A perineural cyst in the cervical spine is a fluid-filled sac that forms along a nerve root in the neck, and it is exceptionally rare. These cysts, also called Tarlov cysts, overwhelmingly appear in the lower spine, particularly around the sacrum. When one shows up in the cervical region, it catches clinicians off guard because the vast majority of medical literature and clinical experience concerns sacral cysts. The rarity makes diagnosis tricky and the evidence base thin, but several case reports and broader studies on perineural cysts offer a useful picture of what to expect.
What a Perineural Cyst Actually Is
Perineural cysts are dilations of the meningeal lining that surrounds spinal nerve roots, typically forming near the dorsal root ganglion, the cluster of nerve cell bodies just outside the spinal cord. Unlike simple fluid collections, these cysts have nerve fibers embedded in their walls, which is one reason they can cause pain and neurological symptoms when they grow large enough to press on surrounding structures.1BMJ Case Reports. Symptomatic Tarlov cyst in cervical spine The cysts are filled with cerebrospinal fluid and often maintain tiny connections to the subarachnoid space, the fluid-filled area around the spinal cord.
Most perineural cysts sit quietly on imaging and never cause problems. They are considered benign, and the majority are found incidentally during MRI scans ordered for something else entirely.2PubMed Central. Symptomatic cervical perineural (Tarlov) cyst: a case report The trouble starts when a cyst enlarges enough to compress a nerve root or other nearby tissue.
Why the Cervical Spine Is an Unusual Location
The sacral canal, especially at the S2 and S3 levels, is by far the most common site for perineural cysts.3PLoS ONE. Incidence of Spinal Perineurial (Tarlov) Cysts among East-European Patients A meta-analysis covering over 13,000 subjects confirmed that sacral cysts strongly outnumber those found at any other spinal level.4PubMed Central. Global incidence of spinal perineural Tarlov’s cysts and their morphological characteristics: a meta-analysis of 13,266 subjects Cervical, thoracic, and lumbar perineural cysts do occur, but they are rare enough that each published case tends to appear as an individual case report rather than part of a series.
Why the sacral region dominates is not fully settled. The sacral nerve roots have a longer course within the spinal canal, and the dural sleeves in the lower spine may be more susceptible to the hydrostatic pressures of cerebrospinal fluid. Cervical nerve roots, by contrast, exit the spine more quickly and at different angles, which may make cyst formation less likely. One study of an East-European population noted that all cervical perineural cysts in their dataset were found in women, hinting at possible sex-linked anatomical or hormonal factors, though the numbers were too small to draw firm conclusions.5PLoS ONE. Incidence of Spinal Perineurial (Tarlov) Cysts among East-European Patients
How a Cervical Perineural Cyst Causes Symptoms
The leading explanation for why some perineural cysts become painful while others remain silent involves a ball-valve mechanism. The tiny connections between the cyst and the subarachnoid space allow cerebrospinal fluid to flow into the cyst during moments of increased pressure, like coughing, straining, or changing position. Fluid enters more easily than it leaves, so the cyst gradually inflates. As it expands, it pushes against neighboring nerve fibers and can eventually compress the nerve root itself.6Clin Med Rev Case Rep. Symptomatic Cervical Perineural Tarlov Cyst: A Case Report
This mechanism explains why symptoms often fluctuate. Patients commonly report that pain worsens with coughing, standing, or sudden movements, all of which briefly spike cerebrospinal fluid pressure and push more fluid into the cyst. It also helps explain why some large cysts remain asymptomatic: if the valve-like connection allows fluid to flow freely in both directions, pressure inside the cyst stays low and the nerve root is not compressed. The onset of symptoms can be gradual or sudden, depending on how quickly fluid accumulates and whether a particular cyst’s anatomy favors one-way flow.7Clin Med Rev Case Rep. Symptomatic Cervical Perineural Tarlov Cyst: A Case Report
What Symptoms Look Like in the Neck
When a perineural cyst in the cervical spine becomes symptomatic, it typically produces radicular symptoms: pain, tingling, or numbness that radiates from the neck into the shoulder, arm, or hand along the path of the compressed nerve root. The pattern depends on which nerve root is affected. A cyst at C5-C6 might cause pain and sensory changes in the outer forearm and thumb, while one at C7-C8 could affect the inner arm and hand, and potentially cause weakness in the triceps or grip.8PubMed Central. Successful Conservative Management of a Patient With Symptomatic Cervical Perineural Cysts: A Case Report
Reported cases describe a consistent clinical picture. One involved a 44-year-old woman with a three-week history of right-sided C6 nerve root symptoms traced to a cyst at C5-C6.9PubMed Central. Symptomatic cervical perineural (Tarlov) cyst: a case report Another described a 56-year-old woman with four weeks of neck and arm pain, tingling, and mild triceps weakness stemming from cysts affecting the C7 and C8 nerve roots.10PubMed Central. Successful Conservative Management of a Patient With Symptomatic Cervical Perineural Cysts: A Case Report What is worth noting is that these symptoms can mimic a herniated cervical disc or other common causes of neck-related nerve pain, which is precisely why the cyst is often discovered only after imaging for a suspected disc problem.
