Carbon dioxide (CO2) laser-assisted ablation of lumbar discal cyst

Devices for minimally-invasive microdiscectomy: current status and future prospects

Introduction: The current gold standard technique for lumbar disc herniation (LDH) is open lumbar microdiscectomy. The use of a tubular retractor system in the microdiscectomy technique can minimize tissue trauma by muscle-splitting sequential dilation during the surgical approach. This review aimed to describe the devices and surgical procedure of this minimally invasive microdiscectomy (MI-MD) and to discuss the pros and cons of the use of tubular retractors.Areas covered: Published medical literatures were extensively reviewed to summarize the practical devices and techniques related to the MI-MD for LDH. The placement of the tubular retractor by gradual muscle-splitting dilation technique may reduce muscle damage and postoperative wound pain. The use of flexible arm may easily change the tube direction and create a wide surgical field.Expert opinion: With reference to published literature, the MI-MD provides comparable clinical outcomes with less tissue trauma and early recovery. Development of devices for MI-MD is still ongoing. Extensive studies, including high-quality randomized trials, are required to establish a more practical and relevant MI-MD technique.

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.

Laser-Assisted Microdiscectomy for Far Lateral Lumbar Disc Herniation at the L5-S1 Level

OBJECTIVE

Laser-assisted paraspinal microdiscectomy for far lateral lumbar disc herniation (LDH) enables direct access to the foraminal or far lateral zone with minimal tissue injury and preserves facet joints, thereby preventing postoperative segmental instability. We demonstrated the clinical outcomes of this technique and discussed the pros and cons of laser use in lumbar disc surgery.

BACKGROUND

The microdiscectomy technique for L5-S1 far lateral zone may be difficult due to the limited surgical field with narrowed disc space, hypertrophied facet, and sacral ala. Thus, we used carbon dioxide (CO₂) laser for sophisticated decompression.

METHODS

Eighty-four patients who were treated with microdiscectomy for far lateral LDH at the L5-S1 level were evaluated. Among them, 40 patients were treated using CO₂ laser-assisted microdiscectomy, and the remaining 44 patients using conventional microdiscectomy. Perioperative and postoperative data were compared between the two groups with 2 years of follow-up. Clinical outcomes were assessed using the visual analog scale (VAS), Oswestry disability index (ODI), and modified Macnab criteria.

RESULTS

VAS and ODI significantly improved in both groups. An excellent or good outcome was rated in 80% and 77.3% of the laser and conventional group, respectively. There was no significant difference in global outcomes. However, hospital stay and time to return to work were significantly shorter in the laser group (p < 0.05).

CONCLUSIONS

CO₂ laser-assisted paraspinal microdiscectomy is effective for treating far lateral LDH. The pinpoint laser scalpel enables delicate and complete decompression in a limited surgical field with minimal tissue trauma.

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.

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.