Sacral meningeal cysts, encompassing entities such as Tarlov cysts and meningeal diverticula, are an underrecognized cause of lower urinary tract dysfunction, pelvic pain, and a spectrum of other neurologic symptoms. The intricate presentation of such cases underscores the pivotal role of precise imaging and classification for effective diagnosis and management. This video abstract presents a case that, while initially referred to as dural ectasia, underscores the nuanced distinctions within sacral cystic lesions, contributing to the broader understanding of their impact on patient symptomatology and treatment outcomes.

This presentation focuses on a 26-year-old female with a history of Ehlers-Danlos syndrome and polycystic ovary disease, experiencing severe pelvic pain, urinary dysfunction, and positional headaches. Initially managed with aspiration and fibrin glue injection, the cyst refilled within six days, underscoring the limitations of conservative treatments. The clinical decision-making process, weighed heavily by the potential risks of neurogenic complications from surgery, is explored.

Despite the rapid recurrence of the cyst post-aspiration and significant concerns regarding the surgical risks of neurogenic bowel and bladder damage, the decision to proceed with surgery was made. The surgical intervention included sacral laminoplasty, cyst resection, and dural reconstruction. Contrary to initial fears, the patient showed remarkable postoperative improvement in bladder function, pain relief, and overall quality of life, challenging preconceived notions about the risks associated with surgical management of such complex cases.

This case illustrates the need for a flexible, patient-centered approach in the management of sacral meningeal cysts. While initial non-surgical interventions and concerns regarding potential surgical complications are valid, this patient’s successful outcome post-surgery highlights the importance of reevaluating treatment strategies in the face of therapeutic failure. The experience underscores the significance of thorough diagnostic evaluation and the potential for surgical intervention to profoundly improve patient symptoms and quality of life, even in cases initially deemed high risk for surgical complications.

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Paredes Mogica et al. (2023) Sacral Tarlov perineurial cysts: a systematic review of treatment options. J Neurosurgery Spine  40(3):375-388.