1305 - Coexisting Tarlov Cyst and Lumbar Degenerative Disease: Diagnostic Challenges and Therapeutic Response to TFESI

79-year-old female presenting with symptomatic ruptured sacral Tarlov cyst coexisting with multilevel lumbar degenerative disease, including L4–5 spondylolisthesis and foraminal stenosis.

Case Description: A 79-year-old female with a past medical history of hypothyroidism, hyperlipidemia, and osteopenia presented with acute exacerbation of chronic low back pain radiating to the bilateral buttocks, pelvis, groin, and thighs. Initial CT and radiographs revealed L4–5 spondylolisthesis, multilevel degenerative disc disease, and moderate foraminal stenosis. MRI demonstrated interval enlargement of a right S1 Tarlov cyst, increasing from 1.1 cm to 1.6 cm, with imaging features suggestive of proteinaceous or hemorrhagic content. Conservative treatments, such as NSAIDs, opioids, neuropathic agents, muscle relaxants, prednisone, and physical therapy, were insufficient in managing pain. A right L5 and S1 transforaminal epidural steroid injection (TFESI) was performed under fluoroscopic guidance for treatment. Two weeks post-procedure, patient reported marked improvement, discontinued opioid usage, and experienced better sleep. At three months, she reported 98% improvement, with only mild episodic muscle spasms not interfering with activities of daily living.

Discussions: Symptomatic Tarlov cysts are uncommon and often overlooked, as their clinical manifestations overlap with degenerative lumbar disease. Enlargement or rupture increases the likelihood of symptomatology. Management strategies remain debated, ranging from conservative measures to percutaneous or surgical approaches, with variable outcomes. In this case, coexisting foraminal stenosis and cyst enlargement complicated the diagnosis. TFESI provided substantial and sustained relief, supporting its role as a minimally invasive, targeted intervention in select patients.

Conclusions: This case highlights the importance of considering rare entities such as Tarlov cysts in the differential diagnosis of low back and radicular pain. In elderly patients with complex spinal pathology, TFESI may provide effective and durable symptomatic improvement without surgical intervention.