Author: Dr Ngian Kite Seng & Dr Tan Chong Tien
Date: February 2012 Issue
Welcome back to a new series of Spine Clinics 2012. This year, we will be presenting a series of common and not so common conditions, together with a brief wirte up of its diagnosis and treatment options. Hopefully, this will be of use when you treat your patients.
PRESENTATION
This 36 year old Chinese male presented with right buttock pain radiating to the back of the thigh and occasional pain in the perianal region. Pain is worse with walking for a distance and with sitting. Straight leg raise was limited to 60 degrees on the right. There was no neurological deficits at rest. There was no bladder or bowel abnormalities. He was otherwise well. When first seen, he had symptoms for 1-2 months. Sitting and walking for more than 5 minutes caused discomfort.
INVESTIGATIONS
Investigations included MRI of the Lumbosacral spine which showed a large Tavlov Cyst at S1 on the right and S2 on the left. There was no bony erosion.
MRI of the cervical gland thoracic spine showed no neural compression. MRI of the right thigh and hip showed mild hip effusion but was otherwise normal.
The neurologist’s opinion was that the symptoms were due to pressure from the Tavlov Cyst as there were no other pathologies found.
TREATMENT:
Symptoms were persistent for about 6 months despite observation and medications. He also tried acupuncture. He was very much affected as he could not sit comfortably for even 5-10 minutes. Surgery was eventually conducted after 6 months of symptoms.
SURGERY:
There was a large cyst at S1 and S2 communicating with the main dural sac via a narrow neck. The pressure in the cyst changes with filling of the cyst. Sacral nerves travel through the neck of the cyst to exist the sacral canal. As such, we decided on simple decompression of the S1 root and a laminectomy and not excision of the cyst which will require the sacrifice of sacral nerves passing through the neck and cyst.
PROGRESS:
Soon after surgery, he could sit longer for about 1-2 hours. Walking was improved to 20 minutes. However, it took several months for him to recover more and when seen 6 months post-surgery, he was able to sit for 4-5 hours before feeling any aches, and could even walk quite normally.
DISCUSSION:
Tavlov cysts are meningeal dilations of the posterior nerve root sheath that most often affect sacral roots. The distinctive feature of Tavlov cyst is the presence of nerve fibers in the cyst wall or within the cyst itself. It is estimated to affect 5-9% of the population.
Most Tavlov cysts are small and asymptomatic and are often incidental findings on MRI scans. Asymptomatic cysts do not need treatment.
Some large Tavlov cysts may however cause symptoms: Backache, radicular symptom, and even bladder and bowel dysfunction have been reported.
