Discal cyst of the lumbar spine

A postoperative complication of lumbar discectomy: A discal/annular cyst

Background

A postoperative discal/annular cyst following lumbar discectomy may reproduce the symptoms/signs of a recurrent lumbar disc herniation (i.e., back pain and radiculopathy).

Case Description

A 21-year-old rugby player developed leg pain after an uncomplicated lumbar microdiscectomy. The repeat lumbar magnetic resonance imaging confirmed a postoperative lumbar annular/ discal cyst, for which he underwent repeat surgery. The diagnosis was further confirmed histopathologically at surgery.

Conclusion

Although rare, postoperative discal/annular cysts may be potential causes of recurrent postoperative pain and lumbar radiculopathy mimicking recurrent disc herniations.

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.

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.

Redefining the Evolution of Spinal Discal Cyst Under Percutaneous Endoscopy: Report of Two Cases

Discal cyst has been recognized as a distinct cause of back pain and radiculopathy. The clinical features are similar to other pathologies as disc prolapse and stenosis. Various treatment modalities have been described, ranging from nerve blocks to surgical excision. There are scarce reports on the endoscopic appearance of discal cysts. The present paper based on two cases operated by transforaminal and interlaminar endoscopy at our institute demonstrates the explicit intraoperative view and different pathological components of discal cysts.

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.

Successful Treatment of a Symptomatic Discal Cyst by Percutaneous C-arm Guided Aspiration

Although discal cysts are a rare cause of low back pain and radiculopathy. Currently, surgical excision is usually the first-line treatment for discal cysts. However, alternative treatment methods have been suggested, as in some cases symptoms have improved with interventional therapies. A 27-year-old man presented with an acute onset of severe pain, and was found to have a discal cyst after an open discectomy. The patient underwent cyst aspiration and steroid injection through the facet joint under C-arm guidance. After the procedure, the patient's pain improved to NRS 0-1. On outpatient physical examination 1 week, and 1 and 3 months later, no abnormal neurological symptoms were present, and pain did not persist; thus, follow-up observation was terminated. When a discal cyst is diagnosed, it is more appropriate to consider interventional management instead of surgery as a first-line treatment, while planning for surgical resection if the symptoms do not improve or accompanying neurologic deficits progress.

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

Various complications after microendoscopic discectomy (MED) are well known, but postoperative discal cyst is a unique and relatively unknown complication. Here, we report on two teenage patients who presented with postoperative discal cyst after MED for herniated nucleus pulposus (HNP), which resolved after conservative treatment. The patients were diagnosed with HNP at L4-5 and L5-S1 based on MRI and then treated by MED. Postoperative discal cyst was diagnosed on MRI after recurrence of symptoms. Both patients were managed conservatively. T2-weighted MRI demonstrated hyperintense collections adjacent to the operated intervertebral disc level, which were communicating with the corresponding disc annulus. Because the clinical symptoms were relatively mild, the patients were managed conservatively; both made a complete clinical recovery with radiological evidence of improvement. Postoperative discal cyst is a relatively unknown complication after MED for HNP. Surgeons should be aware of this postoperative complication when operating on young individuals with HNP.

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.

Discal cyst of the lumbar spine: a case report

Discal cysts are a rare cause of lumbar radiculopathy. There are only a few reports of this disease in medical literature. The authors describe the case of a 40-year-old man with a lumbar discal cyst that led to radiculopathy. An intraspinal extradural cystic mass was responsible for low and high signal intensities observed in lumbar lesions on T1 and T2 weighted magnetic resonance images. This cyst was a grossly spherical mass with clear serous fluid, which was connected to an adjacent intervertebral disc. Histopathology of the cystic walls revealed fibrous connective tissues without specific cell linings. Clinical symptoms were promptly relieved after surgical resection. Further research on the pathophysiology and treatment of discal cysts are needed.

Retrospective report of symptomatic postoperative discal pseudocyst after lumbar discectomy

BACKGROUND

Rarely, a symptomatic discal pseudocyst can develop after discectomy. Only very recently one clinical article and one case report about this type of pseudocyst were published: Kang and Park (J Korean Neurosurg Soc 49(1):31-36, 2011); Young PM, Fenton DS, Czervionke LF (Spine J. 9(2):e9-e15, 2009). Here, in an attempt to more clearly discriminate this peculiar cyst, the authors retrospectively report the clinical, radiological, and histological findings in 12 symptomatic patients with cystic lesions attached to an operated disc.

