Hitting the Right Nerve: A Rare Case of Vulvodynia from Sacral Tarlov Cyst Treated with a Minimally Invasive Approach - A Case Report.

Introduction: Tarlov cysts, or perineural cysts, are cerebrospinal fluid-filled sacs typically located in the sacral region. Although often asymptomatic, larger cysts can compress adjacent nerve roots, leading to radicular pain, pelvic discomfort or dysfunction. Neurogenic vulvodynia caused by such cysts is rare and frequently misdiagnosed, particularly in women with normal gynecological and dermatological evaluations. Case Report: A 31-year-old nulliparous female presented with a 1-year history of sharp, burning vulvar pain radiating to the perianal region and posterior thigh, significantly impairing daily and sexual activities. Examination was unremarkable except for right ischial spine tenderness. Magnetic resonance imaging revealed a 1.7 × 1.2 × 1.3 cm Tarlov cyst at the right S2 neural foramen compressing the nerve root. After failure of conservative therapy, she underwent fluoroscopy-guided injection of triamcinolone and bupivacaine into the S2 dorsal root sleeve, along with continued physiotherapy and pregabalin. Results: Within 2 weeks, the patient experienced near-complete symptom relief. At 3 and 6-month follow-ups, she remained asymptomatic. Objective scores improved significantly: Visual Analog Scale reduced from 10 to 2, Oswestry disability index from 44% to 14%, and pelvic floor distress inventory-20 score to zero. She resumed normal activities, including pain-free sexual function. Conclusion: This case highlights the importance of considering sacral Tarlov cysts in the differential diagnosis of vulvodynia. A multidisciplinary, minimally invasive approach can offer significant symptom relief. However, longer-term studies are warranted to assess durability and recurrence risk.