Symptomatic cervical perineural cysts are described in the literature as extremely rare, and when they do cause symptoms, the main mechanism is compression of the cervical nerve root.11PubMed Central. Treatment of a symptomatic cervical perineural cyst with ultrasound-guided cervical selective nerve root block: A case report Because the cervical spine is more mobile than the sacrum and hosts the nerve roots controlling the arms and hands, even a modestly sized cyst in this region can produce noticeable symptoms.
How They Are Found
MRI is the primary tool for identifying perineural cysts anywhere in the spine, including the cervical region. On MRI, these cysts appear as well-defined fluid-filled structures adjacent to the nerve root, showing the same signal characteristics as cerebrospinal fluid. A cervical perineural cyst is typically identified after a patient undergoes imaging for neck pain or radiculopathy and the scan reveals the cyst instead of (or in addition to) a disc herniation.12PubMed Central. Symptomatic cervical perineural (Tarlov) cyst: a case report
The diagnostic challenge lies in distinguishing a perineural cyst from other cystic or tumor-like structures in the spine. The main look-alikes include synovial cysts near the facet joints, nerve sheath tumors, meningoceles, and traumatic fluid collections. One important differentiator is contrast enhancement on MRI: perineural cysts and synovial cysts generally do not light up with contrast dye, while nerve sheath tumors typically do, showing varying patterns of enhancement. When the imaging is ambiguous, contrast administration helps sort out whether a mass needs a biopsy or can be monitored.13Singapore Medical Journal. Clinics in diagnostic imaging (181)
CT myelography, in which contrast dye is injected into the spinal fluid and then imaged with a CT scanner, can sometimes show delayed filling of the cyst, providing further evidence of the one-way valve mechanism described above. This test is used less routinely than MRI but can be helpful when the diagnosis is uncertain or when planning an intervention.
Conservative Treatment and When It Works
For many cervical perineural cysts, the first-line approach is conservative management: rest, activity modification, anti-inflammatory medication, and sometimes a soft cervical collar to limit neck movement. The rationale is straightforward. Since the cyst’s symptoms are driven by pressure fluctuations, reducing activities that spike cerebrospinal fluid pressure can sometimes allow the cyst to stabilize and symptoms to subside on their own.
The evidence from published cases supports this approach. In the case of the 44-year-old woman with a C5-C6 cyst, a two-week course of wearing a soft collar combined with a 15-day course of oral anti-inflammatory medication and activity restrictions resulted in about 90% improvement in symptoms at a two-year follow-up.14PubMed Central. Symptomatic cervical perineural (Tarlov) cyst: a case report The 56-year-old woman with C7 and C8 involvement was also managed conservatively.15PubMed Central. Successful Conservative Management of a Patient With Symptomatic Cervical Perineural Cysts: A Case Report
Beyond basic rest and anti-inflammatories, steroid injections targeted at the affected nerve root have been used. Oral and epidural steroid therapy have been reported as successful for both lumbar and cervical perineural cysts.16PubMed. Conservative management of perineural cysts Another case documented the use of an ultrasound-guided selective nerve root block at the cervical level to manage radicular pain from a perineural cyst.17PubMed Central. Treatment of a symptomatic cervical perineural cyst with ultrasound-guided cervical selective nerve root block: A case report These injections aim to reduce inflammation around the compressed nerve root rather than shrink the cyst itself.
When Surgery Comes Into the Picture
Surgery for perineural cysts is generally reserved for cases where conservative measures fail and symptoms significantly impair daily life. Because cervical cysts are so rare, there is no large surgical series focused specifically on the cervical spine. Most surgical outcome data comes from sacral Tarlov cysts, where the evidence base is larger.
A series of 97 consecutive patients who underwent surgery for Tarlov cysts (predominantly sacral) found that about three-quarters reported good or excellent improvement in symptoms afterward. The complication rate was roughly 18%. Patients whose primary symptom was sacral or lower back pain were more likely to benefit, while those who had undergone previous lower back surgery were less likely to see improvement.18Global Spine Journal. Operative Treatment of Tarlov Cysts – Outcomes and Predictors of Improvement after Surgery: A Series of 97 Consecutive Patients and a Systematic Review of Literature These numbers give a general sense of what surgical treatment looks like for perineural cysts, though outcomes for cervical cysts specifically could differ given the different anatomy and surgical access.
Percutaneous interventions, where a needle is guided into the cyst to drain it or inject fibrin glue to seal it, have also been used. A review covering over 1,000 referrals for Tarlov cysts documented a complication rate of about 21% with percutaneous procedures. The most common complications were temporary increases in sciatica-like pain, spinal fluid leaks requiring a blood patch, and short-lived increases in local pain. Most of these resolved within three months.19PubMed Central. Management of Tarlov cysts: an uncommon but potentially serious spinal column disease—review of the literature and experience with over 1000 referrals Whether percutaneous approaches are appropriate for cervical cysts is a question that has limited direct evidence, given that the anatomy of the neck makes needle access more complex and the stakes of a complication near the spinal cord in the cervical region are higher.
