Hiding in Plain Sight: A Case of Tarlov Perineural Cysts

A 52-year-old woman sought help for intractable lumbosacral pain, which began after she lifted a heavy object and fell onto her back more than 2 decades ago. Additional symptoms included burning, numbness, tingling, and pain in her right hip, posterior thigh, leg, and toes, and diminished sensation and sensitivity throughout her right leg and foot. Muscle spasms/ cramps, which often interrupted sleep, were intermittently present in her right buttock and right lower extremity. Right-foot drop impaired her ability to walk, and she used a wheeled walker with a seat because she could not walk more than a few steps without sitting. Other problems included: Severe pressure-type headaches, chronic abdominal and pelvic pain, cervical and thoracic back pain, frequent urinary tract infections, and urinary incontinence. Her pain increased with sitting, standing, and walking, and had been refractory to ibuprofen 800 mg tid, gabapentin 300 mg tid, oxycodone/acetaminophen 5/325 mg q4h PRN, and cyclobenzaprine 10 mg tid. Her medical history was unremarkable and her family history was notable for above-average height; most women in her paternal family are 5’10’’ to 6’ tall, and most men are 6’4’’ and taller. Many died in their 40s, and her brother and sister had been diagnosed with possible multiple sclerosis. Magnetic resonance imaging (MRI) of her pelvis revealed sacral nerve root cysts that were more completely imaged by sacral MRI (Fig 2). An MRI of the cervical spine from 2007 showed only mild C4-5 disc protrusion, but a repeat MRI in 2009 noted multilevel mild degenerative changes and small (#.6 cm) perineurial cysts at C4-5, C5-6, C6-7, C7-T1. In 2007, an MRI of the thoracic spine was interpreted as normal. The patient stated, ‘‘Everything in my life has been destroyed by these symptoms. It took over 2 decades