Tarlov Cysts Research Articles

Midline sacral meningeal cysts: Neurophysiology abnormalities and their correlation with pelvic sensory and visceral symptoms.

Midline sacral meningeal cysts (MSMCs) are cerebrospinal fluid-filled dural diverticula. Although widely considered asymptomatic, cases involving voiding difficulties or pain have been reported. The aims of this study were, firstly, to describe the clinical presentation of patients with symptomatic MSMCs, secondly, to assess the impact of the cyst on nerve root function, and, thirdly, to assess whether nerve root injury is more frequent in patients with MSMCs than those with Tarlov cysts (TCs). Consecutive patients with MSMCs presenting with at least one pelvic symptom participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamic testing were collected retrospectively. The relationship between neurophysiology, magnetic resonance imaging findings and patients' symptoms were assessed using Fisher's and analysis of variance tests. Neurophysiology findings were compared with those of TC patients. Eleven female patients were included (mean age 42.3 ± 12.4 years). All reported urinary symptoms. Back pain (91%), radicular leg pain (91%), bowel symptoms (45%) and sexual dysfunction (75%) were also frequently reported. Nine patients (82%) had abnormal findings on neurophysiology; three patients (27%) had one abnormal test, and six (55%) had two abnormal tests. Patients with MSMCs were more likely to have at least two abnormal neurophysiology test results compared to TC patients (55% vs. 18%, respectively; p = 0.018). Our results indicate that MSMCs are indeed associated with injury to the sacral somatic innervation when symptomatic. MSMCs are more likely to cause sacral nerve root damage compared to TCs.

Primary Headache Associated with Sexual Activity Presenting with Persistent Genital Arousal Disorder: A Case Report

Persistent genital arousal disorder (PGAD) is characterized by unwanted and distressing genital sensations that are not associated with concomitant sexual interest or thoughts. Several etiologies have been proposed, but the underlying mechanism of the condition remains unclear. In this report, we describe a case of PGAD presenting with primary headache associated with sexual activity (PHASA). A 57-year-old female with no history of headache experienced recurrent, unwanted episodes of genital arousal lasting 3 to 5 days for 4 years. One day, she began to experience intense genital arousal that she had never experienced before. On the fourth day of arousal, while attempting intercourse with her partner, she experienced an abrupt explosive headache, which was repeated during another session of intercourse a week later. The patient underwent laboratory tests, as well as brain magnetic resonance imaging (MRI) and magnetic resonance angiography, all of which showed normal findings. She was referred to a sexual medicine specialist and prescribed amitriptyline, escitalopram, and propranolol with a diagnosis of PGAD. Her sexual arousal gradually diminished, and when she stopped all medications 3 months later, all symptoms had disappeared. On further investigation, spinal MRI revealed a Tarlov cyst. She has been in remission for three years. This case illustrates the co-occurrence of PHASA and PGAD and suggests a possible common pathophysiology shared between these two rare disorders.

Growth rate of a giant Tarlov (perineural) cyst with intrapelvic extension

Background and importanceGiant Tarlov cysts (GTCs) are perineural cysts and their presacral intrapelvic extension are extremely rare entities. We present a case of GTC with intrapelvic extension who has preoperative Magnetic Resonance Imaging (MRI) follow-ups of 12 years, and we demonstrate the annual growth rate and the time-size correlation of a GTC.MethodsCase report.Clinical presentationA 37-year-old woman was admitted with left gluteal pain radiating to left foot, left leg numbness, progressed over 12 years. On MRI, starting from the L5–S1 level, a giant Tarlov cyst with an atypical configuration, is observed. The patient had a known sacral Tarlov cyst, first discovered on MRI obtained 12 years before the surgery. She had 6 consecutive MRI follow-ups in 12 years preoperatively. The cysts diameters have been measured and the growth rate was estimated. We showed for the first time that presented GTC grows in in both Sagittal Diagonal (SD) and Sagittal Craniocaudal (SC) diameters over time with overall annual growth rates, 7.671% for RGR_SD and 6.237% for RGR_SC.ConclusionWhen the time-size correlation is observed, it becomes evident that the GTSs’ growing speed increases over the years because of minimal resistance in the intrapelvic cavity. Early surgery may be considered to prevent rapid growth in the intrapelvic cavity and to reduce possible complications of the giant cyst.

