原文：Spinal cord stimulation for the treatment of chronic pelvic pain after Tarlov cyst surgery in a 66-year-old woman: A case report
作者：Jamal Hasoon , Amnon A. Berger , Ivan Urits , Vwaire Orhurhu , Omar Viswanath, Musa Aner.
Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Boston, MA, United States of America(美国，波士顿)
编译：沈霖 杨敏 审校：郑学胜
Tarlov cysts are extradural meningeal cysts with collections of cerebrospinal fluid within the nerve sheath. These cysts are uncommon but tend to present more often in women. Symptomatic Tarlov cysts can lead to a variety of neurologic symptoms and painful conditions, including chronic pelvic pain. There is no consensus regarding the best treatment for symptomatic cysts. Surgical management has high rates of complication, including chronic pain, but better long-term results for symptom and cyst resolution. We describe a patient who developed worsening pelvic pain and lumbar radiculopathy after surgical management of her Tarlov cysts. Medication failed to relieve the pain, as did a variety of other procedures, before the patient ultimately received significant pain relief from high-frequency spinal cord stimulation. This case may provide guidance for physicians when managing patients suffering from symptomatic Tarlov cysts, or worsening pain symptoms after surgical management of these cysts.
The patient was a 66-year-old woman with a longstanding history of chronic pelvic pain secondary to multiple large Tarlov cysts affecting the S1-S4 nerve roots. She had attempted medication management with acetaminophen, NSAIDs, and neuropathic pain medications. She had also undergone a series of epidural steroid injections and a trial of superior hypogastric plexus blocks but obtain minimal relief with these. She ultimately had surgery for the removal of the Tarlov cysts as well as sacral lamina reconstruction (Fig. 1). However, the patient's surgery resulted in worsening of her chronic pelvic pain, and also produced new-onset back pain and lumbar radiculopathy down both legs. The patient reported constant debilitating back and pelvic pain with intermittent stabbing and burning pain in her legs. Her worsening symptoms were uncontrolled with continued medication management as well as a repeat series of epidural steroid injections.
Given that the patient's worsening symptoms were unrelieved with both medication management and interventional pain procedures, we tried high-frequency spinal cord stimulation for her worsening pain and new-onset radiculopathy.
The patient was counseled regarding the risks and benefits of the procedure and elected to proceed. A spinal cord stimulator lead was introduced into the epidural space and advanced to the superior endplate of T8. A second lead was placed at the superior endplate of T9 (Fig. 2). The patient presented for follow-up after the procedure and reported significant improvement in her symptoms. She noted that the use of SCS had resulted in a 90% improvement of her back pain, a 95% improvement in her pelvic pain, and N50% improvement in her radiculopathy. Additionally, she reported she was much more active and was able to decrease her medication use with the pain relief she obtained from spinal cord stimulation.
There is no consensus on the optimal management of symptomatic Tarlov cysts. Percutaneous cyst drainage is a nonsurgical intervention has been used to treat this condition. This treatment is only temporary though, as cysts tend to gradually reform and symptoms recur. In addition to percutaneous drainage, one study has demonstrated that cyst aspiration with the placement of fibrin glue can prevent recurrence of the cysts. However, these patients are also at significant risk for postprocedural aseptic meningitis.
Surgical treatment of symptomatic cysts varies and can involve complete cyst removal with excision of the affected posterior root and ganglion, decompressive laminectomy, cyst wall resection, and cyst fenestration. The success and complication rates vary greatly by procedure. Again, there is no consensus regarding when surgical management for Tarlov cysts is warranted, though one study suggested that cysts larger than 1.5 cm with associated radicular pain or bowel/bladder dysfunction may benefit the most from surgical intervention.
We would also like to comment on the success of spinal cord stimulation in this patient. SCS has been proven to be effective for treating intractable neuropathic pain such as lumbar radiculopathy and postlaminectomy syndrome. There is also growing evidence that SCS can even be helpful for treating debilitating chronic visceral pelvic pain. We believe this case is of importance as it describes the complicated management of patients with symptomatic Tarlov cysts who ultimately fail to respond to conservative therapy. We also describe the use of SCS in this patient and the benefit it can provide for patients who are suffering from severe radiculopathy after surgery as well as those with chronic pelvic pain (Fig. 3).