- Department of Neurosurgery, Dong Gwang Ju Woori Hospital, Gwangju, Korea
- Department of Neurosurgery, Gwang Ju Woori Hospital, Gwangju, Korea
- Department of Neurosurgery, Chonnam National University Hospital, Gwangju, Korea
Correspondence Address:
Lee Jung-Kil
Department of Neurosurgery, Chonnam National University Hospital, Gwangju, Korea
DOI:10.4103/2152-7806.77026
© 2011 Hyung-Jun K 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: Hyung-Jun K, Dae-Yong K, Tae-Ho K, Ho-Sang P, Jae-Sung K, Jae-Won J, Jung-Kil L. Lumbar discal cyst causing bilateral radiculopathy. Surg Neurol Int 23-Feb-2011;2:21
How to cite this URL: Hyung-Jun K, Dae-Yong K, Tae-Ho K, Ho-Sang P, Jae-Sung K, Jae-Won J, Jung-Kil L. Lumbar discal cyst causing bilateral radiculopathy. Surg Neurol Int 23-Feb-2011;2:21. Available from: http://sni.wpengine.com/surgicalint_articles/lumbar-discal-cyst-causing-bilateral-radiculopathy/
Abstract
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.
Keywords: Bilateral, discal cyst, lumbar spinal stenosis, radiculopathy
INTRODUCTION
Low back and sciatic pain is commonly caused by degenerative conditions such as lumbar disc herniation or spinal stenosis. The discal cyst, which has distinct connection to the corresponding intervertebral disc in the spinal canal, is a less common etiology of a lumbar radiculopathy.[
CASE REPORT
A 48-year-old female presented with low back pain radiating to both buttocks and the posterior thigh for 3 months. She also suffered from neurogenic intermittent claudication (NIC) within 10 minutes. The straight leg-raising test was positive at 60 degrees on both sides. However, sensory or motor of the lower extremity was normal.
Magnetic resonance imaging (MRI) demonstrated a cystic lesion measuring 6 × 16 × 16 mm with low-signal intensity on T1-weighted imaging and high-signal intensity on T2-weighted imaging at the level of the L3-L4 disc. The cystic mass, located in the ventral aspect of the extradural space, displaced the thecal sac dorsally [Figure
DISCUSSION
Discal cyst is extremely rare. To the best of our knowledge, only 57 cases of discal cyst including our case, have been reported in the literature.[
Pathogenesis of discal cysts remains unknown. Two hypotheses for the development of discal cysts have been proposed. Chiba et al,[
MRI is the modality of choice for diagnosis of discal cyst. The cyst is round or oval in shape, with a low-intensity signal in T1-weighted images and a high-intensity signal in T2-weighted sequences that is consistent with a cyst containing liquid. This signal can vary depending on the proteinaceous concentration of fluid, or even the presence of blood. The peripheral rim of the cyst is enhanced on contrast-enhanced MRI.[
Therapeutic guidelines have not been established. Spontaneous regression of the cyst has been reported,[
Kono et al,[
In summary, we present a rare case of a lumbar discal cyst with bilateral radiculopathy. Our case suggests that a discal cyst may cross the midline, resulting in bilateral radiculopathy and NIC. Surgical excision of the cyst offered immediate symptomatic improvement, which was sustained at the two-year follow-up.
Discal cyst is certainly a rare pathology. In addition to the two origins of discal cysts noted by the authors,[
Also, from the standpoint of surgical technique, Kim and Lee,[
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
The authors present a case report concerning a 48-year-old female with bilateral sciatica and neurogenic claudication of 3 months duration secondary to an MR-documented lumbar discal cyst at the L3–L4 level. Low signal T1 and high signal T2 MR studies documented the anatomy of the cyst which was subsequently adequately excised, without the disc space being entered, through a left hemipartial L3 laminectomy. Postoperatively, the patient’s symptoms totally resolved and she remained asymptomatic after two postoperative years.