The Connection to Connective Tissue Disorders
One of the more interesting threads in the perineural cyst literature is the association with connective tissue disorders, particularly Ehlers-Danlos syndrome. People with EDS have weaker connective tissues throughout the body, and this can affect the dura (the tough membrane surrounding the spinal cord) and the perineurium (the sheath around nerves). A review of neurological manifestations in EDS noted anecdotal associations between the condition and Tarlov cysts, though solid epidemiological data confirming how often this co-occurs remains lacking.20PubMed. Neurological and spinal manifestations of the Ehlers-Danlos syndromes
Case reports have documented Tarlov cysts in pediatric EDS patients, which is unusual on two counts: perineural cysts are rare in children overall, and their appearance in someone with a known connective tissue disorder suggests that structural weakness in the dural covering may predispose to cyst formation. One reported case involved an 11-year-old boy with EDS who developed bowel and bladder incontinence traced to a Tarlov cyst.21PubMed Central. A Case of a Tarlov Cyst in a Pediatric Patient With Ehlers-Danlos Syndrome For people with EDS or similar conditions who develop unexplained neurological symptoms, the possibility of a perineural cyst is worth raising with a clinician, even though it remains a low-probability diagnosis.
Who Gets Perineural Cysts and Why Women Appear More Affected
Across all spinal locations, women are disproportionately affected by symptomatic perineural cysts. A review drawing on over 1,000 referrals noted that women more commonly present with long-standing pain and neurological problems from Tarlov cysts.22PubMed Central. Management of Tarlov cysts: an uncommon but potentially serious spinal column disease—review of the literature and experience with over 1000 referrals In the East-European study mentioned earlier, every cervical perineural cyst identified was found in a female patient.23PLoS ONE. Incidence of Spinal Perineurial (Tarlov) Cysts among East-European Patients And the published cervical case reports consistently describe women in their forties and fifties.
The reasons for this sex disparity are not well understood. Hormonal influences on connective tissue elasticity are one hypothesis. Women tend to have somewhat more extensible connective tissue than men, potentially making the dural sheaths around nerve roots more susceptible to ballooning under pressure. Another possibility is detection bias: women may undergo more spinal imaging for pain conditions, increasing the chance of incidental cyst discovery. Without prospective studies tracking cyst development in large populations, the true cause remains speculative.
Mistaken for a Disc Problem
Perhaps the most practical concern for anyone with a cervical perineural cyst is the diagnostic confusion it creates. The symptoms of a cervical perineural cyst, including radiating arm pain, numbness, tingling, and occasional weakness, are identical to those caused by a herniated cervical disc. A clinician who does not look carefully at the MRI or who is unfamiliar with perineural cysts in the cervical region could attribute the symptoms to a disc abnormality, especially since mild disc bulges are common findings in adults and may be present on the same scan.
The distinction matters because the treatment path is different. Disc herniations and perineural cysts share some conservative strategies (rest, anti-inflammatories, sometimes steroid injections), but if conservative treatment fails, the surgical approach diverges completely. Operating on a disc that is not actually causing the patient’s symptoms while ignoring a cyst that is would obviously not resolve the problem. If you have been diagnosed with cervical radiculopathy and standard treatments are not helping, it may be worth asking your radiologist or spine specialist to review the imaging specifically for cystic structures near the nerve root.
Living with an Incidental Finding
Many people learn they have a perineural cyst not because they went looking for one but because it appeared on an MRI done for another reason. If the cyst is not causing symptoms, the overwhelming consensus is to leave it alone. Asymptomatic perineural cysts do not require treatment, and the mere presence of one on imaging does not mean it will ever become a problem.
That said, knowing the cyst exists can be useful information to file away. If you later develop neck pain or radicular symptoms, the cyst becomes a potential suspect worth re-evaluating. A follow-up MRI can determine whether it has grown. The ball-valve mechanism means that a cyst that was stable for years could, in theory, begin expanding after an event that changes cerebrospinal fluid dynamics, such as a prolonged episode of coughing, heavy straining, or trauma. There is no evidence that routine surveillance imaging of asymptomatic cysts changes outcomes, so periodic monitoring is typically guided by symptoms rather than a schedule.
For those whose cervical perineural cyst does become symptomatic, the published cases offer cautious encouragement. The condition is poorly understood compared to disc disease or stenosis, and finding a clinician experienced with Tarlov cysts (even sacral ones) can be difficult. But the available evidence suggests that many symptomatic cervical cysts respond well to conservative treatment, and the prognosis at longer follow-up periods can be quite favorable when the cyst is managed without surgery.