- School of Medicine, Johns Hopkins University, 600 N Wolfe St., Baltimore, MD 21287
- Department of Radiology and Radiological Science, Johns Hopkins University, 600 N Wolfe St., Baltimore, MD 21287
- Department of Neurosurgery, Johns Hopkins University, 600 N Wolfe St., Baltimore, MD 21287
Department of Neurosurgery, Johns Hopkins University, 600 N Wolfe St., Baltimore, MD 21287
DOI:10.4103/2152-7806.68338© 2010 Dasenbrock HH. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Dasenbrock HH, Kathuria S, Witham TF, Gokaslan ZL, Bydon A. Successful treatment of a symptomatic L5/S1 discal cyst by percutaneous CT-guided aspiration. Surg Neurol Int 10-Aug-2010;1:41
How to cite this URL: Dasenbrock HH, Kathuria S, Witham TF, Gokaslan ZL, Bydon A. Successful treatment of a symptomatic L5/S1 discal cyst by percutaneous CT-guided aspiration. Surg Neurol Int 10-Aug-2010;1:41. Available from: http://sni.wpengine.com/surgicalint_articles/successful-treatment-of-a-symptomatic-l5s1-discal-cyst-by-percutaneous-ct-guided-aspiration/
Background:Discal cysts are a rare cause of lumbar radiculopathy. Benefits of percutaneous computed tomography (CT)-guided aspiration of the cyst include decreased rate of infection, avoidance of general anesthesia, and quicker recovery. However, since the publication of a case of cyst recurrence after CT-guided aspiration, few have utilized this potentially valuable technique.
Case Description:We present a patient with a discal cyst arising from the L5/S1 disc causing right S1 radiculopathy. He underwent percutaneous CT-guided aspiration with substantial improvement in his radicular pain with 19 months of follow-up. His improvement was measured quantitatively using the Japanese Orthopedic Association scale: 6/15 pre-procedure, 15/15 post-procedure.
Conclusion:Percutaneous CT-guided aspiration of discal cysts may be a valid initial treatment option for this condition. Patients who do not respond or who have a recurrence can subsequently be treated by surgical excision.
Keywords: CT-guided aspiration, disc cyst, discal cyst, intervertebral disc, percutaneous spinal interventions
Degenerative conditions of the lumbar spine are common causes of radiculopathy. A number of rare conditions exist that may present identically; discal cysts, intraspinal extradural cysts that communicate with the intervertebral disc, are a rare cause of radiculopathy. First reported in English in 1999,[
Percutaneous aspiration of discal cysts has many advantages, including avoiding the risks and complications of open surgery, avoiding general anesthesia, and a faster recovery. A report of recurrence after percutaneous computed tomography (CT)-guided aspiration[
Presentation and examination
A 37 year-old Caucasian male presented with a 7-month history of mild low-back pain and severe right S1 radiculopathy. He had failed conservative management with oral steroids and physical therapy. Physical examination was remarkable for a positive straight leg raise on the right side at 70°.
A magnetic resonance imaging (MRI) scan showed a cystic lesion at the L5-S1 level originating from the right lateral disc causing right lateral recess stenosis and posterior displacement of the traversing nerve root (S1). The cyst was hyperintense on T2-weighted and hypointense on T1-weighted images, with a rim of contrast enhancement present [
The discal cyst was treated with CT-guided aspiration. An 18-gauge needle was advanced into the center of the cyst. Transaxial CT images confirmed the appropriate placement of the needle, and a small amount of fluid was aspirated. Subsequent CT imaging showed a significantly smaller cyst [
The patient reported significant relief of his radiculopathy with excellent pain control documented 19 months post-procedure. His clinical outcome was quantitatively measured using the Japanese Orthopedic Association scale: his preoperative score was 6/15, and his postoperative score improved to 15/15.
Discal cysts occur most commonly in young Asian men.[
There are several theories regarding the etiology of discal cysts. Some have suggested that either disc herniation or trauma leads to the formation of an epidural hematoma, and deficits in its re-absorption lead to the cyst formation.[
Discal cysts have no distinguishing features on history or examination; the diagnosis is best made with MRI, which typically reveals a cystic sac that is hypointense on T1-weighted and hyperintense on T2-weighted images, with a rim of contrast enhancement after gadolinium administration. However, cysts with hemorrhage may be hyperintense on both T1- and T2-weighted images, and the rim of contrast enhancement is not always present.[
The optimal treatment of discal cysts remains debated. The natural history of this condition has yet to be defined, providing little guidance on prognosis. Spontaneous regression of a discal cyst has been reported.[
Percutaneous treatment of discal cysts by CT-guided aspiration has many potential advantages, including decreased infection rates, avoidance of general anesthesia, and faster recovery. Surgical excision can be performed on those who fail initial percutaneous drainage procedures.
Koga et al. first reported the successful treatment of a discal cyst by CT-guided puncture and steroid injection.[
The reports of CT-guided percutaneous aspiration published to date are limited by a small sample size and relatively short mean follow-up period, ranging from 6 to 14.7 months.[
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