When the authors reviewed the literature, they found references which included 57 discal cysts. Most patients were males, averaging 34 years of age, and had discal cysts predominantly at the L4–L5 and L5–S1 levels (64.9%). Symptoms typically included unilateral radiculopathy, unlike the present case which involved bilateral radiculopathy and neurogenic claudication. The authors quoted different hypotheses for the pathogenesis of discal cysts. Although the first hypothesis invoked epidural hematoma as the cause of the cyst, it did not explain why/how the “communicating stalk” developed between the disc and the cyst. The second, more likely hypothesis, offered focal degeneration of the disc with resultant “fluid production”; anatomical data demonstrating a fibrous cyst without a synovial lining supported this hypothesis.
However, the literature offers additional hypotheses regarding the pathoanatomical evolution of discal cysts, while also providing multiple differential diagnoses. In a study by Kobayashi et al., discal cysts communicated with an adjacent disc herniation on both MR and CT studies; this finding was confirmed intraoperatively.[
Gas-filled intradural cysts may also contribute to unilateral radiculopathy.[
In yet another study, an intradural disc herniation containing gas, which appeared as a ring-enhancing “cystic” intradural lesion at the L3–L4 level on a contrast-enhanced MR study, was surgically excised.[
What diagnostic studies best document discal cysts? Although CT-discography readily documents the connection between the disc space and the cyst via an attenuated channel, it poses multiple inherent risks which include durotomy, root injury, infection, allergic reactions, etc. Notably, several non-invasive modalities, including MR and CT-based studies, with/without intravenous contrast, would likely adequately confirm the location and etiology of many of these lesions.
Although there are multiple therapeutic options offered to manage discal cysts, open surgical procedures, and not the minimally invasive ones, offer the most versatile therapeutic alternatives. Certainly, non-surgical treatment in minimally and/or asymptomatic patients may be a reasonable alternative, particularly since some discal cysts will spontaneously resorb.
However, other minimally invasive approaches such as intracystic steroid injections, or fluoroscopic/CT-guided cyst aspiration, are likely to fail. Reasons for failure include first, their inability to address the more complex pathology (e.g. disc herniations, synovial cysts, etc.). Second, the thecal sac and/or nerve roots, located dorsal to the discal cyst (with/without disc herniations), may be perforated with these percutaneous techniques, resulting in cerebrospinal fluid fistula formation, and/or root trauma. Third, these techniques provide minimal access to potentially more complex pathology, and therefore increase the risk to the patient of incomplete, inadequate cyst decompression, and/or cyst recurrence. Although Dasenbrock et al. observed that an L5-S1 discal cyst was successfully aspirated under CT-guidance, they acknowledged that few surgeons were opting for this approach as another study cited cyst recurrence following a similar approach.[
A 48-year-old Asian female presented with a 3-month history of bilateral lumbar radiculopathy. An LS spine magnetic resonance imaging (MRI) revealed an L3-4 discal cyst (hyperintense on T2-weighted sequences and hypointense on T1-weighted images with a slight rim enhancement) crossing the midline and causing bilateral nerve root compression. The patient underwent hemilaminectomy for cyst resection, and aspiration of bloody serous fluid. The cyst was traced back to its discal fistulous attachment where an annular tear was discovered and coagulated. The disk space itself was not violated. Clinical and radiographic follow-up, at 12 and 14 months, respectively, revealed excellent symptomatic and cyst resolution.
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,[
Discal cysts are seen most commonly in young Asian men.[
The etiology of discal cysts is debatable. Some suggestion underlying traumatic epidural hematoma with deficits in its resorption leading to cyst formation.[
MRI is the diagnostic study of choice, typically revealing an extradural intraspinal ventrally located cyst, hypointense on T1-weighted and hyperintense on T2-weighted images, with rim enhancement after gadolinium administration (as seen in this case). However, hemorrhagic cysts may be hyperintense on both T1- and T2-weighted images, and the rim of contrast enhancement is not always present. Discography, albeit invasive, is used diagnostically to confirm a connection between the intervertebral disc and the cyst.
