Removal of a discal cyst using a percutaneous endoscopic interlaminar approach: a case report

Discal cysts and pseudocysts: Single center experience

Introduction

Current knowledge of intervertebral discal cysts is restricted to case reports and surgical case series, typically in young adult males presenting with back pain and radiculopathy.

Objective

We review our single-center experience to describe presentation, management, and outcomes of these rare lesions.

Methods

We performed a retrospective electronic search of our institution database using key words "discal cyst," "disc cyst" and variations. Clinical presentation, imaging findings, management and outcomes were reviewed and tabulated.

Results

Nine patients were identified (4 female), with mean age 49.1 years. Three patients had prior surgery at the level of the cyst. Seven patients presented with back pain, five with additional radiculopathy, one patient with radiculopathy alone, and one asymptomatic. Most discal cysts occurred at L5-S1, were left-sided, paracentral in location with a T2 hypointense rim and variable enhancement. One patient underwent primary cyst resection. Amongst 6 patients who underwent primary image-guided procedures, two had sustained pain relief, three proceeded to cystectomy, microdiscectomy and/or posterior decompressive surgery, and two were lost to follow-up.

Conclusion

Our retrospective cohort includes a wider age group with more heterogeneous clinical features, treatment approaches and response to therapy than that described in the literature. CT or fluoroscopy-guided steroid injection provided short-term symptomatic relief with several cases managed definitively with surgery. Further research is required to better understand and manage these rare lesions.

Clinical impact

Discal cysts and pseudocysts occur in a wider range of patients and with more heterogenous presentations than previously described. Imaging-guided intervention can provide short-term symptomatic relief, but further research is required to optimize long-term management.

Percutaneous Endoscopic Surgery for Lumbar Discal Cyst: Two Case Reports

Discal cyst is a rare disease, the pathogenesis is not yet clear and its symptoms are very similar to lumbar disc herniation. Although some cases may regress spontaneously, most cases of lumbar discal cysts are treated surgically. At present, there is no consensus on the treatment of this disease. The authors report the clinical usefulness of the percutaneous endoscopic transforaminal surgery technique in two patients with the lumbar 4-5 discal cyst. The clinical symptoms of both patients were unilateral lower extremity pain and lower back pain. Magnetic resonance imaging of the lumbar spine revealed lumbar discal cysts, causing compression to the spinal dura and roots. Both patients received conservative treatment for more than 6 months, but the clinical symptoms persisted so surgical treatment by percutaneous endoscopic transforaminal surgery without additional discectomy was performed under local anesthesia. The symptoms were relieved immediately after removal of the discal cysts. Postoperative magnetic resonance imaging showed that both patients had complete excision of discal cysts and complete decompression of the treated segmental. There were no recurrent lesions and complications during the follow-up period. We believe that percutaneous transforaminal endoscopic surgery could be a safe, mini-invasive and appropriate method for the treatment of discal cysts.

Transforaminal Epiduroscopic Laser Ablation for Removal of a Postlaminectomy Synovial Cyst: A Case Report

Background: Synovial cysts rarely occur after a laminectomy and are difficult to detect if there are no symptoms; however, they can cause lower back pain or symptoms of radiculopathy. Various methods are used to treat synovial cysts. Here, we will introduce the first case with treatment using the transforaminal epiduroscopic laser annuloplasty (TELA) system. Case report: A 64-year-old female patient visited the pain clinic with lower back pain and pain radiating from the left lower extremity. An MRI T2 image showed a synovial cyst of facet joint origin at the L4–L5 level; the patient had undergone a laminectomy 10 years ago at the same spinal level. The patient rated the pain an 8 on the numerical rating scale (NRS), and pain was reduced after epidural steroid injection, but symptoms recurred a month later. The cyst ablation was performed using the TELA system with a 1414 nm neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, and after the procedure, pain decreased to 4 points immediately and was reduced to 2 points on the NRS after 1 week. Six months after the procedure, the pain level was measured on NRS 2 and cyst was not recurred in the additional MRI. Conclusion: We introduced the TELA system as a noninvasive therapy for treating synovial cysts. Ablation of cystic necks using a 1414 nm Nd:YAG laser could be a method to prevent cyst recurrence, but long-term follow-up and large scale control studies will be needed to verify the effectiveness of this method.

