Resection and imbrication of symptomatic sacral Tarlov cysts: A case report and review of the literature

Giant Tarlov Cyst presenting as pelvic mass: Often doing less is better

Background

Tarlov cysts are sacral perineural cysts arising between the peri and endoneurium of the posterior spinal nerve root at the Dorsal Root Ganglion and have a global prevalence rate of 4.27%. These are primarily asymptomatic (only 1% with symptoms) and typically arise in females between the ages of 50-60. Patients' symptoms include radicular pain, sensory dysesthesias, urinary and/or bowel symptoms, and sexual dysfunction. Non-surgical management with lumbar cerebrospinal fluid drainage and computerized tomography-guided cyst aspiration typically provide only months of improvement before recurring. Surgical treatment includes a laminectomy, cyst, and/or nerve root decompression with fenestration of the cyst and/ or imbrication. Early surgery for large cysts provides the longest symptom-free periods.

Case Description

A 30-year-old male presented with a very large magnetic resonance-documented Tarlov cyst (Nabors Type 2) arising from bilateral S2 nerve root sheaths with marked pelvic extension. Although he was initially treated with a S1, S2 laminectomy, closure of the dural defect, and excision/marsupialization of the cyst, he later required placement of a thecoperitoneal shunt (TP shunt).

Conclusion

A 30-year-old male with large Nabors Type 2 Tarlov cyst arising from both S2 nerve root sheaths required a S1-S2 laminectomy, dural closure/marsupialization, and imbrication of the cyst, eventually followed by placement of a TP shunt.

Perineural cyst with intracystic hemorrhage following aneurysmal subarachnoid hemorrhage: A case report

RATIONALE

Most perineural cysts are asymptomatic and discovered incidentally at the time of imaging. Although enlargement of the perineural cyst (PC) through a ball-valve mechanism and resultant compression of the adjacent neural or bony structures are known to be a source of pain in PCs, the reason why asymptomatic PCs become symptomatic is unclear. The authors report a case of PC, which was presumed to become symptomatic after subarachnoid hemorrhage without enlargement of the pre-existing PC.

PATIENT CONCERNS

A 47-year-old woman complained of lumbosacral pain after neck clipping for a ruptured cerebral aneurysm.

DIAGNOSES

Magnetic resonance imaging (MRI) revealed a PC with intracystic hemorrhage at the S2 level. In comparison with the size of the PC on computed tomography performed 3 years ago, there was no change in the size. Electrodiagnostic studies performed 6 weeks after the onset of the pain showed subacute right S2 radiculopathy.

INTERVENTIONS

With conservative treatment, her pain gradually diminished.

OUTCOMES

When the lumbosacral pain improved, follow-up MRI showed that a fluid-fluid level within the PC disappeared.

LESSONS

Hemorrhage from the subarachnoid space, such as spontaneous aneurysmal SAH, into the pre-existing PC can cause an asymptomatic PC to become symptomatic without getting enlarged. Stretching of the nerve root due to hemorrhage or irritation of the nerve root due to an inflammatory reaction to blood products can make asymptomatic PCs symptomatic without enlargement of PCs.