Surgical management of a Symptomatic Sacral Tarlov cyst:A case report
Prakash Regmi1, Sandeep Bohara1,Alok C Thakur1, Dipendra K
Shrestha1, Gopal Sedain1
1 Department of Neurosurgery, Tribhuvan University
Institute of Medicine, Maharajgunj 44600, Nepal
Abstract
Tarlov cyst is a type II meningeal cyst most commonly found in the
sacral region. It is mostly asymptomatic, but it may present with low
back pain and bowel or bladder symptoms. Most of these cysts are
incidentally found on imaging. Symptomatic Tarlov cysts are extremely
rare, commonly presenting as sacral or lumbar syndromes or rarely as
cauda equina syndrome. We present a 28-year-old male with sacral Tarlov
cyst, back pain, and urinary symptoms who was successfully managed
surgically. We report this case to increase awareness of this rare
entity.
Keywords: Surgical management, Tarlov cyst, urinary symptoms
Introduction
The perineural cyst was found incidentally during an autopsy by Tarlov
in 1938 and is known as the Tarlov cyst. It is a benign cerebrospinal
fluid (CSF) filled cyst of the spinal roots[1]. The etiology of the
Tarlov cyst is unknown, but cyst growth may result from valve-like
microcommunication permitting only the influx of CSF [2]. These
cysts are often multiple and appear on dorsal nerve roots, most commonly
in the sacral region. Most cysts remain asymptomatic and are found
incidentally on imaging for other symptoms and signs. Few give symptoms
like pain, which can also be associated with bowel or bladder symptoms.
Surgical removal of perineural cysts is recommended if it is symptomatic
and not manageable medically [3]. These cysts can also be managed
conservatively with oral steroids and transforaminal epidural
steroids.[4]
We report a case of a 28-year-old male who had low back pain with
bladder and bowel symptoms caused by a sacral perineural cyst. He was
treated surgically with cyst fenestration.
Case history and examination
A 28-year-old right-handed male presented with a history of difficulty
in passing stool for one and a half years, which was then followed by
increased frequency of urination. Constipation was gradual in onset and
progressive. He then developed lower back pain, which radiated to the
right lower limb. He occasionally developed a tingling sensation in the
lateral aspect of the left lower limb up to the ankle, which was
aggravated due to constipation and was relieved only after passing
stool. The patient developed difficulty in passing urine and had to use
clean intermittent catheterization (CIC) to clear the bladder. There was
no history of trauma, fever, or limb weakness. In the past, he had
undergone a right inguinal hernioplasty.
On examination, the patient had a normal straight leg raising test and
normal power and sensations in bilateral lower limbs.
For the urinary symptoms, the patient was evaluated by a Urologist with
a cystoscopy, which showed a normal compliant bladder with a thin stream
of urine flow. Equivocal obstruction was observed with slightly weak
contractibility. Micturating cystourethrogram (MCU) found a cone-shaped
urinary bladder with increased volume.
Differential diagnosis, investigation and treatment
His lower back pain was persistent and was later evaluated with MRI of
the lumbosacral spine, which showed a fluid signal intensity lesion
(82x22x11mm) in the central spinal canal in the S2, S3, S4, and S5
sacral vertebra. The lesion extends into the right neural foramina of
the S3-S4 level. (fig1)