Rather Large Cyst

[jj337]

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A 59 year old male was referred by neurosurgery for evaluation for interventional therapies. He has left-sided low back pain and right sided radicular pain. He had a L4-5 diskectomy in 1973 and a redo of the surgery in 1985. He has seen 3 different surgeons regarding his pain and has had two different suggestions. He was offered surgery by one surgeon (who apparently quit his job) and two others suggested pain injections (prior to any surgery) to see if this could cover his pain. He states everyone is afraid to touch it. The images are included. It appears that there is communication with the CSF.​

Other than surgery, unsure if anything will really help. ​

Any suggestions?​

 

[PMR 4 MSK]

A 59 year old male was referred by neurosurgery for evaluation for interventional therapies. He has left-sided low back pain and right sided radicular pain. He had a L4-5 diskectomy in 1973 and a redo of the surgery in 1985. He has seen 3 different surgeons regarding his pain and has had two different suggestions. He was offered surgery by one surgeon (who apparently quit his job) and two others suggested pain injections (prior to any surgery) to see if this could cover his pain. He states everyone is afraid to touch it. The images are included. It appears that there is communication with the CSF.​

Other than surgery, unsure if anything will really help. ​

Any suggestions?​

That looks like my sister's MRI post-lami a few years ago. Only surgery likely to help. You might calm it down for few weeks, or stone him with meds so he forgets about it, but that is not a temporary lesion, it's permanent until removed/fixed.

 

[TX PAIN DOC]

I had a similar patient with an equally impressive MRI. Neurosurgeon who we worked with would not touch it either. He told us pseudomeningoceles and CSF cysts need to be sent back to original surgeon as a post-op complication. He warned me about doing any procedures near it to avoid any CSF leak. He said a drain may need to be placed or dura repaired.

Fortunately, original Ortho spine surgeon took patient to surgery and he is doing well. 👍

 

[Tenesma]

1) that isn't a facet cyst

2) his right radicular pain is likely due to severe foraminal stenosis - did you see those sagittal cuts at L4/L5 and L5/S1 - and likely has nothing to do with the cyst

3) If I were to do an injection I would (under CT guidance: use a 27gauge needle and inject contrast into the cyst, then do a transforaminal ESI at right L4/l5 and L5/S1 to address the radicular pain - if you do it under fluoro you will likely hit the sac)...

4) it is hard to comment on the left lower back pain with lack of other slices --- a CT would be helpful to assess what was done surgically, because if he had an overly aggressive facetectomy as part of his lami for discectomy, he may in fact have some segmental instability and need a fusion any way...

5) my first step: 1) CT (no contrast) 2) have a talk with the surgeon about his plan should my TFESI provide relief of the radicular pain.

 

[lobelsteve]

I would not bother with injection until this seroma of csf is surgically corrected. Not enough views with making on axial vs sagittal cuts to know how much recess stenosis is at each level. 1 or 2 level fusion just to fix what the last guy screwed up. Then I'd wait 12 weeks and get to work on whatever pains were worst at that time.

 

[SSdoc33]

seems to me you'd need a CT myelogram, or "possible CSF cystogram" or whatever you want to call it to see if indeed there is CSF communication. if so, im not sure why one cant perform a cystectomy and fix the dural defect. either way, this is surgeon territory. once you put a needle in that back, it becomes your problem, regardless of the outcome. even if you just do a skin wheal, any further complication or lack or improvement will be set squarely in your lap. i am very skeptical that injection would help, anyway

 

[jj337]

Thanks for the suggestions...

I don't really want to stick a needle in there mostly because I don't think it will help and if I get into the sack I am hosed. Considered a caudal but it probably won't help either.