Neurologic pelvic pain: Diagnosis and treatment, with attention to hip–spine–pelvis exam

This article summarizes the 2023 International Continence Society (ICS) Workshop 5 focused on neurologically mediated chronic pelvic pain (CPP) (Workshop 5). A team of experts share practical advice and tools for assessment, diagnosis and management relevant to pudendal neuropathy or other nerve entrapment, central nervous system diagnoses such as herniated disc, radiculopathy, Tarlov cyst, tethered cord, hip confounders, and systemic neuropathy such as small fiber neuropathy, neuroinflammatory disease (e.g. Lyme, Multiple Sclerosis) and central sensitization.

Nerve Cuff Reconstruction for Sacral Duct Tarlov Cyst

ObjectiveTo investigate factors influencing the long-term prognosis of patients with sacral Tarlov syndrome after nerve root cuff reconstruction. MethodsA total of 42 patients with sacral Tarlov cysts who underwent nerve root cuff reconstruction at the First Medical Center of the Chinese PLA General Hospital between December 2015 and December 2021 were retrospectively reviewed. All cases were confirmed using magnetic resonance imaging and pathology. All patients were followed up for 24 months after surgery. Improvement in self-evaluation of health was defined as a good prognosis, while a decline in self-evaluation of health was defined as a poor prognosis. The demographic characteristics and clinical data were compared between patients with good and poor prognoses. Multivariate logistic regression analysis was performed, taking poor prognosis as the dependent variable and parameters with P<0.1 in the univariate analysis as independent variables to identify the risk factors. ResultsSignificant differences were observed in disease duration, lower limb weakness, defecation dysfunction, and defecation dysfunction between patients with good and poor prognoses. Multivariate logistic regression analysis showed that disease duration (Odds ratio [OR]: 0.961, 95% CI: 0927–0.995) and defecation dysfunction (OR: 0.005, 95% CI: 0.0–0.368) were independent risk factors for poor prognosis after nerve cuff reconstruction in patients with sacral Tarlov cysts (all P < 0.05). ConclusionsPatients with sacral Tarlov cysts undergoing nerve root cuff reconstruction, particularly those with longer preoperative disease duration and dysuria, are at increased risk of poor long-term prognosis.

