Postoperative discal cyst: An unusual complication after microendoscopic discectomy in teenagers

Postoperative discal pseudocyst: Report of A case with an unusual complication after microlumbar discectomy and successful treatment by transforaminal endoscopic lumbar decompression

Background

Lumbar discal pseudocysts are uncommon complications that can arise following lumbar spine surgery. It manifests as a fluid-filled sac near the intervertebral disc, causing pain and discomfort. Understanding its causes, symptoms, and management is crucial for patients and healthcare professionals involved in postoperative spinal care.

Case Description A

35-year-old female developed a discal pseudocyst after undergoing laminectomy and discectomy for lumbar disc herniation. The patient presented with recurrent lower back pain, radiculopathy, and neurological deficit two months post-surgery. Imaging revealed a discal pseudo cyst causing compression of the traversing right L5 nerve root. Given the refractory nature of her symptoms, an endoscopic procedure was offered. Using the transforaminal endoscopic technique, the pseudo cyst was identified and removed, leading to immediate symptomatic relief.

Conclusion

This article reports the rare occurrence of discal pseudocyst and highlights the use of endoscopic techniques in its surgical management. Surgeons should be aware of the minimally invasive techniques, as they can offer less morbidity, shorter recovery times, and reduced healthcare costs compared to traditional open surgery.

Postoperative discal pseudocyst caused by percutaneous endoscopic lumbar discectomy: two case reports and a literature review

Postoperative discal pseudocyst (PDP) is a rare complication that can occur after percutaneous endoscopic lumbar discectomy (PELD), microendoscopic discectomy, and laminectomy. The PDP pathogenesis and pathological process remain unclear. We described two PDP cases following PELD, with long-term follow-up results. The first patient was an Asian male, 30 years old, who experienced unbearable low back pain with right lower limb radiating pain for 2 years. The second patient was also an Asian male, 21 years old, who experienced low back pain with bilateral lower limb numbness. Both patients were diagnosed with lumbar disc herniation, underwent PELD, and relapsed after discharge. The diagnosis was PDP in each case, and conservative treatment was initiated with oral anti-inflammatory drugs and rest. Eventually, the symptoms in both patients resolved. Magnetic resonance imaging showed that the discal cysts had disappeared. The follow-up of these two PDP cases after PELD showed good results, demonstrating that PDP may be a self-healing disease. Conservative treatment is effective, and surgery should be performed only in an emergency. These case reports and literature review can help improve the understanding of PDP.

Surgical treatment of recurrent postoperative discal pseudocyst: A case report and literature review

INTRODUCTION

Postoperative discal pseudocyst (PDP) is rare. Few studies have reported on the recurrence of PDPs, and there is a lack of understanding of their clinical features and treatment methods. This study discusses the clinical characteristics and treatment of recurrent PDPs.

PATIENT CONCERNS

A 25-year-old man presented with radiating pain and numbness in the lateral left calf and dorsum of the foot.

DIAGNOSIS

Postoperative discal pseudocyst.

INTERVENTIONS

He underwent lumbar discectomy, which provided immediate postoperative relief. However, the symptoms recurred 45 days later. Magnetic resonance imaging (MRI) showed a lesion compressing the dura and nerve roots at the site of the previous surgery. The lesion appeared hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging. The patient was treated conservatively for 1 month without significant relief. He then underwent lumbar discectomy and cyst removal, which immediately relieved his symptoms. However, 27 days later, the patient again developed the same symptoms. MRI examination showed recurrence of PDP. As 1 month of conservative treatment failed to relieve the patient's symptoms, we performed posterior instrumented lumbar fusion and cyst removal.

OUTCOMES

The patient's symptoms disappeared, and have not recurred for 1 year at the time of writing.

CONCLUSIONS

PDP is a rare complication of lumbar discectomy. Repeat lumbar discectomy can effectively treat PDP, but the cyst can recur. We, for the first time, used posterior instrumented lumbar fusion to successfully treat recurrent PDP.

