J Korean Neurosurg Soc.  2012 Apr;51(4):208-214. 10.3340/jkns.2012.51.4.208.

Clinical Outcomes of Percutaneous Endoscopic Surgery for Lumbar Discal Cyst

• Ha SW
• Ju CI
• Kim SW
• Lee S
• Kim YH
• Kim HS

• KMID: 2066912
• DOI: http://doi.org/10.3340/jkns.2012.51.4.208

Abstract

OBJECTIVE
Discal cyst is rare and causes indistinguishable symptoms from lumbar disc herniation. The clinical manifestations and pathological features of discal cyst have not yet been completely known. Discal cyst has been treated with surgery or with direct intervention such as computed tomography (CT) guided aspiration and steroid injection. The purpose of this study is to evaluate the safety and efficacy of the percutaneous endoscopic surgery for lumbar discal cyst over at least 6 months follow-up.
METHODS
All 8 cases of discal cyst with radiculopathy were treated by percutaneous endoscopic surgery by transforaminal approach. The involved levels include L5-S1 in 1 patient, L3-4 in 2, and L4-5 in 5. The preoperative magnetic resonance imaging and 3-dimensional CT with discogram images in all cases showed a connection between the cyst and the involved intervertebral disc. Over a 6-months period, self-reported measures were assessed using an outcome questionaire that incorporated total back-related medical resource utilization and improvement of leg pain [visual analogue scale (VAS) and Macnab's criteria].
RESULTS
All 8 patients underwent endoscopic excision of the cyst with additional partial discectomy. Seven patients obtained immediate relief of symptoms after removal of the cyst by endoscopic approach. There were no recurrent lesions during follow-up period. The mean preoperative VAS for leg pain was 8.25+/-0.5. At the last examination followed longer than 6 month, the mean VAS for leg pain was 2.25+/-2.21. According to MacNab' criteria, 4 patients (50%) had excellent results, 3 patients (37.5%) had good results; thus, satisfactory results were achieved in 7 patients (87.5%). However, one case had unsatisfactory result with persistent leg pain and another paresthesia.
CONCLUSION
The radicular symptoms were remarkably improved in most patients immediately after percutaneous endoscopic cystectomy by transforaminal approach.

Keyword

Lumbar discal cyst; Percutaneous endoscopic transforaminal cystectomy

MeSH Terms

Cystectomy
Diskectomy
Follow-Up Studies
Humans
Intervertebral Disc
Leg
Magnetic Resonance Imaging
Radiculopathy

Figure

• 

  Fig. 1 A : Preoperative magnetic resonance (MR) sagittal image showing discal cyst on L4-5. B and C : Preoperative discogram with 3D reconstruction computed tomography showing a connecting channel between the cyst and the corresponding disc. D : Postoperative MR image showing discal cyst which has been successfully removed. 3D : 3-dimensional.

• 

  Fig. 2 Endoscopic view of discal cyst by transforaminal approach. A : Right L5 nerve root is compressed by discal cyst with adhesion. B : Discal cystic stalk is connected to disc material beneath the L5 nerve root. C : L5 nerve root could be free after removal of discal cyst as well as cystic stalk.

• 

  Fig. 3 A and B : Preoperative magnetic resonance (MR) showing discal cyst on L3-4. C : Preoperative discogram with 3D reconstruction computed tomography showing a connecting channel between the cyst and the corresponding disc. D : Postoperative MR image showing discal cyst which has been successfully removed. E and F : Preoperative MR showing discal cyst on L5-S1. G : Postoperative MR image. 3D : 3-dimensional.

Reference

1. Abdullah AF, Wolber PG, Warfield JR, Gunadi IK. Surgical management of extreme lateral lumbar disc herniations : review of 138 cases. Neurosurgery. 1988; 22:648–653. PMID: 3374776.

2. Akhaddar A, Ajja A, Albouzidi A, Elmostarchid B, Boucetta M. Cystic schwannoma of the cauda equina mimicking hemangioblastoma. Neurochirurgie. 2008; 54:101–103. PMID: 18371989.

3. Baker JK, Hanson GW. Cyst of the ligamentum flavum. Spine (Phila Pa 1976). 1994; 19:1092–1094. PMID: 8029749.

4. Baum JA, Hanley EN Jr. Intraspinal synovial cyst simulating spinal stenosis. A case report. Spine (Phila Pa 1976). 1986; 11:487–489. PMID: 3750088.

5. Boviatsis EJ, Stavrinou LC, Kouyialis AT, Gavra MM, Stavrinou PC, Themistokleous M, et al. Spinal synovial cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review. Eur Spine J. 2008; 17:831–837. PMID: 18389295.

6. Brish A, Payan HM. Lumbar intraspinal extradural ganglion cyst. J Neurol Neurosurg Psychiatry. 1972; 35:771–775. PMID: 4647850.

