1020 - Cyst of the Disc

Case Diagnosis: Discal cyst of the lumbar spine

Case Description: A 22-year-old male, with no significant medical history, presented with worsening low back pain radiating into his left buttocks over several months. He denied prior trauma. He's a fisherman, lifting heavy objects daily. Pain reported as severe, worse with bending forward.
Trialed physical therapy, received TFESI to the L4/L5 region, and lyrica 50mg twice daily with minimal improvements.

MRI of L4/L5-spine revealed: a moderate posterior disc herniation and an inferior, adjacent cystic lesion causing narrowing of the lateral recess; suspected to be a discal cyst.

Physical exam was significant for limited spinal active range of motion and painful forward spinal flexion. There was a positive straight leg raise test on the left. Muscle strength, sensation, deep tendon reflexes, and gait were all intact.

Discussions: Discal cysts on magnetic resonance imaging have been described as having high signal intensity on T2 weighted images and low signal intensity on T1 images. There are no clear guidelines for the management and treatment of discal cysts. The literature has documented a variety of treatment approaches ranging from medical management to surgery, with initial conservative treatment with rest analgesia, and PT for patients that are neurologically stable. Temporizing management include epidural steroid injections. Surgical interventions include endoscopic CT guided percutaneous aspiration with or without steroid injection, or open posterior decompression vs. partial hemilaminectomy with or without microdiscectomy; the latter with risks of altered biomechanics and spinal instability.

The patient decided to continue physical therapy and conservative management, while also speaking with a surgeon. The patient has progressed significantly over the past 8 weeks.

Conclusions: Overall, documentation of discal cysts in the literature is very limited. In addition, evidence of the successful management of these cysts is even more sparse. Physical therapy with multiple lumbar injections showed positive results for our patient.