骶管囊肿文献导读：神经根囊肿引起的坐骨神经痛

原文：Sciatic neuralgia associated with a perineural (Tarlov) cyst

作者：Peter C. Emary, John A. Taylor

Chiropractic Department, D’Youville College, Buffalo, NY（美国 纽约州）

编译：沈霖 杨敏      审校：郑学胜

Case Presentation

A 56-year-old man presented with a 2-year history of severe and progressing left-sided low back and leg pain, described as “sharp” and “pinching” when either walking or arching his lower back. The pain severity was rated as a nine out of 10, and his overall Bournemouth Questionnaire1 score totalled 39 out of a possible 70, where zero equals no disability and 70 equals complete disability. The low back and leg symptoms were most intense in the evening. Flexing his left leg at the knee joint and or taking non-steroidal anti-inflammatory medication (Ibuprofen, Advil) provided relief. On physical examination, the Straight Leg Raise test (at approximately 30° of hip flexion), the Hibb’s test, and the Yeoman’s test each elicited pain and parasthesia down the patient’s left leg; the Double Leg Raise, seated Kemp’s, and Nachlas’ tests were negative. Lower limb neurological examination (including motor, reflex, sensory, and vibratory testing) was normal.

一位56岁的男性患者，有2年严重的左腰部和腿部疼痛的病史，主要表现为行走或弯曲下背部时疼痛。疼痛的严重程度被评为9/10，Bournemouth问卷总得分为39分，满分为70分，其中0分表示无残疾，70分表示完全残疾。腰部和腿部症状在夜间最为严重。弯曲左膝部或服用非甾体抗炎药（布洛芬，Advil）可以缓解疼痛。体检时，直腿抬高试验（髋关节屈曲约30°）、Hibb试验和Yeoman试验均引起患者左腿疼痛和麻木；双腿抬高试验、坐姿Kemp试验和Nachlas试验均为阴性。下肢神经检查（包括运动、反射、感觉和振动测试）正常。

Lumbar spine magnetic resonance imaging (MRI) had been performed at a hospital one month earlier. In the attending radiologist’s report, there was a left-sided perineural/arachnoid cyst (measuring 1.1 cm) noted at the L4-5 level in addition to degenerative changes at L4-5 and L5-S1. However, no clinical correlation or recommendation for further investigations or treatment was given. Copies of the patient’s MR images were subsequently obtained and these clearly revealed that the perineural cyst was displacing the left L4 nerve root and had resulted in posterior vertebral body scalloping and enlargement of the left L4-5 neural foramen (Figures 1 and 2). Based on these findings, the patient was diagnosed with sciatic neuralgia resulting from a left-sided L4-5 perineural cyst.

一个月前，患者在一家医院做了腰椎磁共振成像。在放射科医生的报告中，除了L4-5和L5-S1的退行性改变外，还有一个左侧的神经根囊肿（长1.1厘米）。然而，当时并没有认为其与患者症状有临床相关性或进一步调查或治疗的建议。随后我们获得了患者的磁共振图像，这些图像清楚地显示神经根囊肿卡压了左侧L4神经根，并导致椎体后部扇形改变及左侧L4-5神经孔扩大（图1和图2）。根据这些发现，病人被诊断为坐骨神经痛，并考虑是由左侧L4-5神经根囊肿引起。

The patient in this case was referred back to his primary care physician with a recommendation for neurosurgical consultation. A conservative approach was taken, however, and after four months the patient’s sciatic symptoms spontaneously resolved. Because a second MRI was not obtained, it is possible that the patient’s imaging findings were coincidental to his clinical symptoms. Regardless, his improvements were still maintained at follow-up (via telephone) one year later.

在神经外科医生的建议下，这个病例中的病人被转回他的初级保健医生那里。患者采取了保守治疗的方法，四个月后病人的坐骨神经的症状自然消失了。由于没有进行第二次核磁共振成像检查，因此我们推测病人的影像学表现可能与他的临床症状一致，得到了缓解。一年后通过电话随访，患者症状改善仍然非常明显。

专家点评：郑学胜主任医师认为，临床上腰段的神经根囊肿发病率相对骶管囊肿要低很多，且很多患者并没有明显的临床症状。本例患者虽然通过保守治疗症状得到了缓解。但对于症状保守治疗无法缓解的患者，仍应该积极进行外科治疗。我中心今年也遇到一例相似的患者，下面与大家分享一下。

患者，男性，44岁，因“右侧臀部、腿部疼痛不适2年余”入院。患者经长时间的保守治疗后无效，症状进行性加重，行走约500米左右就因为右下肢疼痛需要休息，入院前无法正常行走，疼痛难忍。入院体格检查提示右侧直腿抬高试验阳性。患者经长时间的药物保守治疗无效，在影像学检查排除了其他可能的原因后，我们最后诊断考虑为腰5骶1神经根囊肿引起的坐骨神经痛，最后与患者充分沟通后，我们给予患者行神经根囊肿封堵术治疗。治疗后，患者疼痛症状随即明显好转，目前已恢复正常行走。

 对于一些相对特殊罕见的神经根囊肿的患者，需要明确囊肿所在节段和患者症状是否相对应；重视体格检查，充分完善影像学检查后排除其他可能原因后，制定进一步的治疗方案。同时，对于不在骶管内的腰骶神经根囊肿，由于其发病机制与骶管囊肿基本是一致的，因此可以考虑直接针对病因治疗，行神经根漏口封堵术，同样也能够取得令人满意的治疗效果。