7. Buchwald C, Børgesen SE. Intraspinal thoracolumbar dermoid. Case report. Acta Neurochir (Wien). 1989; 101:163–164. PMID: 2618823.

8. Chiba K, Toyama Y, Matsumoto M, Maruiwa H, Watanabe M, Nishizawa T. Intraspinal cyst communicating with the intervertebral disc in the lumbar spine : discal cyst. Spine (Phila Pa 1976). 2001; 26:2112–2118. PMID: 11698889.

9. Chou D, Smith JS, Chin CT. Spontaneous regression of a discal cyst. Case report. J Neurosurg Spine. 2007; 6:81–84. PMID: 17233298.

10. Coscia MF, Broshears JR. Lumbar spine intracanalicular discal cysts : two case reports. J Spinal Disord Tech. 2002; 15:431–435. PMID: 12394670.

11. Demaerel P, Eerens I, Goffin J, Wilms G. Spontaneous regression of an intraspinal disc cyst. Eur Radiol. 2001; 11:2317–2318. PMID: 11702179.

12. Fardon DF, Milette PC. Nomenclature and classification of lumbar disc pathology. Recommendations of the Combined task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine (Phila Pa 1976). 2001; 26:E93–E113. PMID: 11242399.

13. Goyal A, Singh D, Singh AK, Gupta V, Sinha S. Spontaneous rupture of spinal dermoid cyst with disseminated lipid droplets in central canal and ventricles. J Neurosurg Sci. 2004; 48:63–65. PMID: 15550900.

14. Goyal RN, Russell NA, Benoit BG, Belanger JM. Intraspinal cysts : a classification and literature review. Spine (Phila Pa 1976). 1987; 12:209–213. PMID: 3589815.

15. Hsu KY, Zucherman JF, Shea WJ, Jeffrey RA. Lumbar intraspinal synovial and ganglion cysts (facet cysts). Ten-year experience in evaluation and treatment. Spine (Phila Pa 1976). 1995; 20:80–89. PMID: 7709284.

16. Ishii K, Matsumoto M, Watanabe K, Nakamura M, Chiba K, Toyama Y. Endoscopic resection of cystic lesions in the lumbar spinal canal : a report of two cases. Minim Invasive Neurosurg. 2005; 48:240–243. PMID: 16172971.

17. Jeong GK, Bendo JA. Lumbar intervertebral disc cyst as a cause of radiculopathy. Spine J. 2003; 3:242–246. PMID: 14589206.

18. Kambin P, Cohen LF, Brooks M, Schaffer JL. Development of degenerative spondylosis of the lumbar spine after partial discectomy. Comparison of laminotomy, discectomy, and posterolateral discectomy. Spine (Phila Pa 1976). 1995; 20:599–607. PMID: 7604330.

19. Kim JS, Choi G, Lee CD, Lee SH. Removal of discal cyst using percutaneous working channel endoscope via transforaminal route. Eur Spine J. 2009; 18(Suppl 2):201–205. PMID: 19034535.

20. Koga H, Yone K, Yamamoto T, Komiya S. Percutaneous CT-guided puncture and steroid injection for the treatment of lumbar discal cyst: a case report. Spine (Phila Pa 1976). 2003; 28:E212–E216. PMID: 12782997.

21. Kono K, Nakamura H, Inoue Y, Okamura T, Shakudo M, Yamada R. Intraspinal extradural cysts communicating with adjacent herniated disks: imaging characteristics and possible pathogenesis. AJNR Am J Neuroradiol. 1999; 20:1373–1377. PMID: 10473000.

22. Lee HK, Lee DH, Choi CG, Kim SJ, Suh DC, Kahng SK, et al. Discal cyst of the lumbar spine: MR imaging features. Clin Imaging. 2006; 30:326–330. PMID: 16919553.

23. Lim G, Kim HS, Kim SW, Shin H. Discal cyst diagnosed by radiologic finding. J Korean Neurosurg Soc. 2007; 41:418–420.

24. Mayer HM, Brock M. Percutaneous endoscopic discectomy : surgical technique and preliminary results compared to microsurgical discectomy. J Neurosurg. 1993; 78:216–225. PMID: 8267686.

25. Mizutamari M, Sei A, Fujimoto T, Taniwaki T, Mizuta H. L5 radiculopathy caused by a ganglion cyst of the posterior longitudinal ligament in a teenager. Spine J. 2009; 9:e11–e14. PMID: 18640878.

26. Murata K, Ikenaga M, Tanaka C, Kanoe H, Okuaaira S. Discal cysts of the lumbar spine: a case report. J Orthop Surg (Hong Kong). 2007; 15:376–379. PMID: 18162691.