Clinical Application of Percutaneous Transforaminal Endoscopic Surgery in Lumbar Discal Cyst

BACKGROUND

Discal cyst is very rare and can cause intractable low back pain and radiating leg pain. Symptoms are hard to distinguish from lumbar disc herniation. The best treatment for discal cyst is controversial. Most lumbar discal cysts are treated surgically, while most studies of percutaneous transforaminal endoscopic surgery are case reports. This study investigated the clinical value of percutaneous transforaminal endoscopic surgery for lumbar discal cyst.

METHODS

A retrospective study was conducted in 9 patients with a discal cyst from June 2016 to November 2018. All patients had been treated by percutaneous transforaminal endoscopic surgery via a superior vertebral pedicle notch approach. Surgical outcomes were evaluated preoperatively and postoperatively using a visual analog scale for leg pain and the Oswestry Disability Index. At the final follow-up, patients were evaluated for clinical efficacy using modified Macnab criteria.

RESULTS

All 9 patients had remission of symptoms after removal of discal cysts. Postoperative magnetic resonance imaging showed that all patients had complete excision of discal cysts and complete decompression of the treated segment. There were no recurrent lesions during follow-up. Mean operative time was 68.67 ± 14.02 minutes. Mean hospitalization time was 4.22 ± 1.64 days. Preoperative visual analog scale and Oswestry Disability Index score improved significantly after surgery. Visual analog scale leg score improved from 7.88 ± 1.05 preoperatively to 1.78 ± 0.66 at final follow-up (P < 0.05), and ODI score improved from 53.65 ± 12.46 to 16.25 ± 8.76 (P < 0.05). According to the modified Macnab criteria, 5 patients (55.6%) were rated excellent, 3 patients (33.3%) were rated good, and 1 patient (11.1%) was rated fair at final follow-up, with an overall excellent and good rate of 88.9%. There were no serious complications during follow-up.

CONCLUSIONS

Percutaneous transforaminal endoscopic surgery could be a safe, minimally invasive surgical treatment for discal cyst, particularly suitable for patients who cannot undergo general anesthesia.

Surgical Treatment of Lumbar Spinal Discal Cyst: Is It Enough to Remove the Cyst Only without Following Discectomy?

Discal cysts are a rare cause of low back pain and radiculopathy with unknown pathophysiologic mechanism. Associated symptoms are difficult to distinguish from those caused by extruded discs and other spinal canal lesions. Most discal cysts are treated surgically, but it is unclear whether the corresponding intervertebral disc should be excised along with cyst. We conducted a retrospective clinical review of 27 patients who underwent discal cyst excision at our institution between 2000 and 2017. The mean follow-up period was 63.6 months. We recorded symptoms, radiographs, operative findings, postoperative complications, and short- and long-term outcomes. Structured outcome assessment was based on Numeric Rating Scale (NRS) for pain intensity, Oswestry disability index, and Macnab classification. All patients underwent partial hemilaminectomy and microscopic cyst resection without discectomy. All patients had preoperative back or leg pain. Other preoperative clinical features included motor weakness, neurogenic intermittent claudication, and cauda equina syndrome. After surgery, NRS scores of back and leg pain decreased. The other symptoms also improved. During long-term follow-up, patients reported no restrictions on daily life activities, and were satisfied with our intervention. There were no cases of cyst recurrence. We conducted a review of the literature on lumbar discal cysts published before January, 2018. Including our cases, 126 patients were described. We compared two surgical modalities—cystectomy with and without discectomy—to elucidate both effectiveness and long-term complications. We found that microsurgical cystectomy without corresponding discectomy is an effective surgical treatment for lumbar discal cysts, and is associated with a low recurrence rate.

