Other / General Medicine
Myrna Hanna, DO
Resident Physician
Montefiore Medical Center
New Hyde Park, New York, United States
Sammy Wu, MD
Cancer Rehabilitation Physiatrist
Memorial Sloan Kettering Cancer Center
White Plains, New York, United States
Lisa Ruppert, MD
Cancer Rehabilitation Physiatrist
Memorial Sloan Kettering Cancer Center
New York, New York, United States
Sammy Wu, MD
Memorial Sloan Kettering Cancer Center
Brooklyn, New York, United States
Neurofibromatosis Type 2 (NF2) with a Symptomatic Tarlov Cyst
Case Description:
A 42-year-old woman with NF2 presented with constipation, dyspareunia, incomplete bladder emptying, and worsening right sacral/coccyx pain. Her back pain began in 2023, worsened with aerobic exercise, bowel movements, and intermittently radiated posteriorly down both legs. Physical exam was notable for decreased sensation in the L2, L3, L4, L5, and S2 dermatomes at the right leg, sacral/coccyx pain with flexion and lumbar pain with extension. MRI of the spine revealed a 4.4 × 3.1 × 2.9 cm Tarlov cyst at the right S2 neural foramen. MRI of pelvis did not show pelvic neurofibromas. Electromyography confirmed a chronic right S2 radiculopathy. She was referred for pelvic floor therapy and interventional pain evaluation.
Discussions:
NF2 commonly presents with multiple intracranial and spinal tumors, but this case was complicated by a symptomatic Tarlov cyst. Although often incidental, Tarlov cysts can cause chronic back pain and pelvic floor dysfunction, Initial treatment emphasizes conservative strategies, including targeted rehabilitation and pain control. For refractory cases, percutaneous cyst aspiration or surgical decompression should be considered. About 81% of patients treated surgically and 79% of patients treated through aspiration are symptom-free at 1 year. Recurrence rates are lower in surgically treated cysts compared to percutaneously treated cysts (8% versus 20%).
Conclusions:
We highlight a unique presentation of S2 radiculopathy and pelvic floor dysfunction in a patient with NF2 likely due to compressive symptoms from a Tarlov cyst. In oncological patients, it is important to keep a broad differential and to consider all tumor related sequelae. Clinical correlation along with imaging and electrodiagnostic studies can help guide tailored treatment plans. In this case, the patient underwent a right L5/S1 interlaminar epidural steroid injection which provided partial relief for two weeks, and she was referred for neurosurgical consultation for consideration of cyst-directed management.
