(134) Development of a Multidisciplinary Step-Care Management Algorithm and Surgical Outcomes of PGAD/GPD Patients with Tarlov Cyst-Induced Sacral Radiculopathy

Abstract

Abstract Introduction Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is characterized by persistent, unwanted genital arousal and/or other genito-pelvic dysesthesia, including burning, itch, pain in the clitoris/penis, mons pubis, vulva/scrotum, vagina, urethra, perineal region, bladder, and/or rectum. Patients with PGAD/GPD are significantly bothered/distressed and catastrophization and suicidal ideation are common. In 2012 Komisaruk reported that PGAD/GPD could be mediated by Tarlov cyst-induced sacral radiculopathy. In 2016 we developed a multidisciplinary step-care management algorithm with specialists in sexual medicine, spine surgery, sex therapy, physical therapy, and neurophysiology to diagnose Tarlov cyst-induced sacral radiculopathy. Objective To utilize a novel multidisciplinary step-care management algorithm to identify PGAD/GPD patients with Tarlov cyst-induced sacral radiculopathy who could benefit from Tarlov cyst spine surgery, and to evaluate the long-term safety and efficacy of the surgery. Methods Clinical data were collected on PGAD/GPD patients who underwent Tarlov cyst spine surgery between 2016 and 2020 with at least 1-year follow-up. The management algorithm used to identify and treat Tarlov cyst-induced sacral radiculopathy involves: detailed psychosocial assessment and medical history; non-invasive assessments for sacral radiculopathy; targeted diagnostic caudal epidural injection that results in temporary clinically significant reduction of PGAD/GPD symptoms; and surgical intervention with Tarlov cyst spine surgery. Treatment outcome was based on the validated patient global impression of improvement (PGI-I) measured at intervals post-operatively. Results Ten patients (8 women, 2 men), mean age 40 years (range 19 - 66), met inclusion criteria. Patients were discharged the same day or following morning post-operatively. No serious complications occurred. Follow-up was >12 months (range 13 - 22 months). Seven (70%) patients reported post-operative clinical improvement on PGI-I at last follow up: two patients reported “very much better”, three patients reported “much better” and two patients reported “little better”. Two patients had no improvement. Only one patient was much worse, however we believed that the PGI-I score of 6 reflected the worsening of the PGAD/GPD condition and not a specific result of the surgical procedure. Conclusions Distressing PGAD/GPD symptoms can be caused by Tarlov cyst-induced sacral radiculopathy. This case series with long-term follow-up demonstrates that spine surgery effectively treats PGAD/GPD patients with Tarlov cyst-induced sacral radiculopathy established by a multidisciplinary step-care management algorithm. Imbricating the Tarlov cyst using minimally invasive spine surgery techniques was associated with clinical improvement in 70% of these select patients. Disclosure No