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,[
Treatment options exist, though surgical resection is the most commonly employed modality. Successful CT-guided percutaneous aspiration of discal cysts has been reported.[
Commentary
Lumbar discal cyst causing bilateral radiculopathy
- University of Illinois, Chicago (Ret.), Center for Pain Treatment and Rehabilitation, Lake Forest Hospital, Lake Forest, Illinois USA. Email:
ron@pawl.com
Commentary
Lumbar discal cyst causing bilateral radiculopathy
- Department of Neurological Surgery, The Albert Einstein College of Medicine, Bronx, NY 10467 and Neurosurgical Spine and Education, Winthrop University Hospital, Mineola, NY 11501, USA. Email:
dch3@columbia.edu
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
The authors present a case report concerning a 48-year-old female with bilateral sciatica and neurogenic claudication of 3 months duration secondary to an MR-documented lumbar discal cyst at the L3–L4 level. Low signal T1 and high signal T2 MR studies documented the anatomy of the cyst which was subsequently adequately excised, without the disc space being entered, through a left hemipartial L3 laminectomy. Postoperatively, the patient’s symptoms totally resolved and she remained asymptomatic after two postoperative years.
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
When the authors reviewed the literature, they found references which included 57 discal cysts. Most patients were males, averaging 34 years of age, and had discal cysts predominantly at the L4–L5 and L5–S1 levels (64.9%). Symptoms typically included unilateral radiculopathy, unlike the present case which involved bilateral radiculopathy and neurogenic claudication. The authors quoted different hypotheses for the pathogenesis of discal cysts. Although the first hypothesis invoked epidural hematoma as the cause of the cyst, it did not explain why/how the “communicating stalk” developed between the disc and the cyst. The second, more likely hypothesis, offered focal degeneration of the disc with resultant “fluid production”; anatomical data demonstrating a fibrous cyst without a synovial lining supported this hypothesis.
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
However, the literature offers additional hypotheses regarding the pathoanatomical evolution of discal cysts, while also providing multiple differential diagnoses. In a study by Kobayashi et al., discal cysts communicated with an adjacent disc herniation on both MR and CT studies; this finding was confirmed intraoperatively.[
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
Gas-filled intradural cysts may also contribute to unilateral radiculopathy.[
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
In yet another study, an intradural disc herniation containing gas, which appeared as a ring-enhancing “cystic” intradural lesion at the L3–L4 level on a contrast-enhanced MR study, was surgically excised.[
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
What diagnostic studies best document discal cysts? Although CT-discography readily documents the connection between the disc space and the cyst via an attenuated channel, it poses multiple inherent risks which include durotomy, root injury, infection, allergic reactions, etc. Notably, several non-invasive modalities, including MR and CT-based studies, with/without intravenous contrast, would likely adequately confirm the location and etiology of many of these lesions.
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
Although there are multiple therapeutic options offered to manage discal cysts, open surgical procedures, and not the minimally invasive ones, offer the most versatile therapeutic alternatives. Certainly, non-surgical treatment in minimally and/or asymptomatic patients may be a reasonable alternative, particularly since some discal cysts will spontaneously resorb.
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
However, other minimally invasive approaches such as intracystic steroid injections, or fluoroscopic/CT-guided cyst aspiration, are likely to fail. Reasons for failure include first, their inability to address the more complex pathology (e.g. disc herniations, synovial cysts, etc.). Second, the thecal sac and/or nerve roots, located dorsal to the discal cyst (with/without disc herniations), may be perforated with these percutaneous techniques, resulting in cerebrospinal fluid fistula formation, and/or root trauma. Third, these techniques provide minimal access to potentially more complex pathology, and therefore increase the risk to the patient of incomplete, inadequate cyst decompression, and/or cyst recurrence. Although Dasenbrock et al. observed that an L5-S1 discal cyst was successfully aspirated under CT-guidance, they acknowledged that few surgeons were opting for this approach as another study cited cyst recurrence following a similar approach.[
A review of case report: Lumbar discal cyst causing bilateral radiculopathy
Commentary
Discal cysts: Rare causes of nerve root compression
- Department of Neurosurgery, Johns Hopkins University, 600 N. Wolfe Street, Meyer 7-109, Baltimore, MD 21287, USA. Email:
abydon1@jhmi.edu
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