A 40-year-old male presented with a 3-year history of sensory changes involving the S2–S3 distribution in the right leg (e.g., hypoesthesia without motor weakness or dysuria). The lumbosacral MRI showed a noncontrast enhancing right-sided cystic mass at the S2–S3 level; it had the same intensity as CSF on both the T1- and T2-weighted images []. Coronal fat-suppressed T2-weighted images revealed the mass likely originated from the right S3 nerve root and was additionally compressing the right S2 nerve root [].\nA laminoplastic laminotomy was performed at three levels using an ultrasonic bone curette. At surgery, the S3 nerve root was enveloped within cyst wall and the S2 nerve root was clearly compressed [Figure and ]. Partial resection of the cyst wall and imbrication of residual tissue was performed []. An inlet from the subarachnoid space was identified, and its obliteration was confirmed by a Valsalva maneuver []. This subarachnoid connection was sealed with adipose tissue and fibrin glue []. Plication of the cyst wall was performed with nonpenetrating titanium clips (Vascular Clip System; LeMaitre Vascular Inc., Burlington, MA) []. No postoperative CSF leakage occurred, and spinal lumbar drainage was not warranted. The patient's preoperative sensory disturbance resolved. The postoperative MRI showed a reduction in the cyst's size [Figure and ] and no residual compression of the S2 nerve root []. Histopathological examination confirmed collagen connective tissue without nerve fibers, findings consistent with a Tarlov cyst []. The patient remained asymptomatic 6 months later, and the 6-month postoperative sacral MRI demonstrated no cyst recurrence.
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).