(083) CHRONIC VULVAR PAIN AND URINARY DISTURBANCES REVEALING A LARGE TARLOV CYST IN A 41-YEAR-OLD WOMAN: A CASE REPORT

Abstract Introduction Perineural cysts, also known as Tarlov cysts, are cerebrospinal fluid-filled nerve root cysts predominantly located at the sacral spine. While typically asymptomatic, large Tarlov cysts may elicit discomforting symptoms. Diagnostic challenges stem from limited understanding and symptom overlap with various disorders. Objective This case report explores the presentation of a 41-year-old female patient exhibiting symptoms of vulvar pain and urinary disturbances, which were ultimately attributed to a large Tarlov cyst, highlighting the complexities of diagnosis and management associated with this condition. Methods A 41-year-old female patient with a past medical history of linear scleroderma, chronic left hip pain with leg length discrepancy, and family history of endometriosis presented to her primary care physician with vulvar pain and urinary symptoms. She had burning vulvar pain, predominantly on the left side, radiating from the vulvar vestibule to the perineum, which gradually worsened over 6 months. She also had lower back pain radiating into her legs and calves, along with increased urinary frequency, urgency, retention and burning upon micturition. Patient underwent a 11-month treatment regimen following a referral to pelvic pain specialist, including being initiated on gabapentin and vaginal suppositories, which provided significant pain relief. However, over time, her vulvar pain gradually worsened, and gabapentin was replaced with pregabalin. She underwent six weeks of pelvic floor physical therapy and received a series of peripheral nerve blocks, including multiple pudendal nerve blocks, trigger point injections and hydrodissection of connective tissue around the nerves, yielding little pain relief. Due to persistent vulvar pain, the patient was referred to our clinic. Her examination revealed tenderness upon palpation over the lumbar-sacral spine and sacroiliac joint and para-spinal muscle spasm on the left side. She had provoked vestibulodynia that was predominately on the posterior aspect of the vestibule with a Q-tip test 8/10, and about 4/10 at anterior vestibule. She also continued to have tenderness in her pelvic floor muscles. Given her history and physical exam, a spinal pathology was suspected, and lumbosacral MRI was ordered. Results The lumbosacral MRI revealed a Tarlov cyst measuring 7.7 cm x 3.9 cm x 4.2 cm, extending from the L5-S1 disc level to the S3-S4 vertebral body junction. The patient was subsequently referred to a neurosurgeon who performed a twelve-hour surgery, including a dissection of the intrasacral meningeal cyst that was causing sacral nerve root compression and subsequent wrapping of the weakened right S2-S3 nerve roots. Postoperatively, the pain, although decreased, persisted due to nerve root thinning and long-term compression of the sacral nerve roots. She is currently being managed by our clinic, pain specialists and rehabilitation. A two-year recovery period is anticipated. Conclusions This case underscores the diagnostic challenge of vulvar pain in the context of a Tarlov cyst and emphasizes the necessity for heightened clinical suspicion and comprehensive evaluation. Additionally, the case highlights the importance of considering MRI of the lumbosacral spine as an early investigation in patients presenting with otherwise unexplained chronic vulvar pain, offering a valuable diagnostic tool for identifying conditions like Tarlov cysts that might otherwise remain elusive. Disclosure No.

(084) PERSISTENT GENITAL AROUSAL DISORDER/GENITO-PELVIC DYSESTHESIA (PGAD/GPD) SECONDARY TO TARLOV CYST-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is characterized by persistent, unwanted genital arousal and/or other dysesthesia, including burning, itch and/or pain in the genito-pelvic area such as clitoris, vulva, perineal region and/or peri-anal region (pudendal nerve), umbilicus, urethra, bladder, vagina, and/or rectum (pelvic nerve) and also including the lower extremity buttock, thigh, calf, foot (sciatic nerve). Patients with PGAD/GPD are significantly bothered/distressed, and catastrophization and suicidal ideation are common. In 2012 Komisaruk reported that PGAD/GPD could result from Tarlov cyst-induced sacral radiculopathy. We developed a multidisciplinary step-care management algorithm with specialists in sexual medicine, spine surgery, sex therapy, physical therapy, and neurophysiology to diagnose and treat Tarlov cyst-induced sacral radiculopathy. Objective To utilize a 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 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 diagnostic assessments for sacral radiculopathy; sacral MRI with Tarlov cyst protocol; targeted diagnostic caudal epidural injection; and if appropriate, Tarlov cyst spine surgery using minimally invasive surgery techniques. Treatment outcome was based on the validated Patient Global Impression of Improvement (PGI-I) measured at regular 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 &amp;gt;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 believe that the PGI-I score of 6 reflected the worsening of the PGAD/GPD condition and not specifically the result of the surgical procedure. Conclusions Distressing PGAD/GPD symptoms can be caused by Tarlov cyst-induced sacral radiculopathy. A multidisciplinary step-care management algorithm allows selection of appropriate surgical candidates. To the best of our knowledge, this is the largest case series of patients with PGAD/GPD treated with Tarlov cyst spine surgery with at least 1 year follow-up. Using minimally invasive spine surgery techniques, spine surgery on the Tarlov cyst was associated with clinical improvement in 70% of select patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

Perineural Cysts of Tarlov: A Case Study

This is a case of perineural cysts of Tarlov in a female patient who complains of having a chronic pain in the neck. An MRI scan was done which revealed a normal spine and vertebral column. Tiny bilateral perineural cysts were found on the MRI scan. This case study will gather all the information about the formation of perineural cysts of Tarlov, prevalence, appearance on MRI, associated conditions, and differential diagnosis.

