myelography may be used to detect communication between the cyst and the subarachnoid space.

When Do They Become Problematic?

Not all Tarlov cysts require treatment. However, intervention is considered if:

• The cyst is large enough to compress adjacent nerves or spinal cord

• There are progressive neurological symptoms

• There is intractable pain not responding to conservative management

Management Options

1. Conservative Management:

   • Most asymptomatic or mildly symptomatic cases can be managed with:

     • Pain medications

     • Physical therapy

     • Cervical collar (for intermittent symptom relief)

     • Lifestyle modification to reduce mechanical stress on the cervical spine

2. Interventional Pain Management:

   • CT-guided cyst aspiration and fibrin glue injection (though results may be temporary and recurrence is common).

   • Cervical epidural steroid injections or Selective nerve root block under ultrasound guidance which we do in our center (for associated radiculopathy).

3. Surgical Management (Reserved for selected cases):

   • Microsurgical cyst excision, cyst fenestration, or nerve root sleeve reconstruction.

   • Surgery has potential risks, especially in the cervical spine, and is only considered when there’s disabling pain, progressive neurological deficit, or failure of conservative and interventional options.

Challenges and Controversies

• Lack of awareness: Many healthcare providers may overlook cervical Tarlov cysts due to their rarity.

• Symptomatic vs. incidental: Not all cysts found on MRI are symptomatic; correlation with clinical signs is essential.

• Recurrence: Even after aspiration or surgery, cysts may recur, and outcomes can be variable.

Final Thoughts

Though rare, cervical Tarlov cysts should be considered in patients with unexplained neck and upper limb pain, especially when MRI shows a suspicious lesion. A multidisciplinary approach involving neurologists, pain physicians, and spine surgeons ensures optimal management. Patient education, individualized therapy, and cautious interpretation of radiology findings are key in managing this uncommon but significant clinical entity.

Author: Dr. Pavan Kumar Bichal
Pain Specialist