Case Report Published on 29 Jul, 2026

Low Back Pain with a “Crowning Sensation”: A Case of a Sacral Tarlov Cyst Coexisting with Lumbar Intervertebral Disc Herniation

Tarlov Cyst with Crowning Sensation
Vol. 21 No. 2 : 2026 (1177-1184)

Mohd Ariff Sharifudin Mohd Ariff Sharifudin
Siti Aishah Ahmad Maulana Siti Aishah Ahmad Maulana
Mai Nurul Ashikin Taib Mai Nurul Ashikin Taib
Mohamad Zakwan Helmi Abu Bakar Mohamad Zakwan Helmi Abu Bakar
Ummu Habibah Sulaiman Ummu Habibah Sulaiman

Abstract
Tarlov cysts are often incidental findings on spinal imaging but can cause atypical symptoms that mimic or coexist with common spinal disorders, posing a diagnostic challenge. A 48-year-old female presented with six months of worsening low back pain radiating to the buttocks and posterior thighs. Initial management for a suspected lumbar disc herniation provided only partial relief. Crucially, she reported a distinctive “crowning sensation” - a feeling of perineal pressure and fullness akin to childbirth—exacerbated by sitting. Lumbosacral magnetic resonance imaging (MRI) revealed a dual pathology: a mild L3/L4 disc protrusion and a 12 x 8 mm Tarlov cyst at S2. The radicular pain was attributed to the disc, while the crowning sensation was highly suggestive of S2-S4 nerve root compression from the cyst. A multidisciplinary team consensus recommended optimised conservative management with neuromodulatory medications, targeted physiotherapy, and ergonomic lifestyle counselling to minimise prolonged sitting. At one-year follow-up, her radicular pain improved significantly, and the crowning sensation was well-controlled, occurring only briefly with prolonged sitting. The “crowning sensation” is a particular red flag for sacral pathology. While a definitive causal link cannot be established, the high specificity of the crowning sensation for sacral nerve root compression suggests that the Tarlov cyst is the most likely cause. This case highlights the importance of considering Tarlov cysts in patients with persistent low back pain and atypical pelvic symptoms. Lumbosacral MRI is critical for identifying such dual pathology, enabling effective, tailored conservative management and avoiding unnecessary high-risk surgery.
Keywords : Crowning sensation; low back pain; magnetic resonance imaging; perineural cyst; Tarlov cyst,
Abstrak
Sista Tarlov sering kali merupakan penemuan rawak pada pengimejan tulang belakang tetapi boleh menyebabkan gejala atipikal yang menyerupai atau wujud bersama gangguan tulang belakang lazim, sehingga mencetuskan cabaran diagnostik. Seorang wanita berusia 48 tahun hadir dengan sejarah sakit belakang bawah yang semakin teruk selama enam bulan, dengan rasa sakit menjalar ke punggung dan paha belakang. Pengurusan awal bagi suspek herniasi cakera lumbar hanya memberikan kelegaan separa. Yang penting, beliau melaporkan sensasi “pengucupan” yang tersendiri - perasaan tekanan dan kenyang di perineum seakan-akan proses kelahiran - yang semakin teruk ketika duduk. Pencitraan resonans magnet (MRI) lumbosakral mendedahkan patologi berganda: penonjolan cakera ringan di peringkat L3/L4 dan sista Tarlov bersaiz 12 x 8 mm di peringkat S2. Sakit radikular dikaitkan dengan patologi cakera, manakala sensasi pengucupan menunjukkan mampatan saraf akar S2-S4 daripada sista tersebut. Konsensus pasukan multidisiplin mencadangkan pengurusan konservatif yang dioptimumkan dengan ubat neuromodulator, fisioterapi disasarkan, dan kaunseling gaya hidup ergonomik untuk meminimumkan duduk berpanjangan. Pada susulan setahun, sakit radikularnya bertambah baik dengan ketara, dan sensasi pengucupan dapat dikawal dengan baik, hanya muncul seketika ketika duduk terlalu lama. Sensasi pengucupan merupakan petanda khusus bagi patologi sakrum. Walaupun hubungan kausal pasti sukar dibuktikan, kekhususan tinggi sensasi ini untuk mampatan saraf akar sakrum menunjukkan bahawa sista Tarlov adalah punca paling mungkin. Kes ini menekankan kepentingan mempertimbangkan sista Tarlov dalam kalangan pesakit dengan sakit belakang bawah berterusan dan gejala pelvis atipikal. MRI lumbosakral adalah penting untuk mengenal pasti patologi berganda seperti ini, sekaligus membolehkan pengurusan konservatif efektif dan tersuai serta mengelakkan pembedahan berisiko tinggi yang tidak diperlukan.
Kata Kunci : Pencitraan resonans magnet; sakit belakang bawah; sensasi pengucupan; sista perineural; sista Tarlov,

Correspondance Address
*Correspondence: ariffsharifudin@unisza.edu.my; dr.ariff.s@gmail.com


(a) Sagittal T2-weighted and (b) sagittal T1-weighted MRI images of the lumbosacral spine. The red arrows pointed to a Tarlov cyst at the S2 level. On the T2-weighted image, the cyst appearred hyperintense (bright), reflecting its fluid content consistent with cerebrospinal fluid (CSF). In the T1-weighted image, the lesion was isointense to the CSF. The cyst was located within the sacral canal.

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