Evaluating the Efficacy of Volume Isotropic Turbo Spin Echo Acquisition Versus T2-Weighted Turbo Spin Echo Imaging in the Diagnosis of Nerve Root and Perineuronal Pathologies in Spinal Disorders.

Background While two-dimensional (2D) turbo spin echo (TSE) sequences offer better through-plane resolution than three-dimensional (3D) isotropic TSE sequences images, with a narrower thickness of the slice, 3D isotropic TSE sequences are known to have a weaker in-plane resolution as well as blurring of the image. These elements may make it more difficult to distinguish between nearby structures that may affect nerve roots and small nerve roots during spinal imaging. This study aimedto analyze the accuracy of T2 TSE sequence and volumetric isotropic TSE acquisition in determining the indentation of nerve roots and perineural diseases such as nerve sheath tumors and Tarlov cysts. Methods Fifty patients who attended the Department of Radiodiagnosis for magnetic resonance (MR) spine participated in this prospective study. Routine MR lumbosacral (LS) spine sequences, such as survey, coronal T2short-tau inversion recovery (STIR), sagittal T2 TSE, sagittal T1 TSE, and axial T2 TSE, were carried out after a localizer was acquired. More sequences from volume isotropic turbo spin echo acquisition (VISTA) were acquired. For both 2D and 3D sequences, the visibility ratings for perineural cysts, spinal canal stenosis, and nerve root indentation were evaluated. Visibility ratings ranged from zero to four. Results In the cases of perineural cyst, spinal canal stenosis, and nerve root impingement, the mean difference between the VISTA and T2 TSE visibility scores was 0.04, 0.54, and 0.56, respectively. The VISTA and T2 TS had standard deviation differences of 0.006, 0.026, and 0.06, respectively. The "t" values for nerve root impingement, spinal canal stenosis, and perineural cysts were, in order, 50, 180, and 70. Because the p-value was <0.01, a statistically significant variation has been observed. Conclusion In the diagnosis of neural and perineuronal disorders, the visibility scores for 3D T2 TSE (VISTA) were considerably better than those for 2D T2 TSE in identifying perineural cysts, spinal canal stenosis, and nerve root indentation.

An Uncommon Cause of Chest Pain from Tarlov Cysts

Tarlov cysts are often regarded as an incidental finding found on imaging as most patients are asymptomatic. However, Tarlov cysts can be symptomatic or increase in size over time to cause symptoms. We present a case of an uncommon cause of chest pain in a patient with Marfan syndrome who underwent extensive investigations before being diagnosed with radicular chest pain from Tarlov cysts at the thoracic level. Decompression of Tarlov cysts resulted in resolution of his chronic devastating chest pain.

Symptomatic Tarlov Cyst – Case Report and Review of the Literature

Here we describe the case of a 53 year old woman presenting with low back pain with radiation was diagnosed with sacral bilateral Tarlov cyst. She was treated by laminectomy, disintegration of cyst and duroplasty. Histopathological examination of the cyst wall was confirmed the diagnosis. Symptomatic Tarlov cysts are extremely rare, commonly presenting as sacral or lumbar pain syndromes, sciatica or rarely as cauda equina syndrome. Tarlov cysts should be considered in the differential diagnosis of patients presenting with these complaints. Bang. J Neurosurgery 2023; 12(2):125-128

Symptomatic lumbar Tarlov cyst resolution after computed tomography-guided percutaneous trans-sacral fibrin glue intracystic injection: A case report and literature review

Symptomatic lumbar Tarlov cyst resolution after computed tomography-guided percutaneous trans-sacral fibrin glue intracystic injection: A case report and literature review

Thecaloscopy Reduces the Risk of Recurrent Perineural (Tarlov) Cysts after Microsurgical Resection.

