骶管囊肿文献导读：类似附件肿块的Tarlov’s囊肿

原文：Perineural (Tarlov) cysts mimicking adnexal masses: a report of three cases

作者：M. W. C. H’NG, U. I. D. K. WANIGASIRI and C. L. ONG

Department of Diagnostic Imaging, KandangKerbau Women’s and Children’s Hospital, Singapore新加坡

编译：杨敏沈霖   审校：郑学胜

Perineural (Tarlov) cysts are usually incidental fifindings during magnetic resonance imaging (MRI) performed for low back pain. However, in a tertiary women’s hospital, they may present as incidental fifindings on gynecological ultrasound imaging. Approximately 40 000 pelvic scans are performed annually in our department. Tarlov cysts were identifified in three women between August 2007 and September 2008. In two patients (Cases 1 and 3), these cysts were initially misdiagnosed as hydrosalpinges on ultrasound examination, the latter having a differential diagnosis of an ovarian cyst. Two patients (Cases 1 and 2) were symptomatic, although Case 2 had symptoms that could not entirely be accounted for by the location of the cyst. Although asymptomatic, Case 3 underwent laparoscopy with a view to salpingectomy/cystectomy. In these patients, confifirmation of Tarlov cysts was subsequently made on either computed tomography (CT) or MRI. All three patients were managed conservatively. Here we describe their clinical presentation, the appearance of the cysts on ultrasound imaging and on CT or MRI, and their eventual outcomes. Copyright  2009 ISUOG. Published by John Wiley & Sons, Ltd.

Tarlov’s囊肿(神经囊肿)经常在因为腰痛就诊的患者进行核磁共振成像（MRI）时被偶然发现。然而，在一些妇产科医院，一些患者可能会在妇科超声检查时偶尔发现囊肿。在我科每年约有4万次盆腔扫描。2007年8月至2008年9月，在三名妇女中发现了Tarlov’s囊肿。其中两个病人（病例1和3），囊肿最初的超声检查被误诊为输卵管积水，后者需要与卵巢囊肿的鉴别诊断。两名患者（病例1和2）有症状，尽管病例2的症状不能完全由囊肿的位置来解释。虽然无症状，病例3接受腹腔镜检查，以期进行输卵管切除术/囊肿切除术。这些病人最终通过中，CT和MRI确诊为Tarlov’s囊肿。三名患者均采用保守治疗。此文中我们描述他们的临床表现，囊肿在超声成像和CT或MRI上的表现。

Case 1

Images from a 29-year-old woman with lower abdominal discomfort and intermittent left thigh pain (Case 2). (a) Coronal ultrasound image showing a mass between the left internal iliac artery (large arrow) and pelvic side wall (arrowheads), appearing to have a presacral origin. (b) Contrast-enhanced computed tomography with coronal reformat confifirming a left S1 Tarlov cyst (arrows) just lateral to the left internal iliac artery.

影像来自一位29岁女性，有下腹部不适和左大腿间歇性疼痛症状（病例2）。（a） 冠状位超声图像显示左髂内动脉（大箭头）和骨盆侧壁（箭头）之间有肿块，似乎有骶前起源。（b） 对比增强CT冠状面重建证实左S1Tarlov’s囊肿（箭头所示）位于左髂内动脉的外侧。

Case 2

Images from a 29-year-old woman with postpartum pelvic pain associated with radicular symptoms (Case 1). (a) Sagittal ultrasound image showing a left adnexal mass (arrows) that could be traced posterior to the uterus (U) and anterior to the pelvic brim (arrowheads), suggesting a neurogenic tumor. (b) Coronal fast spin-echo T2-weighted magnetic resonance image revealing bilateral S1 Tarlov cysts of almost equal size (arrows).

影像来自一位29岁的产后妇女，产后盆腔内疼痛伴神经根症状（case 1）。（a）超声图像显示左侧附件肿块（箭头所示）位于子宫（U）后方，盆腔缘前方(向上的箭头)，提示是一个神经源性肿物。（b）T2加权磁共振冠状位成像显示双侧大小几乎相等的S1 Tarlov’s囊肿（箭头所示）

Case 3

Images from a 26-year-old woman who was asymptomatic (Case 3). (a) Coronal ultrasound image showing a lobulated cystic structure (arrows) in the right adnexal region and posterior to the uterine cervix (C), with an origin that could be traced dorsally to the sacrum, suggesting a neurogenic structure. (b) Axial fast spin-echo T2-weighted magnetic resonance image confifirming multiple Tarlov cysts (arrows), the largest involving the right S2 nerve root.

一位无症状的26岁妇女的图像（病例3）。（a） 冠状位超声图像显示在右侧附件区和子宫颈后部（C）有一个分叶状囊性结构（箭头所示），其起源可追溯到骶骨，表明是神经源性结构。（b） T2加权磁共振成像证实多个Tarlov’s囊肿（箭头），最大的累及右侧S2神经根。

专家点评：上海新华医院神经外科腰骶神经中心郑学胜主任指出，目前在临床上，骶管囊肿突入盆腔的患者，由于临床表现常伴有盆腔症状、旁观和肠道症状，往往首先会到妇科或者肛肠科就诊，容易导致误诊。有些患者是由常规妇科体检超声检查被偶尔发现，这部分患者也往往先就诊于妇科。其中，不乏有被误诊为附件囊肿行妇科手术案例。因此，对于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，或者CT薄层扫面冠状位重建，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。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。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。