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Images in Neurology
May 18, 2020

Unexpected Resolution of a Symptomatic Tarlov Cyst Following Hysterectomy

Author Affiliations
  • 1Computational Neurosciences Outcomes Center, Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
JAMA Neurol. Published online May 18, 2020. doi:10.1001/jamaneurol.2020.1078

A 52-year-old woman presented with a 6-month history of coccygeal tenderness, perineal pain, and discomfort along with vaginal heaviness and fullness. The pain was intermittent and refractory to medical management and worsened 2 weeks before presentation following sexual intercourse. The patient was otherwise neurologically intact. On imaging, the patient had a large, multifibroid uterus as well as multiple sacral perineural cysts, with the largest one being a 5.2-cm left S3 cyst with presacral extension (Figure 1). The symptoms were not believed to be associated with the perineural cyst and the patient was advised to undergo treatment for fibroids. The patient underwent a uterine hysterectomy without any relief of pain symptoms. At follow-up 2 weeks after her hysterectomy, the patient reported persistent, worse pain with no bowel/bladder or other neurological disturbance. However, she was again advised against surgery given the high risk of cerebrospinal fluid (CSF) fistula because of the large cyst size and uncertainty about symptom improvement following surgery. The patient was also advised to undergo a new sacral magnetic resonance imaging scan to evaluate for any increase in cyst size because the tamponading effect of uterus was now absent. At follow-up 6 weeks after her hysterectomy, the patient reported a gradual relief of pain symptoms. Follow-up imaging results 3 months later revealed a marked decrease in the size of the largest perineural cyst (Figure 2). There was no change in the size of other cysts. The patient also reported a dramatic resolution of her symptoms and was no longer taking pain medications. At 1-year follow-up, the patient remained symptom-free.

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