• Semih Gungor and Asli Ozcan.
• Division of Pain Medicine, Department of Anesthesiology, Hospital for Special Surgery-Weill Cornell Medicine Touro College of Osteopathic Medicine, New York.
• Medicine (Baltimore). 2018 Sep 1; 97 (37): e12389.

RationalePerineural cysts, commonly referred to as Tarlov cysts, are cerebrospinal fluid-filled dilations between the perineurium and endoneurium typically arising at the junction of posterior and dorsal root ganglia in the neural foramina. This anatomical location is in close proximity to usual needle trajectory during performing transforaminal epidural injection, and therefore presents a potential risk of dural puncture and associated complications.Patient ConcernsSevere lower extremity pain interfering with activities of daily living.DiagnosesLumbar radiculopathy secondary to left-sided L4-5 disc herniation in the presence of multilevel Tarlov cysts in the neural foramina.InterventionsPosterior interlaminar epidural steroid injection technique was preferred, as opposed to transforaminal approach, to avoid potential risk of dural puncture and associated complications in the presence of multilevel Tarlov cysts in the neural foramina.OutcomesThe patient responded favorably to epidural steroid injection via interlaminar approach with complete resolution of pain, symptoms, and signs. There were no complications. The patient was able to tolerate physical therapy, wean pain medications, and achieve normal activities of daily living without any significant limitations.LessonsIn patients presenting with an MRI report of "Tarlov cysts", meticulous evaluation of diagnostic images should be an essential first step before considering invasive spinal procedures. Should there be any presence of Tarlov cyst in close proximity to planned needle trajectory, we recommend appropriate modification of spinal intervention to avoid potential complications.

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