原文：Abdominal pain secondary to a sacral perineural cyst

作者：Curtis W. Slipman, MD*, Atul L. Bhat, MD, Sarjoo M. Bhagia, MD, Zacharia Issac, MD, Russell V. Gilchrist, DO, David A. Lenrow, MD

编译：沈霖 杨敏   审校：郑学胜

Tarlovfirst described sacral perineural cysts after observing them during autopsy dissections of filum terminale. Tarlovdistinguished these cysts from other extradural meningeal lesions on the basis of the following observations. These cysts arise at the junction of the dorsal root ganglion and the nerveroot, and display the phenomenon of delayed filling on myelography. The spinal perineural cyst arises between the arachnoid that covers a nerve root (perineurium) and the outer surface of its pia (endoneurium), and its walls are formed of these elements. The majority of these cysts areasymptomatic; they are classically reported as an incidental finding during various imaging studies used for patients with low back and/or leg pain. Subsequent to the initial description by Tarlov, there have been anecdotal reports discussing perineural cysts causing sacral pain, sacral fractures, coccygodynia, back pain, intermittent claudication and lumbosacral radiculopathy. In a population presenting with low back pain, the prevalence of sacral perineural cysts has been reported as 4.6%. However, in only 1% of the entire population were these cysts responsible for either local sacral pain or sacral radiculopathy. In the rare instance where the sacral perineural cyst is causing significant symptoms, surgical intervention may be warranted. In this report, we describe a patient with abdominal pain accompanying leg pain as a secondary manifestation of a large sacral perineural cyst.

Tarlov首先描述了骶骨神经周围囊肿，是其在尽心终丝的解剖时观察到的。Tarlov根据以下观察结果将这些囊肿与其他硬脑膜外病变区分开。这些囊肿出现在背根神经节和神经根的交界处，脊髓造影显示延迟充盈现象。脊髓神经膜囊肿发生于覆盖神经根的蛛网膜和神经内膜之间。这些囊肿大多数是无症状的；在用于腰痛和/或腿痛的各种影像学研究中，它们通常偶然被发现。在Tarlov最初的描述之后，陆续有报道讨论了神经周围囊肿引起骶骨疼痛、骶骨骨折、骶尾部疼痛、背部疼痛、间歇性跛行和腰骶神经根病。在有腰痛症状的人群中，骶骨神经周围囊肿的患病率为4.6%。然而，只有1%的人是由这些囊肿引起的局部骶骨疼痛或骶神经根病变。因此，骶骨神经周围囊肿引起明显症状，手术治疗是必要的。在这篇报告中，描述一个伴随着腿痛的腹痛病人，是一个大的骶骨神经周围囊肿引起的症状。

A 47-year-old woman presented to our academic interdisciplinary spine center with a chief complaint of abdominal and left leg pain. She had been experiencing left lowerwas no splenomegaly, hepatomegaly or any tenderness on palpation of the abdomen. Percussion over the thoracolumbar and lumbosacral spine was not painful. Upon auscultation, normal active bowel sounds were heard. Sensory examination was intact to pinprick, light touch and proprioception. Muscle stretch reflexes were normal in both upper and lower extremities. Hoffman and Babinski were negative. There were no motor or sensory abnormalities. Digital rectal examination demonstrated that anal tone was normal and no masses were palpable. She demonstrated a normal gait pattern. Sacroiliac joint provocative maneuvers, including Gaenslen test, Fabere test, sacroiliac joint compression, shear test, iliac gapping and Yeoman test, were negative. Lumbar discogenic provocative maneuvers, including pelvic rock and sustained hip flexion, were negative.

MRI of the thoracic spine was performed without evidence of any abnormality. The lumbosacralMRI showed large perineural cysts eroding the sacrum and extending into the retroperitoneum (Figs. 1–3). No other significant abnormalities were observed.

一位47岁的女性来到跨学科脊柱中心，主诉腹部和左腿疼痛。她的左下半部没有脾肿大、肝肿大或腹部触诊时有任何触痛。对胸腰椎和腰骶椎的叩诊也无疼痛。听诊时，听到正常的主动肠鸣音。浅感觉检查：针刺、轻触、本体感觉完好。上下肢肌力、肌张力、反射正常。霍夫曼和巴宾斯基症呈阴性。没有运动或感觉异常。直肠指诊显示肛门张力正常，无明显肿块。她表现出正常的步态。骶髂关节激发性动作，包括Gaenslen试验、Fabere试验、骶髂关节压缩试验、剪切试验、髂骨间隙试验和约曼试验均为阴性。腰椎间盘源性刺激性动作，包括骨盆摇滚和持续髋关节屈曲，均为阴性。

胸椎MRI检查未发现异常。腰骶部MRI显示巨大神经周围囊肿侵蚀骶骨并延伸到腹膜后（图）。未发现其他明显异常。

点评：

1、  虽然骶管囊肿引起腹痛症状较为罕见，但是我们在临床工作中需要更加仔细的鉴别诊断，避免漏诊和误诊。

2、  目前在临床上，巨大的骶管囊肿突入盆腔的情况相对比较少见。文献报告，大约仅有5%的骶管囊肿患者会出现囊肿突入盆腔的表现。这些患者往往伴有骶骨骨质破坏以及骶前孔的扩大。临床表现主要以腰部、骨盆、会阴部、骶尾部疼痛，或表现为坐骨神经痛，部分患者合并膀胱、肠道或性功能障碍。很多患者往往首先会到妇科或者肛肠科就诊，且容易导致误诊。这类患者建议完善骶尾椎多平面的MRI扫描，尤其是冠状位的磁共振的重建，对于判断囊肿的起源、囊肿个数及神经根出口位置均有相当大的帮助。对于巨大骶管囊肿突入盆腔且有相应临床症状的患者原则上因积极尽早手术治疗。而对于无明显症状的患者也应建议手术治疗。突入盆腔的囊肿由于骨质缺损，囊肿增大往往进展比较快，而囊肿越大临床上治疗起来就越困难。

3、  此类病人由于症状往往首先就诊于妇科或者肛肠科，一旦误诊，被当作单纯的盆腔囊肿或附件囊肿进行开腹手术，后果不堪设想。此类囊肿起源于骶神经根，囊肿漏口位于骶管内骶神经鞘，因此此时最重要的是对于囊肿的漏口进行封堵，才能最终达到根治的目的。