Intractable Lumbosacral Pain and Radiculopathy from a Recurred Large Tarlov Cyst
Meda Raghavendra MD, Rohan Meda
Loyola University Medical Center, Maywood, IL and Neuqua Valley High School, Naperville, IL
INTRODUCTION
TARLOV CYST
Tarlov's cysts are perineural cysts usually located in the sacral spine and
are incidental findings on MRI.(1) But some patients develop severe back
pain, radiculopathy, and neurological deficits including loss of
bowel/bladder function. Pain management may be medically challenging.
Cyst recurrence is common despite surgery. However, recent case
series show encouraging results.(2). Various analgesic pills do not get
absorbed and they just came out of the colostomy. Some opioids may not
be well tolerated. Fentanyl patches may not stick well. Sustained release
formulations of opioids are not available in liquid form. Antineuropathic
drugs like gabapentin and nortriptyline are also not available in liquid or
parenteral forms. Many branded analgesics are not covered by insurance.
Spine interventions like lumbar/caudal epidural or transforaminal
injections may not be practical, depending upon the size and location of
the cyst.
Tarlov cysts consist of CSF filled cysts in the sacral spine. They can
occasionally grow into big cysts, causing significant low back pain and
neurological deficits. Surgery is definitive treatment. However, the cysts are
known to recur. This poster is about a gentleman whose sacral cyst recurred
after surgery and who continues to have severe low back pain and left
lumbar radiculopathy. There are many medical challenges in treating this
gentleman.
CASE REPORT
52 y old gentleman presented with severe lumbosacral pain that radiated to
left leg. He had colostomy and he self catheterized for urine. He walked with
unsteady posture. His physical exam indicated left radicular features. MRI
showed a large sacral spinal cyst.
Managing patient's pain proved to be challenging. In the beginning his pain
was managed with hydrocodone-acetaminophen and gabapentin.
Nortriptyline made him too sleepy. He underwent sacral laminectomy, cyst
fenestration and imbrication with rotational flap. But the cyst recurred within
few weeks and his symptoms worsened. Hydrocodone-acetaminophen,
morphine ER/IR pills were not getting absorbed and started coming out into
his colostomy bag. Methadone and oxycodone were not tolerated. Fentanyl
patches did not stick well. Many branded analgesics were not covered by
his insurance. Spinal interventions were not practical, considering the big
size of the cyst.
Spinal cord stimulation therapy may be technically challenging and
expensive. Intrathecal therapy is not practical, since there is
communication with the big sacral cyst.
MRI lumbar spine sagittal view showing
recurrence of large sacral Tarlov cyst
REFERENCES
1. Vivek A., Irene R. Tarlov cysts. Incidental finding during subarachnoid
drain placement. Anesthesiology 2016.(125).598.
2. Elsawaf, A., Awad, T.E. & Fesal, S.S. Surgical excision of symptomatic
sacral perineural Tarlov cyst. Case series and review of literature. Eur
Spine J (2016). doi:10.1007/s00586-016-4584-3
Over the past 2 years, his pain has somewhat stabilized with the following
regimen:
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DISCUSSION
Fentanyl patch 25mcg/hr changed every two days instead of every three
days. He applies adhesive tape over the patch so that it sticks better.
Liquid morphine 15mg, 8-9 times/day for breakthrough pain.
Gabapentin capsules 2700mg/day
Cyclobenzaprine 10mg as needed.
He does home exercises and has quit smoking; He continues to follow up
with his neurosurgeon.
MRI lumbar spine axial view