Sacral Tarlov cysts (TCs), often asymptomatic, can cause significant pain and severe neurological dysfunction. Conventional treatments are generally associated with high recurrence and complication rates. Specifically, the substantial recurrence rates, which can reach as high as 50%, significantly impact long-term outcomes. Recent evidence increasingly supports the hypothesis that the formation of Tarlov cysts (TCs) may be associated with inflammatory processes within the nerve root sheath, further exacerbated by elevated cerebrospinal fluid (CSF) pressure. This retrospective study explores thecaloscopy, combined with surgical techniques, as a more effective alternative. We observed a total of 78 patients, 48 of whom underwent endoscopic fenestration of the arachnoid sheath in addition to microsurgical resection of the TC. We found that the fenestration of the arachnoid sheath at the level of lumbosacral spinal nerve root entry led to a significantly decreased risk of developing recurrent TCs (5/48 vs. 9/30). Only one of the patients suffered from a persistent new bladder dysfunction after microsurgical resection. This presented technique provides a promising treatment path for the future management of TCs, offering a safe and more effective treatment option compared to previous methods. Additionally, the advantages of the thecaloscopy provide pathophysiological implications regarding the development of perineural cysts.

Surgical Intervention is Associated with Improvement in Health-Related Quality of Life Outcomes in Patients with Symptomatic Sacral Tarlov Cysts: Results from a Prospective Longitudinal Cohort Study

The treatment of symptomatic Tarlov cysts remains a controversial topic within neurosurgery. We describe our experience with patients who underwent surgical intervention for sacral Tarlov cysts at a single institution. General and disease-specific outcome measures were used to assess health-related quality of life. Patients who underwent surgical treatment for one or more sacral Tarlov cysts between 2018 and 2021 were included. The Tarlov Cyst Quality of Life (TCQoL), a validated disease-specific measure, was the primary outcome of the study. Secondary outcomes included general outcome measures: 36-Item Short Form Survey, the Oswestry Disability Index, and Visual Analog Scale. Patients were followed at 3, 6, and 12 months postoperative. Repeated measures analyses were used to assess change from preoperative to 12 months postoperative. Data were obtained from 144 patients who underwent surgery for sacral Tarlov cysts, average age 52.3 ± 11.3 years, 90.3% female. Patients reported significant mean improvement on the TCQoL over time (preoperative 3.2±0.1; 3-months postoperative 2.1±0.1; 6-months 1.9±0.1; 12-months 1.9±0.1; P< 0.001). Patient age and duration of symptoms were not associated with outcome. 82.3% of patients reported improvement on TCQoL. There was not a significant difference in the proportion of patients reporting improvement on TCQoL by cyst size (small 90.9% vs. large 77.9%; P = 0.066). Our longitudinal series demonstrated patient-reported improvement following surgery for symptomatic sacral Tarlov cysts using a validated disease-specific health-related quality of life scale through 12 months following surgery. Patient age and preoperative duration of symptoms were not correlated with outcome.

Post-traumatic hemorrhage in a large sacral Tarlov cyst causing acute radiculopathy

Symptomatic Tarlov cysts (TCs) are an under-recognized clinical entity that should be considered in the differential for lower back pain. These are more common in women and can also be a cause of pelvic pain. Hemorrhagic TCs have been rarely reported in the literature, with symptoms ranging from lower back pain and radiculopathy to symptoms of cauda equina syndrome. We report on a female patient in her 50s who presented with radicular symptoms as a consequence of TC hemorrhage. Magnetic resonance imaging is the gold standard investigation, and this showed post-traumatic hemorrhage causing irritation of the sciatic nerve. Hemorrhagic TC is an important differential to consider in the setting of acute radicular pain, and the symptoms can be resolved with conservative management.

Efficacy of neuroendoscopic-assisted surgery in the management of symptomatic sacral perineural (Tarlov) cysts: a technical report.