Revision surgery for symptomatic postoperative pseudocyst following full-endoscopic lumbar discectomy: clinical characteristics and surgical strategies

BACKGROUND

A symptomatic postoperative pseudocyst (PP) is a cystic lesion that is formed in the operation area of the intervertebral disc, leading to worse symptoms. Some minority patients who developed PP experienced rapidly aggravating symptoms and could not be treated by any kind of conservative treatment. However, no clinical studies have evaluated the clinical characteristics and surgical strategies of symptomatic PP requiring a revision surgery after full-endoscopic lumbar discectomy (FELD). This study aimed to demonstrate the clinical characteristics and surgical strategies of symptomatic PP requiring a revision surgery after FELD.

METHODS

We retrospectively analyzed the data of patients who received FELD revision surgeries due to symptomatic PP formation between January 2016 and December 2021. Common characteristics, time intervals of symptom recurrence and revision surgery, strategies for conservative treatment and revision surgery, operative time, imaging characteristics, numeric rating scale (NRS) score, Oswestry disability index (ODI) and overall outcome rating based on modified MacNab criteria were analyzed.

RESULTS

Fourteen patients (males = 10, females = 4), with a mean age of 24.4 years, were enrolled. The mean time intervals of symptom recurrence and revision surgery were 43.5 and 18.9 days respectively. While the patients were conservatively managed with analgesics and physical therapy, pain persisted or progressively worsened. In comparison to the initial herniated disc, the PP was larger in 11 cases, and up- or down-migrated in four cases. The PP location included the lateral recess (n = 12), foraminal (n = 1), and centrolateral (n = 1) zones. One of the two cases treated by percutaneous aspiration (PA) was eventually treated by FELD as pain was not relieved. Follow-ups revealed an improved mean NRS score from 7.1 to 1.4, mean ODI from 68.6 to 7.9% and promising overall surgical outcomes.

CONCLUSIONS

The progressively severe pain experienced due to PP might be a result of its enlargement or migration to the lateral recess and foraminal zones. As complete removal of capsule is the goal, we recommend FELD instead of PA.

Postoperative discal pseudocyst after percutaneous endoscopic transforaminal discectomy treated by drainage: Case report

RATIONALE

This article reports 2 cases of symptomatic postoperative discal pseudocysts (PDP), a rare complication of percutaneous endoscopic transforaminal lumbar discectomy (PELD). In this report, we propose a possible mechanism of PDP and introduce an effective therapeutic strategy. To our knowledge, there have been no reports of the use of indwelling drainage techniques for the PDP treatment after PELD.

PATIENT CONCERNS

Herein, we report 2 cases of PDP after PELD in our hospital. Both patients had disc herniation at the L4/5 level, and the symptoms of low back pain and radiculopathy were significantly relieved after PELD. However, the signs in both 2 cases recurred 20 days after surgery. MRI indicated PDP in both 2 patients with high intensity on T1- and T2-weighted imaging in the primary surgical area.

INTERVENTIONS

Given the progressive symptoms in both cases, PELD was performed again and 3-lumen drainage catheters were placed at the surgical site for adequate drainage.

OUTCOMES

The patient's symptoms were significantly relieved after adequate drainage and disappeared 3 months after surgery. There was no clinical or MRI recurrence at the 6-month follow-up.

CONCLUSION

According to operative findings, we found that PDP symptoms may not be attributable mainly to cyst compression but to the excessive accumulation of local inflammatory factors. Treatment of PELD combined with indwelling drainage is feasible and effective in treating PDP.

Lumbar discal cyst and post-operative discal pseudocyst: a case series

Four cases of lumbar cyst (2 discal cysts and 2 post-operative discal pseudocysts) who presented predominantly with features of sciatica without any motor, sensory or sphincteric disturbances. The patients were treated conservatively, and the management was aimed to avert any untoward surgical intervention taking into consideration patient safety and care. Two had previous lumbar decompressive discectomy. During the mean follow-up period of 13 months, there was progressive recovery of symptoms in all our 4 patients. All our patients were successfully managed by conservative approach. An intervertebral disc cyst should be considered in young patients in the differential diagnosis of any extradural intraspinal mass ventral to the thecal sac, notwithstanding its rarity. Alongside, conservative management can be offered as first line of management with appropriate patient selection that is absence of any motor/sensory/sphincteric disturbances. Facetal micro-instability could be one of the aetiologies of this pathology which necessitates further study.

