Giant Symptomatic Bilateral Sacral Tarlov Cysts – A Case Report

Sacral perineural cyst was first described as an incidental autopsy finding by Tarlov in 1938 [1]. Tarlov or perineural cysts are nerve root cysts found most commonly at the sacral spine level arising between covering layers of the perineurium near the dorsal root ganglion [2]. Paulsen reported the incidence of Tarlov cysts as 4.6% in back pain patients where a consecutive 500 MRIs were considered of which 20% patients were symptomatic [3]. Fewer than 100 cases of symptomatic Tarlov cyst have been described in literature but this case is unique in the sense that the cysts were gigantic and involved both S2 nerve roots causing bilateral S2 radiculopathy, which has been associated with higher morbidity [4]. There is only one case of bilateral single level Tarlov cysts in reported literature [5].

A 27-year-old female presented with bilateral radiculopathy involving both S2 dermatomes with more pain on the right side for six months prior to presentation to our clinic. She had difficulty in walking due to pain and could walk only with assistance. On clinical examination, straight leg raise was restricted to 30 degrees with reflexes being (++). Her sensory nervous system examination was normal as was her anal and urinary sphincter tone. Her laboratory studies were normal and she was negative for hepatitis B antigen and hepatitis C antibodies. MRI of the lumbosacral spine showed bilateral giant S2 Tarlov cysts (Figures 1 and 2).