Discal Cyst of the Lumbar Spine: Case Report of a Rare Clinical Entity

Being a rare clinical entity, discal cyst presents indistinguishably from other causes of lower back pain and radiculopathy. It is an extremely rare pathology with unclear pathogenesis, indeterminate natural history with no consensus on the ideal management of the condition. We report a rare case of discal cyst in a patient who presented to our centre with localised low back pain and subsequently left sided radicular pain. With the aid of MRI and with clear surgical indication we proceeded with endoscopic removal of the cyst and intraoperatively confirmed its origin from the adjacent disc. The patient had immediate relief of his symptoms and no postoperative complications. We recommend that endoscopic surgery can be an effective alternative to conventional open surgery for discal cyst of the lumbar spine.

Transition of a herniated lumbar disc to lumbar discal cyst: A case report

Background:

Another rare cause of lower back pain with radiculopathy is the discal cyst. It is believed to arise from degeneration of a herniated disc, although many other theories of its origin have been proposed. Here, we report a patient with lower back pain/radiculopathy attributed originally to a herniated lumbar disc, which transformed within 6 months into a discal cyst.

Case Description:

A 42-year-old male had a magnetic resonance (MR) documented herniated lumbar disc at the L4-5 level. It was managed conservatively for 6 months, after which symptoms recurred and progressed. The follow-up MR study revealed a discal cyst at the L4-5 without residual herniated disc. Of interest, the cyst communicated with the L4-5 intervertebral disc, which was herniated under the posterior longitudinal ligament and the disc space. During surgery, the cyst was completely removed, and his symptoms/signs resolved.

Conclusion:

A discal cyst develops as pathological sequelae of a degenerated herniated disc. Although rare, these lesions must be considered among the differential diagnoses in young patients with radicular back pain. MR study clearly documents these lesions, and surgical excision of the cyst is the treatment of choice.

Lumbar discal cyst in an elite athlete

Our patient, a 22-year-old starting wide receiver for an NCAA Division I football team, presented with low back pain and sciatica. A lumbar-spine MRI without contrast demonstrated findings suspicious for discal cyst. The patient was referred for surgery, and the lesion was resected. The rarity of discal cyst makes it difficult to diagnose because most radiologists are not aware of the entity. An organized approach to diagnosis can facilitate appropriate management.

Lumbar intervertebral discal cyst: a rare cause of low back pain and radiculopathy. Case report and review of the current evidences on diagnosis and management

Study Design Case Report and review of the literature.

Objective The objective of the article is to report an illustrative case successfully treated by microsurgery and to review the literature on the current evidence on diagnosis and management of lumbar discal cysts.

Methods A 43-year-old male patient presented with severe back pain, radiating down to the right leg, as well as with paraesthesias in the right L3 and L4 dermatomes. Magnetic resonance imaging of the lumbar spine revealed an intraspinal, extradural space-occupying lesion at the L3–L4 disc level, causing compression of the neural structures. The lesion was surgically removed and a diagnosis of lumbar discal cyst was made. Postoperatively, symptoms improved and the patient was discharged with no complications. A systematic review of pertinent articles published up to February 2014 was performed. Key articles were searched to identify studies describing the diagnosis and management modalities of lumbar discal cysts and the comparative effectiveness and safety of microsurgery versus endoscopic treatment.

Conclusions Discal cysts are rare causes of low back pain and radiculopathy. Few cases have been reported; however, conclusive information about their natural history is not available and the best mode of treatment remains controversial. We submit that lumbar intervertebral disc cysts, with their peculiar radiological and anatomic features, should be considered in the differential diagnosis among rare causes of low back pain and radiculopathy.

Which treatment method should be preferred for lumbar discal cysts? A case report and a review of the literature

Discal cysts are extremely rare pathologies that occur most often in the lumbar region. The clinical symptoms of discal cysts are indistinguishable from those of a lumbar disc herniation. The aetiology and pathogenesis of discal cysts remain unknown. The optimal treatment of discal cysts also remains controversial. Most cases of lumbar discal cysts are treated surgically, while some cases regress spontaneously. In this article, we report a case of a lumbar discal cyst treated surgically by microdiscectomy. We discuss the treatment options for discal cysts in the context of the literature.