The Tarlov cysts are pathological enlargements of the cerebrospinal fluid spaces between the endoneurium and perineurium, which can cause intolerable sciatic pain, motor impairment of lower limbs, and bladder/bowel dysfunction. Currently, the treatment results are unsatisfactory due to the low cure rates and extensive surgical trauma. Thus, there is an ongoing exploration of surgical techniques for Tarlov treatment. In the current study, we present a novel neuroendoscopic-assisted technique that combines the fenestration, leakage sealing, and tamponade of the Tarlov cyst. Between January 2020 and December 2021, a total of 32 Tarlov patients were enrolled and received neuroendoscopic-assisted surgery. Their pre- and post-surgical Visual Analogue Scale (VAS) scores, major complaints, and MR imaging were recorded for comparison. 27 of 32 patients (84.4%) patients demonstrated immediate pain relief as their VAS scores decreased from 5.6 ± 1.5 to 2.5 ± 1.1 (p < 0.01) on the first day after surgery. At the 3-month follow-up, the patients' average VAS score continued to decrease (1.94 ± 0.8). Meanwhile, saddle paresthesia, urinary incontinence, and constipation were relieved in 6 (50%), 4 (80%), and 5 (41.7%), respectively, according to patients self-report. No surgical-related complication was observed in any of the cases. We conclude that neuroendoscopic-assisted surgery is an effective surgical method for symptomatic Tarlov cysts with minimized complications.

Symptomatic Tarlov cysts: A case series and effectiveness of multimodal rehabilitation plus pharmacological treatment

BackgroundTarlov 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. AimsWe 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 methodsRetrospective 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. ResultsTreatment improved mean pelvic floor muscle contraction from 9.2±6.01mmHg to 10.6±5.2mmHg (P=.3111) and maximal pelvic floor muscle contraction from 41.2±21.98mmHg to 45.8±17.51mmHg (P=.4430), and decreased pain from 8±1.26 points to 4.6±2.65 points (P=.0343). ConclusionsTarlov 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.

(148) “Zebras” in Sexual Medicine from Cauda Equina Pathology

Abstract Introduction Unrelenting, bothersome sexual medicine problems in individuals with a vulva or penis sometimes do not respond to conventional therapies, frustrating both patient and provider. These distressing problems can be categorized as a genito-pelvic dysesthesia (GPD), including genito-pelvic (penile, scrotal, clitoral, vulvar, vestibular, vaginal, bladder, rectal) pain, persistent genital arousal disorder (PGAD), sleep related prolonged erections (SRPE) and hard-flaccid syndrome (HFS), currently considered as “zebras” in sexual medicine. We recently published a study on 20 patients with PGAD/GPD who underwent a multi-disciplinary management algorithm, were determined to have lumbosacral annular tear induced sacral radiculopathy, and with one year follow-up post-spine surgery, 80% revealed improvement in symptoms. Objective To apply our (spine-sexual medicine) multi-disciplinary management algorithm to sexual medicine “zebras”. Methods Patients who presented between July 1, 2021, and June 30, 2023, to our sexual medicine clinic were included in the study cohort. The management algorithm was as follows: biopsychosocial history, multiple validated instruments, physical examination, neurogenital testing, regional anesthesia testing, lumbosacral MRI, and when appropriate, a caudal epidural or transforaminal epidural spinal injection. Those with clinically significant symptom reduction from the spinal injection were offered appropriate spine surgery. Patient Global Impression of Improvement (PGI-I) was assessed post-operatively (1 = very much better, 2 = much better, 3 = better, 4 = no change, 5 = worse, 6 = much worse and 7 = very much worse. Results Our study cohort consisted of 24 patients, 14 with a vulva and 10 with a penis, mean age 42 years (range 25-69) who presented to our clinic over a period of two years. The patients' GPD complaints included genital pain (13), PGAD (6), SRPE (2), HFS (1), bladder pain (1) and rectal pain (1). All patients had results of neurogenital and regional anesthesia tests consistent with sacral radiculopathy, then underwent a diagnostic focal lidocaine spinal injection. Each had a positive response to either a transforaminal epidural spinal injection and underwent lumbar endoscopic spine surgery (n = 21) or a caudal epidural and underwent Tarlov cyst surgery (n = 3). PGI-I scores after surgery indicative of improvement (PGI-I = 1, 2, 3) at one week was 10/22 (45%), at 6 weeks was 9/17 (53%) at 3 months was 9/16 (56%) and at 6 months was 5/6 (83%). Conclusions Patients presenting with sexual medicine complaints not successfully managed by routine treatment strategies often experienced delay in diagnosis and excessive healthcare-seeking behavior resulting in significant distress. In our experience, GPD can result from triggers in the cauda equina, far from the location of the presenting genito-pelvic symptom(s). Our cohort of sexual medicine “zebras” who underwent our multi-disciplinary management algorithm were diagnosed with sacral radiculopathy. These patients opted for spine surgery and reported improvement of symptoms that continued to get better over time. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Eliquence.