27. Nabeta M, Yoshimoto H, Sato S, Hyakumachi T, Yanagibashi Y, Masuda T. Discal cysts of the lumbar spine. Report of five cases. J Neurosurg Spine. 2007; 6:85–89. PMID: 17233299.

28. Ogawa Y, Kumano K, Hirabayashi S, Aota Y. A ganglion cyst in the lumbar spinal canal. A case report. Spine (Phila Pa 1976). 1992; 17:1429–1431. PMID: 1462225.

29. Onofrio BM, Mih AD. Synovial cysts of the spine. Neurosurgery. 1988; 22:642–647. PMID: 3374775.

30. Ozer AF, Oktenoglu T, Sasani M, Bozkus H, Canbulat N, Karaarslan E, et al. Preserving the ligamentum flavum in lumbar discectomy: a new technique that prevents scar tissue formation in the first 6 months postsurgery. Neurosurgery. 2006; 59:ONS126–ONS133. discussion ONS126-ONS133. PMID: 16888542.

31. Porchet F, Chollet-Bornand A, de Tribolet N. Long-term follow up of patients surgically treated by the far-lateral approach for foraminal and extraforaminal lumbar disc herniations. J Neurosurg. 1999; 90:59–66. PMID: 10413127.

32. Ross JS, Robertson JT, Frederickson RC, Petrie JL, Obuchowski N, Modic MT, et al. ADCON-L European Study Group. Association between peridural scar and recurrent radicular pain after lumbar discectomy: magnetic resonance evaluation. Neurosurgery. 1996; 38:855–861. discussion 861-863. PMID: 8692415.

33. Sakas DE, Farrell MA, Young S, Toland J. Posterior thecal lumbar disc herniation mimicking synovial cyst. Neuroradiology. 1995; 37:192–194. PMID: 7603593.

34. Sasani M, Ozer AF, Oktenoglu T, Canbulat N, Sarioglu AC. Percutaneous endoscopic discectomy for far lateral lumbar disc herniations : prospective study and outcome of 66 patients. Minim Invasive Neurosurg. 2007; 50:91–97. PMID: 17674295.

35. Shah RV, Lutz GE. Lumbar intraspinal synovial cysts: conservative management and review of the world's literature. Spine J. 2003; 3:479–488. PMID: 14609693.

36. Tanaka M, Nakahara S, Ito Y, Nakanishi K, Sugimoto Y, Ikuma H, et al. Surgical results of sacral perineural (Tarlov) cysts. Acta Med Okayama. 2006; 60:65–70. PMID: 16508691.

37. Tomecek FJ, Anthony CS, Boxell C, Warren J. Discography interpretation and techniques in the lumbar spine. Neurosurg Focus. 2002; 13:E13. PMID: 15916397.

38. Toyama Y, Kamata N, Matsumoto M, Nishizawa T, Koyanagi T, Suzuki N, et al. Pathogenesis and diagnostic title of intraspinal cyst communicating with intervertebral disk in the lumbar spine. Rinsho Seikei Geka. 1997; 32:393–400.

39. Tsou PM, Alan Yeung C, Yeung AT. Posterolateral transforaminal selective endoscopic discectomy and thermal annuloplasty for chronic lumbar discogenic pain : a minimal access visualized intradiscal surgical procedure. Spine J. 2004; 4:564–573. PMID: 15363430.

40. Tsou PM, Yeung AT. Transforaminal endoscopic decompression for radiculopathy secondary to intracanal noncontained lumbar disc herniations: outcome and technique. Spine J. 2002; 2:41–48. PMID: 14588287.

41. Vasani SS, Demetriades AK, Joshi SM, Yeh J, Ellamushi H. Traumatic intraspinal extradural ganglion cyst in a teenager : case report and review of the literature. Clin Neurol Neurosurg. 2007; 109:88–91. PMID: 16647199.

42. Voyadzis JM, Bhargava P, Henderson FC. Tarlov cysts : a study of 10 cases with review of the literature. J Neurosurg. 2001; 95:25–32. PMID: 11453427.

43. Watanabe N, Ogura T, Kimori K, Hase H, Hirasawa Y. Epidural hematoma of the lumbar spine, simulating extruded lumbar disk herniation : clinical, discographic, and enhanced magnetic resonance imaging features. A case report. Spine (Phila Pa 1976). 1997; 22:105–109. PMID: 9122773.

44. Wu X, Zhuang S, Mao Z, Chen H. Microendoscopic discectomy for lumbar disc herniation : surgical technique and outcome in 873 consecutive cases. Spine (Phila Pa 1976). 2006; 31:2689–2694. PMID: 17077737.

45. Young PM, Fenton DS, Czervionke LF. Postoperative annular pseudocyst : report of two cases with an unusual complication after microdiscectomy, and successful treatment by percutaneous aspiration and steroid injection. Spine J. 2009; 9:e9–e15. PMID: 18280218.