A 45-year-old man was transferred to the emergency room, reporting a severe headache as well as sudden onset nausea. Upon neurological examination, he was found to be drowsy, but was otherwise normal. Brain CT revealed SAH in the bilateral Sylvian fissure, basal cistern and interhemispheric fissure (Fig. ). Three-dimensional brain CT angiography showed a right feeding anterior communicating artery aneurysm (Fig. ). Emergent cerebral angiography and endovascular coil embolization were performed (Fig. ). After embolization, the headache was alleviated and the patient's status improved each day. Soon after recovery, he reported worsening pain in the left perineal area. The pain was intermittent at onset and aggravated by sitting down, walking, straining and coughing. Although bed rest relieved the pain, he had difficulty falling asleep due to the pain. He had no history of previous back problems or recent trauma. Upon a second neurological examination, no abnormalities were found. Two weeks after embolization, lumbar spine MRI revealed 2 separated PCs at the S1 and S2 level affecting the left S2 root with high signal intensity in T2 and T1 images, suggestive of a hemorrhage within the cysts (Fig. ). The diameter of the larger cyst was 1.4 cm. The left S2 root was smaller than the right S2 root because it was compressed by increased intracystic pressure. Given that his symptoms were not relieved with analgesics or a caudal block, and the radiological evidence of PCs, we decided to perform cyst fenestration and imbrication.\nUnder general anesthesia, we performed partial laminectomies at S1 and S2 via a posterior approach. The 2 separate cysts were tense and swollen. When we incised the cyst, dark old blood drained out and the cyst contracted. After the hematoma evacuated, we could find the S2 nerve root inside the cyst (Fig. ). The patient's pain was relieved immediately after cyst fenestration and imbrication. In a follow-up 5 years after the surgery, the patient remained symptom free with no complications.
This 61-year-old man presented with 2-year history of increasing lumbosacral pain and hypesthesia. On neurologic exam, he showed right L5 and S1 radiculopathy. His symptoms were aggravated by standing, walking, climbing, coughing and lifting, and relieved by sitting. The patient rated his pain 7 of 10 on the visual analogue score (VAS). He had bladder dysfunction and abnormal sensation for urination, and reported insertion of a Foley catheter 2 months ago. Preoperative MR imaging demonstrated 30×17×11 mm sized sacral cyst with another small cyst from L5 to S2 level (). Myelogram and CT showed the contrast-filled bridge between the thecal sac and the cystic mass and sacral cyst causing compression of adjacent nerve roots (). An L5 laminectomy and S1-3 en bloc laminectomy were performed. After careful dissection of the cyst wall, we observed the superior surface of the cyst compressing S1 nerve root ventromedially and S2 nerve root dorsally (). It was connected with a small cyst that was adhesive to right S2 and S3 nerve roots. The main cyst originated from inferomedial side of right L5 nerve root. The cyst was opened and its content appeared the same as the CSF content. We ligated the neck of the cyst and its wall was cut down away from the adjoining root sleeve. The sacral lamina was recapped at the back again with using heavy silk sutures (). His lumbosacral pain and radiculopathy improved progressively after surgery. Postoperative two weeks, he removed the Foley catheter. Follow up MR imaging after 6 months demonstrated complete resolution of the cyst (). At one year follow up, he had mild back pain (2 of 10 on the VAS).