METHODS

From January 2007 to May 2010, 12 patients who experienced recurrent symptoms after successful lumbar discectomy were diagnosed with postoperative discal pseudocyst (PDP). After discectomy, the mean time to relapsing radiculopathy was 23.3 days (range, 9-38 days) with a mean of 6.8 ± 1.3 on the visual analogue scale (VAS). PDPs were detected on magnetic resonance imaging (MRI) at 31.2 days (range, 14-60 days) after the initial surgery. Of these 12 patients, 6 were treated conservatively (group C) and 6 by surgery (group S).

RESULTS

In the six patients in group C, the mean duration of relapsing pain was 77.8 days (range, 20-225 days), and near total or total regression of the cyst was detected at a mean of 82.7 days (range, 23-240 days) after initial detection by MRI. Time to spontaneous regression of PDP varied widely. In the six patients in group S, surgical treatment was administered within a few days of MRI diagnosis and achieved successful pain relief.

CONCLUSIONS

Postoperative discal pseudocyst appears to develop after lumbar discectomy and can regress spontaneously.

Lumbar diskal cyst containing intervertebral disk materials

The diskal cyst is a relatively new clinical entity and develops clinical symptoms of a unilateral single nerve root lesion. Although many cases of diskal cyst have been reported, the pathogenesis of diskal cyst remains unclear, and several theories regarding the pathogenesis have been proposed. This article presents 2 cases of diskal cyst communicating with an adjacent herniated disk. Magnetic resonance imaging findings showed diskal cysts in the epidural space of the lumbar spine. Surgical resection was performed, and apparent connections between the corresponding disk and cysts were found. Histopathologic examinations of the cyst wall demonstrated cartilaginous tissue including nucleus pulposus and annulus fibrosis. These patient's symptoms improved remarkably postoperatively, and there was no recurrence of diskal cyst.The hypothesis supported by many authors is hemorrhage from the epidural venous plexus. Diskal cysts arise first from an underlying intervertebral disk injury that causes an annulus fibrosis fissure in the posterior intervertebral disk. Hemorrhage from the epidural venous plexus with a rich blood flow then occurs in the space between the peridural membrane and vertebral body. However, in our cases, we confirmed that the diskal cyst could have developed from the resorption process of an intervertebral disk herniation. Only 5 cases of diskal cyst demonstrating the presence of cartilaginous tissue in the cyst have been reported. Our 2 cases are rare and support the hypothesis of resorption of intervertebral disk herniation.

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.

Symptomatic post-discectomy pseudocyst after endoscopic lumbar discectomy

OBJECTIVE

The objectives of this study were to determine the frequency of symptomatic postdiscectomy pseudocyst (PP) after endoscopic discectomy and to compare the results of surgical and conservative management of them.

METHODS

Initial study participants were 1,503 cases (1,406 patients) receiving endoscopic lumbar discectomy by 23-member board of neurosurgeons from March 2003 to October 2008. All patients' postoperative magnetic resonance imaging (MRI) scans were evaluated. On the postoperative MRI, cystic lesion of T2W high and T1W low at discectomy site was regarded as PP. Reviews of medical records and radiological findings were done. The PP patients were divided into two groups, surgical and conservative management by treatment modality after PP detection. We compared the results of the two groups using the visual analogue scale (VAS) for low back pain (LBP), VAS for leg pain (LP) and the Oswestry disability index (ODI).

RESULTS

Among 1,503 cases of all male soldiers, the MRIs showed that pseudocysts formed in 15 patients, about 1.0% of the initial cases. The mean postoperative interval from surgery to PP detection was 53.7 days. Interlaminar approach was correlated with PP formation compared with transforaminal approach (p=0.001). The mean VAS for LBP and LP in the surgical group improved from 6.5 and 4.8 to 2.0 and 2.3, respectively. The mean VAS for LBP and LP in the conservative group improved from 4.4 and 4.4 to 3.9 and 2.3, respectively. There was no difference in treatment outcome between surgical and conservative management of symptomatic PP.

CONCLUSION

Although this study was done in limited environment, symptomatic PP was detected at two months' postoperative period in about 1% of cases. Interlaminar approach seems to be more related with PP compared with transforaminal approach.

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.

Spontaneous regression of a cervical intraspinal cyst in a dog

We report a cervical intraspinal cyst in a dog that was initially tetraparetic but spontaneously recovered completely. MRI revealed a well-demarcated intraspinal cyst located dorsally to a degenerated intervertebral disc. The location of the cyst and its signal features on MRI resembled those of discal cysts previously reported in humans. It has been reported in dogs that clinical signs of a intraspinal cyst are similar to those of intervertebral disc herniation and both conditions require surgical intervention. Unexpectedly, our case showed rapid spontaneous recovery and the follow-up MRI revealed complete resolution of the intraspinal cyst and spinal cord compression. Spontaneous recovery of degenerative intraspinal cyst may occur in dogs, similar to rare human cases as reported previously.