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

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.