Different operative findings of cases predicted to be symptomatic discal pseudocysts after percutaneous endoscopic lumbar discectomy

Abstract

Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive treatment for lumbar disc herniation (LDH). This report focused on one of the rare complications of PELD: symptomatic postoperative discal pseudocyst (PDP). A 27-year-old male patient (case 1) presented with recurrent radiculopathy in his left leg. Twenty days previously, he had undergone PELD for left L4/5 LDH and his symptoms temporarily improved. A 14-year-old female patient (case 2) also developed recurrent pain in her left leg. Thirty days previously, she had undergone PELD for left L4/5 LDH and her symptoms disappeared. On the basis of the finding of an expandable round lesion at the evacuated sites of LDH on magnetic resonance imaging (MRI), with low intensity of T1-weighted imaging and high intensity on T2-weighted imaging, we predicted symptomatic PDP in both cases. Given the progressive leg pain in both cases, surgical treatments were adopted (case 1: microendoscopic discectomy, case 2: PELD). During the operation, we confirmed that case 1 was a simple recurrence of LDH and case 2 was symptomatic PDP. Previous studies on symptomatic PDP included cases diagnosed without operative findings. Therefore, it should be carefully considered that such cases might be a simple recurrence of LDH.

Keywords: Percutaneous endoscopic lumbar discectomy (PELD); complication; lumbar disc herniation (LDH); minimally invasive; postoperative discal pseudocyst (PDP).

Figure 1

Preoperative radiographic and intraoperative findings in a patient with recurrent lumbar disc herniation (case 1). (A-C) Preoperative magnetic resonance imaging (MRI) findings of the initial operation: (A) sagittal view of the T1-weighted image (T1WI), (B) sagittal view of the T2-weighted image (T2WI), and (C) axial view of the T2WI. (D-F) Preoperative MRI findings of the second operation: (D) sagittal view of the T1WI, (E) sagittal view of the T2WI, and (F) axial view of the T2WI. (G,H) Intraoperative photographs: after the removal of a part of the vertebral arch and ligamentum flavum, the L5 nerve root was retracted to the right side (upper side in the photographs). The smooth surface of this cystic lesion could be observed (G). After puncturing the surface, a solid nucleus pulposus appeared (H, tip of the forceps).

Figure 2

Preoperative radiographic findings and intraoperative findings in a patient with symptomatic postoperative discal pseudocyst (case 2). (A-C) Preoperative magnetic resonance imaging (MRI) findings of the initial operation: (A) sagittal view of the T1-weighted image (T1WI), (B) sagittal view of the T2-weighted image (T2WI), and (C) axial view of the T2WI. (D-F) Preoperative MRI findings of the second operation: (D) sagittal view of the T1WI, (E) sagittal view of the T2WI, and (F) axial view of the T2WI. (G,H) Intraoperative photographs: after reaching the vertebral foramen, we first confirmed the smooth and thin surface of this expanding cystic lesion (G). After puncturing the surface, we observed spouting serous fluid and annulus tear on the further side of the cyst (H).