Intraoperative discography for detecting concealed lumbar discal cysts

Lumbar discal cyst is a rare cause of radiculopathy. Their exact pathogenesis and the optimal treatment modality remain unidentified. Depending on their location, discal cysts cannot always be easily identified intraoperatively. We describe 2 patients with discal cysts and introduce an intraoperative discography technique for discal cyst location. Both patients were treated with surgical excision; with intraoperative discography, the cystic lesions could easily be detected and removed.

Bilateral discal cysts managed by partial hemilaminectomy and microscopic resection of hemilateral cyst

STUDY DESIGN

A case report.

OBJECTIVE

The objective of this article was to report a case of bilateral lumbar discal cysts and discuss the clinical, radiological, and surgical findings.

SUMMARY OF BACKGROUND DATA

Discal cysts are rare lesions and to our knowledge there has been no report on multiple discal cysts at one disc level.

METHODS

The patient's history, clinical examination, imaging findings, and treatment were reported.

RESULTS

We reported on the case of a 33-year-old woman with left lower back and lower extremity pain. Neurological imagings demonstrated bilateral cysts at the L4-L5 disc level. She underwent left partial hemilaminectomy at the L4-L5 level and microscopic resection of the left cyst. The cyst contained bloody serous fluid. A connection between the cyst wall and the L4-L5 intervertebral disc and a small laceration in the annulus fibrosus were identified. Histologic examination revealed a cyst lined by fibrous connective tissue without synovium. Her symptoms improved remarkably immediately after surgery. Follow-up imaging 3 months after the operation showed that the bilateral cysts had completely disappeared.

CONCLUSION

This is the first reported case of bilateral discal cysts at one disc level. Magnetic resonance images demonstrated rounded cysts on both sides of the posterior longitudinal ligament, which suggests that the discal cysts in our case were unlikely to have developed from an epidural hematoma. Partial hemilaminectomy and microscopic resection of the left cyst lead to complete regression of the bilateral cysts. This suggests that there was a communication between the two cysts via the intervertebral disc and that the content of the right cyst passed from the cyst to the disc.

Lumbar discal cyst causing bilateral radiculopathy

BACKGROUND

Discal cyst is a rare lesion that can result in clinical symptoms typical of disc herniation manifesting as a unilateral single nerve root lesion. To the best of the authors' knowledge, this is the first reported case of discal cyst resulting in bilateral radiculopathy.

CASE DESCRIPTION

A 48-year-old female presented with bilateral sciatica and neurogenic claudication for 3 months. Magnetic resonance imaging revealed an extradural cystic lesion compressing the ventral aspect of the thecal sac at the level of the L3-L4 intervertebral disc. The lesion showed low and high signal intensities on T1- and T2-weighted images, respectively. Total excision of the cyst was achieved after a left hemipartial laminectomy of L3, and an obvious communication with the disc space was found. Bilateral sciatica was immediately resolved after surgery, and was sustained at the two-year follow-up. The histological diagnosis was consistent with a discal cyst.

CONCLUSIONS

Although a discal cyst is extremely rare, the possibility of a discal cyst should be considered in differential diagnosis of patients with radiculopathy, particularly when encountering any extradural mass lesion ventral to the thecal sac. Surgical resection is the most employed therapeutic method for symptomatic lumbar discal cysts.

Discal cysts of the lumbar spine: report of five cases and review of the literature

Discal cysts are rare causes of low back pain and radiculopathy. Only few reports in the literature describe these pathologies. In this article, the authors report five cases (3 males and 2 females) of lumbar discal cysts treated surgically by microdiscectomy. These patients were admitted with a history of back pain and/or sciatalgia. Magnetic resonance imaging of the lumbar spine of all patients revealed lumbar discal cysts, causing compression to the spinal dura and roots. All patients were treated by partial hemilaminectomy and microscopic cyst resection. Postoperatively, the complaints showed improvement, and the patients were discharged with no complications. The cases of lumbar discal cysts are described in the literature as individual case reports, therefore; the authors performed a wide systemic review of all these cases published in PubMed and MedLine, including the patients in the present report. The data of all patients were analyzed to obtain statistically based estimated information about the incidence, the epidemiology, the natural history and the optimum management of these lesions.