PMC9314737_01
Presence of large bilateral sacral radicular cysts on MRI coronal (A), axial (B) and sagittal (C) T2-weighed sequences predominantly on the right L5 and S1, S2 and S3 roots (red arrows) and on the left L5 root (A). (C) correspond to dotted plane in (B). (B) Pelvic cystic formation of 36 x 29 mm on the right S1 nerve root (MRI axial view T2-weighed sequence), right (red arrow) and left (green arrow) sciatic nerves. (D) 3D reconstruction of the different cysts associated with the different nerve roots. Fluid-fluid level, on axial (E) and sagittal (F) T2-weighed sequences. (F) correspond to dotted plane in (E). Bleeding was noticed predominantly on the right L5 and S1 cysts (red asterisk) and appearing to sheath the distal portion of right S1 (red arrow). This intracystic hemorrhagic complication was probably due post-partum (G,H) Aspiration of a hemorrhagic liquid under pelvic-abdominal CT-scan guidance. (I) Fluid aspect. (J) Dimensions of this hemorrhagic cyst immediately after aspiration (CT-scan axial view): 31 x 25 mm. (K) MRI control 1 year after the procedure, with 3D reconstructions (L). Remodeling of the cyst was observed. A reduction of 7% of its initial volume was determined by volumetric analysis before and after the procedure, and the S1 root is better visualized. R = Right, L = Left, A = Anterior, P = Posterior.
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F1
Tarlov cysts extending from L5 to S3 roots discovered in 2016 on an MRI done for low back pain (Figures 1A, B), was admitted to our center 7 days after delivery for painful S1 right sciatica (intensity of 10 on visual analogic scale (VAS)). The patient presented without neurological motor deficit, especially on ankle plantar flexors and hip extensors testing. Magnetic resonance imaging (MRI) showed a large pelvic cystic formation of 36 x 29 mm on the right S1 nerve root (Figures 1D-F), with a fluid-fluid level corresponding to a post-partum hemorrhagic complication and compressing the distal portion of right S1 nerve. After a multidisciplinary discussion, a CT-guided puncture-aspiration of the cyst under local anesthesia was decided (Figures 1G, H). The procedure was performed without any complications; 8 cc of a hemorrhagic fluid was aspirated (Figure 1I), relieving the patient's sciatica immediately (intensity of zero on the VAS scale after the procedure). No sealing procedure was performed to limit the risk of intracystic rebleeding, and to avoid the risk of recompression due to the cyst filling on the S1 root. (Figure 1J) illustrates the decompression of the sciatic verve concomitant with the cyst shrinkage after aspiration (31 x 25 mm). The patient was still pain-free (VAS zero) at 12 months follow-up, and the Tarlov cyst did not fill-up on the MRI follow-up (Figures 1J, K).