A bibliometric and visualization study of global research trends in sacral Tarlov cyst from 2000 to 2022.

Symptomatic sacral Tarlov cyst (STC) exerts a significant negative impact on the patient's quality of life, highlighting the significance of the increasing number of studies on STC. However, bibliometric analyses in this research field are scarce. Thus, this study aims to provide a comprehensive knowledge structure and identify the research trends of STC through bibliometrics. Articles related to STC from 2000 to 2022 were sourced from the Web of Science Core Collection database. VOSviewer 1.6.16, CiteSpace 6.1.6, GraphPad Prism 8.2.1 and R-package "bibliometrix" were used to analyse the data and generate knowledge maps. A total of 930 studies on STC from 2000 to 2022 were included. The findings revealed a consistent yet upward trend in the number of annual publications in this field. The United States, China and Turkey were the most prolific and influential countries contributing to this field, with the University of Illinois, the University of Maryland and the National Institute of Standards & Technology being the most notable research institutions. Key journals include World Neurosurgery [Impact Factor (IF) = 2.210], Journal of Vascular Surgery (IF = 4.860) and Journal of Neurosurgery-Spine (IF = 3.467). Additionally, Tarlov Mj, Tarlov E and Zachariah Mr exhibit the highest number of publications, making them the leading authors in this field. A twenty-year retrospection of research trends using keyword analysis reveals four principal directions, namely "definition", "pathogenesis", "diagnosis" and "treatment". Currently, therapeutic surgical intervention is the key treatment for this disease, with future treatments primarily hinging on minimally invasive methodologies rooted in microendoscopic and endoscopic techniques. This pioneering, comprehensive scientific bibliometric study provides a holistic summary of STC research trends and hot spots spanning the past 22 years. The results identify existing research frontiers and chart maps for future studies, serving as a valuable reference for scholars vested in this field.

CASE STUDY OF A TARLOV CYST IN A SYRIAN PATIENT

Tarlov cyst is a rare disease that affects the nervous system, which is a vesicle filled with spinal cord fluid, the cyst surrounding the nerve are fluid-filled sacs that greatly affect the nerve root and are detected by magnetic resonance in some cases the bag expands and put pressure on the affected nerve root. Several treatment methods have been used, including pharmacological and non-pharmacological methods such as cortisone injections and surgery. As a result of the multiplicity of information about Tarlov’s cyst disease, a questionnaire was conducted for the project to prove the views of its being a rare disease and to find out the extent of awareness in society in differentiating between symptoms associated with Tarlov’s cyst and other neurological diseases, we found that 86.4% of people who contributed in our questionnaire were not able to identify the disease, so we found its important to study the Tarlov cyst case that was diagnosed in 2019 which belongs to a 20-year-old girl. X-ray and MRI were used to diagnose Tarlov's Cyst after one year of the first visit to the doctor. After treating the cyst with muscle relaxants and cortisone for one year the pain persisted and surgery was carried out in 2021. Late diagnosis is common and the degree of knowledge of the disease is low even among medical practitioners. Therefore, we concluded that awareness must be spread through increased research and scientific seminars to introduce it, especially with regard to the medical branches.