43-year-old female without insurance with progressive back pain for two years due to multiple symptomatic Tarlov Cysts

Suwanee, GA

Introduction: Tarlov Cysts (TCs) are meningeal cysts that can affect spinal nerve roots, usually in the sacrum. Pathology is largely unclear. Women are twice as affected as men, with increased incidence around 40-50 years old. These cysts are generally asymptomatic and incidentally found on imaging. Estimated prevalence is 4.6%, with approximately 1% of TCs causing nonspecific symptoms like low back pain. Due to its vague symptomatology, TCs are commonly misdiagnosed. Because most TCs are asymptomatic, treatment guidelines for symptomatic cysts are ill-defined; however, surgical removal should be considered for TCs >1.5cm or causing symptoms to prevent possible progression to nerve root impingement, neurologic deficits, intractable sciatica, or cauda equina syndrome.

Patient Case: A 43-year-old woman complaining of severe lower back pain and numbness is referred to the ED by her orthopedist for concern of cauda equina syndrome. Symptoms radiate to her right lateral thigh, groin, and buttock bilaterally. She describes a significant 2-year history of progressive intractable lower back pain resulting in her losing her job and health insurance. During this time, she saw various physicians who attributed her symptoms to insomnia, anxiety, kidney stones, hemorrhoids, IBS, and sciatica. Colonoscopy, spine x-rays, and abdomen/pelvis CT were largely unremarkable. Hydroxyzine, acetaminophen-codeine, trigger point injections, and oxycodone-acetaminophen yielded no relief. On physical examination in the ED, she is afebrile and wincing in pain. Sensation of the right lateral thigh is diminished, with intact rectal sensation. RLE strength is 4/5, and LLE 5/5. Reflexes are 2+ and symmetric. Spine MRI reveals numerous TCs measuring up to 1.9 cm from T12 to S3. She is referred back to her orthopedist where she opts for conservative treatment, including SI joint, trigger point, and facet steroid injections, oral analgesics, warm baths, and core strengthening exercises. After 5 months of failed treatment, she undergoes spinal laminectomy with TC removal, ultimately providing significant resolution of symptoms and restoring her ability to perform activities of daily living.

Discussion: Due to its vastly asymptomatic nature, TCs are commonly considered incidental findings when noted on imaging. As illustrated in this case, our patient underwent multiple assessments for her back pain before diagnosing her multiple symptomatic TCs. Her uninsured status may have contributed to her delayed diagnosis, given patient and physician hesitancy to proceed with expensive or invasive testing for her workup. However, it is important to consider less common conditions such as symptomatic TCs in the differential for patients suffering from otherwise unexplained progressive low back pain. Obtaining spinal MR imaging earlier in the patient’s presentation may have prevented progression to neurologic deficits, loss of job, and prolonged decrease in quality of life.