骶管囊肿文献导读：巨大、多发、双侧、突入盆腔骶管囊肿的影像学表现

原文：Giant multiple and bilateral presacraltarlov cysts mimicking adnexal mass – imaging features

作者：Monique Boukobza, alexandreRoussel, Pedro, Fernandez-Rodriguez, Jean-pierrreLaissy

Department of Radiology, assistance publique-Hôpitaux de paris, Bichat Hospital, 46 rue Henri Huchard, paris 75018, France（法国，巴黎）

编译：沈霖 杨敏  审校：郑学胜

Tarlov cysts (TCs), also known as perineural cysts, typically develop at the junction of the dorsal ganglion and spinal posterior nerve root and have mainly a sacral location. They are a common incidental finding on lumbosacral MRI. In most cases, they are small and asymptomatic. Huge presacral TCs are exceptionally rare. The uncommon endopelvic extension of a giant TC can lead to misdiagnosis and unnecessary laparotomy. We have reported a case of giant, multiple, and bilateral Tarlov cysts, with endopelvic extension, paucisymptomatic, mimicking an adnexal mass in a 49-year-old woman.

Tarlov囊肿（骶管囊肿）又称神经根囊肿，通常发生背侧神经根及脊髓后支神经根，主要位于骶部。通常腰骶部磁共振检查会意外发现这一疾病。在大多数情况下，骶管囊肿通常是比较小且无症状的。巨大的骶前骶管囊肿非常罕见。而巨大少见的突入盆腔内骶管囊肿可能导致误诊和不必要的剖腹手术。我们报告一例巨大、多发、双侧的骶管囊肿，并突入盆腔的患者。该患者无特别的临床症状，影像学表现类似于附件肿块。

A 49-year-old woman, without past medical history, presented with lower abdominal discomfort for several months. Physical examination demonstrated a floppy, cyst-like mass. Clinical examination was otherwise normal. An ultrasonographic examination revealed normal uterus and ovaries and also a cystic mass containing free echo fluid separated from the right ovary.

患者是一位49岁女性，无既往病史，出现下腹不适数月。体格检查显示一个柔软的囊肿样肿块。临床检查未见明显异常。超音波检查显示子宫和卵巢正常，也有一个囊性肿块，内含游离回声，与右侧卵巢分离。

Sacral MRI revealed several huge, bilateral, and almost symmetric cystic dilatations originating from the right and left L5, S1, S2, and S3 nerve root sleeves consistent with perineural cysts, ie, TCs. The cysts were filled with fluid, showed the same signal intensity as that of CSF on T1- and T2-weighted images, and were observed to be oval and lobulated. The cysts entered the presacral space through the right and left, enlarged L5–S1, S1– S2, S2–S3, and S3–S4 foramens, extending anteriorly into the pelvis (Figure 1A–D). Bone erosion – “scalloping” – was confined to posterior left S2 body.

骶椎MRI显示了数个巨大的、双侧的、几乎对称的囊性扩张，分别起源于双侧L5、S1、S2和S3神经根袖，与普通的骶管囊肿类似一致。囊肿内充满液体，在T1和T2加权像上显示与脑脊液相同的信号，呈卵圆形和分叶状。囊肿通过左右两侧增大的L5-S1、S1-S2、S2-S3和S3-S4孔进入骶前间隙，向前延伸至盆腔（图A-D）。同时可见“扇贝状”的骨侵蚀局限于左后S2骶骨体。

The endopelvic segment of the cysts measured up to 48 mm in the greatest dimension (left [L] L5; right [R]; and left S1). The measurements of the other cysts were as follows: L5 (L), 42 mm; S2 (R and L), 20 mm; and S3 (R and L), 34.2 mm. A total of 8 huge cysts were found in this patient. TC at left L5 was adjacent to the left ovary (Figure 1E) and the TC at S3 protruded along the right side of the rectum. TCs at S1 and S2 levels exerted extrinsic mass effect on the adjacent sigmoid loop (Figure 1E and F). All cysts had a complex pattern of being multiloculated with numerous internal septations. Three-dimensional (3D) acquisition, allowing multiplanarreformation, gave numerous information on the relationship of the cysts with the root fibers and surrounding structures. There was no TC enhancement after gadolinium chelate contrast administration (Figure 1G).

盆腔内囊肿的最大尺寸为48mm（左[L]L5；右[R]；左S1）。其他囊肿的测量结果如下：L5（L），42 mm；S2（R和L），20 mm；S3（R和L），34.2 mm。共发现8个巨大囊肿。左L5的囊肿与左卵巢相邻（图E），S3的囊肿沿直肠右侧突出。S1和S2水平的囊肿对相邻的乙状结肠有占位效应（图E和F）。所有的囊肿都有复杂的多房型和大量的内部分隔。通过MRI三维（3D）采集，多平面的重建，提供了大量关于囊肿与根纤维和周围结构关系的信息。钆螯合造影剂给药后，骶管囊肿没有增强（图G）。

专家点评：郑学胜主任指出，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。常规的手术入路对于突入盆腔部分的囊肿较难处理，因此，此时最重要的是对于囊肿的漏口进行封堵，以达到根治的目的。以下是本中心治疗的骶管囊肿突入盆腔的病例，手术之后患者症状均有明显好转，且磁共振复查也非常满意。