Postoperative discal pseudocyst and its similarities to discal cyst: A case report

BACKGROUND

Postoperative discal pseudocyst (PDP) is a rare condition that presents after surgery for lumbar disc herniation. Due to the lack of information, the diagnosis and treatment of PDP remain controversial. Herein, we report a PDP case that occurred following percutaneous endoscopic lumbar discectomy and received conservative treatment. Additionally, we review all the published literature regarding PDP and propose our hypothesis regarding PDP pathology.

CASE SUMMARY

A 23-year-old man presented with a relapse of low back pain and numbness in his left lower extremity after undergoing percutaneous endoscopic lumbar discectomy for lumbar disc herniation. Repeat magnetic resonance imaging demonstrated a cystic lesion at the surgical site with communication with the inner disc. The patient was diagnosed as having PDP. The patient received conservative treatment, which resulted in rapid improvement and spontaneous regression of the lesion, and had a favorable outcome in follow-up.

CONCLUSION

PDP and discal cyst (DC) exhibit similarities in both histological and epidemiological characteristics, which indicates the same pathological origin of PDP and DC. The iatrogenic annular injury during discectomy might accelerate the pathological progression of DC. For patients with mild to moderate symptoms, conservative treatment can lead to great improvement, even inducing spontaneous regression. However, surgical cystectomy is necessary in patients with neurological deficits and where conservative treatment is ineffective.

Symptomatic postoperative discal pseudocyst following percutaneous endoscopic lumbar discectomy: A case report and review of the literature

RATIONALE

Percutaneous endoscopic lumbar discectomy (PELD) is an effective treatment for lumbar disc herniation and postoperative discal pseudocyst (PDP) can rarely develop after PELD.

PATIENT CONCERNS

A 30-year-old man experienced low back pain and pain in the right lower extremity for 1 month, which aggravated for 3 days.

DIAGNOSES

Preoperative CT and MRI showed lumbar disc herniation at the L4/5 level. Then the patient underwent PELD under local anesthesia and his symptoms disappeared immediately after surgery. After 37 days of PELD, the patient complained of recurrent low back pain on the right side, and pain on the outer side of his lower leg. MR imaging revealed cystic mass with low signal on T1-weighted images (T1WI), and high signal on T2-weighted images (T2WI). The patient was diagnosed with a symptomatic PDP after PELD.

INTERVENTIONS

Initially, the patient was treated with conservative treatment, including administration of aescin and mannitol by intravenous infusion, physical therapy, sacral canal injection. Then he underwent discography at L4/5 and ozone ablation under local anesthesia.

OUTCOMES

The patient's condition improved significantly after 1 week of surgery and was discharged. One-year and 3-month follow-up revealed no recurrence of low back pain and leg pain.

LESSONS

PDP is one of the rare complications of PELD, usually occurs in young patients. Patients with PDP have a low signal intensity on T1WI and high signal intensity on T2WI, which can be treated by conservative treatment, interventional therapy, and surgical treatment.

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.

A Rare Case of a Discal Cyst Following Percutaneous Endoscopic Lumbar Discectomy via a Transforaminal Approach

A discal cyst is a rare lesion that causes low back pain and radiculopathy of the lower extremities. There are several reports of discal cysts occurring after surgery, but data are limited on their occurrence after percutaneous endoscopic discectomy (PED). A 21-year-old man with disc herniation at the L4-L5 disc level underwent PED via a transforaminal approach. The immediate postoperative course was uneventful and his symptoms were relieved. Six weeks after surgery, low back pain and mild pain in the left thigh recurred. Magnetic resonance imaging (MRI) revealed a cystic lesion adjacent to the left side of the L4-L5 intervertebral disc. Conservative treatment was ineffective, so we reoperated using PED with the same approach. Pain improved and MRI revealed disappearance of the cystic lesion. When symptoms relapse after PED, it is necessary to consider the occurrence of a cyst.