Background: Benign spinal cysts are relatively common, but can cause significant pain. However, consensus regarding the best method for treating these cysts has not been established. We aimed to examine the usefulness of epiduroscopic neural laser decompression (ENLD), a novel percutaneous treatment, for treating lumbo-sacral cysts. Methods: Ten patients (6 men, 4 women; mean age 45.5 years) with benign lumbo-sacral cysts underwent ENLD. The lumbo-sacral cysts were caused by multiple pathophysiologies and displayed different characteristics. Cysts were evaluated using a recorded epiduroscopic procedure video, magnetic resonance imaging (MRI), and electronic medical records. In all patients, MRI identified cysts with well-defined margins that were compressing the nerves in the lumbo-sacral region and were associated with the pain symptoms of the patients. Retrospectively, we reviewed a series of consecutive patients who underwent surgery (two with discal cysts, four with facet cysts, and four with Tarlov cysts). Low back/leg pain was evaluated using a 1–10 visual analog scale. Functional improvement was evaluated using Oswestry Disability Index scores. Outcomes were evaluated pre- and post-operatively and 1 year post-surgery. Results: Patients were examined between May 2016 and August 2017. Average pain scores improved from 4.7 pre-surgery to 1.8 post-surgery (low back; p < .001) and from 5.8 pre-surgery to 1.6 post-surgery (leg; p < .001). Disability scores decreased from 27.2% pre-surgery to 14.6% post-surgery. Conclusion: Currently, no standard treatment strategy for symptomatic spinal cysts exists. These results show that ENLD using a Holmium: YAG laser can be useful in treating symptomatic benign spinal cysts. Trial registration: Not applicable as this is a retrospective chart review. Keywords: Spinal cysts, Symptomatic, ENLD, Endoscopic spine surgery, Laser surgery Background caused by the hydrostatic pressure of cerebrospinal fluid Benign spinal cysts are a relatively common type of (CSF) or nerve irritation. expanding lesion that form in the spinal canal. Benign Till date, there are only been seven options for cysts can be the cause of both chronic back pain and treating benign cysts—four open invasive options and lower extremity radiculopathy . The negative effects three percutaneous non-invasive procedures. Open of benign cysts are attributed to nerve compression procedures for treating benign cysts include (1) lamin- ectomy for cyst decompression and nerve root resec- tion [2–4], (2) laminoplasty and cyst fenestration , (3) incision and cyst drainage with plication of cyst , * Correspondence: firstname.lastname@example.org (4) and lumbo-peritoneal CSF shunting . Percutan- Department of Neurosurgery, Spine Center, Himchan Hospital, 118 eous procedures for addressing benign cysts include Yongdam-ro, Yunsoo-gu, Incheon 21927, South Korea Joint and Arthritis Research, Orthopaedic Surgery, Himchan Hospital, 120 Sinmok-ro, Yangcheon-gu, Seoul, South Korea Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Kim et al. Journal of Orthopaedic Surgery and Research (2018) 13:136 Page 2 of 7 (1) computed tomography (CT)-guided cyst rupture [8, 9], and intermittent sedation (midazolam, 5 mg/5 mL) were (2) fluoroscopic fenestration and injections , and (3) used for pain control and sedation. The arrangement of trans-foraminal approach and cyst removal or fenestra- the surgical room is depicted in Fig. 1a, and the opera- tion . However, these surgical methods have several tive scene in Fig. 1b. The entry point into the skin was important drawbacks, including the possibility of trig- generally at the midline of the sacral hiatus, which was gering neurological deficits, technical difficulty, and confirmed using a C-arm. After infiltrating the skin at possible complications such as instability of the spine. the entry point with local anesthetic, a 21-gauge needle In addition, while CT and fluoroscopic procedures are was inserted under radiographic guidance (Fig. 1c). Epi- non-invasive, confirmation of cyst rupture using these durography was performed using iodinated contrast techniques is not possible. The trans-foraminal ap- medium to confirm the location of the cyst and sur- proach can be applied only in a few cases without de- rounding neural structures. Next, a 0.3-mm incision was generative changes. made in the skin at the entry point, and a tapered can- SinceChoyetal. firstintroduced epiduroscopic nula was inserted through the sacral hiatus (Fig. 1d). A neural laser decompression (ENLD), the technique and camera-equipped epiduroscope (iDolphin®, Meta Biomed instrumentation of ENLD has significantly improved Co., Ltd., Korea) was then inserted into the target point, . Due to the development of endoscopic cameras and the cyst was visualized. allowing surgical visibility and the effectiveness of laser The principles of the procedures, according to the ablation, ENLD is becoming a viable alternative for in- type of cyst, are illustrated in Fig. 1e.The target point vasive operative procedures . However, to the best of the epiduroscopic catheter was checked against of our knowledge, the use of ENLD to treat cystic radiographic information regarding the location of the spine lesions has not yet been reported. The purpose cyst obtained before surgery and confirmed on MRI of this studywas to introducetheENLD techniqueas using anterior-posterior and lateral views (Fig. 1f, g). a novel percutaneous treatment for spinal symptomatic For safety, discrimination of neural tissue was per- lesions. formed at low power (0.6 J and 6 Hz). Ablation and fen- estration was performed at 1.0 J and 10 Hz. The cysts Methods were ruptured using a Holmium: YAG laser (2100-nm Patients and study design Ho: YAG laser, Holiwon®, Wontech, Korea). After the Ten adult patients participated in this prospective study cystic mass was decompressed, the epiduroscope was between May 2016 and August 2017. We received ap- removed and a sterile dressing applied. In the cases of proval from the Institutional Review Board of Himchan discal and facet cysts, epidural adhesiolysis was per- Hospital Health System (No. 112294-01-201801-01), and formed using 10 mL of a mixture of 0.5% bupivacaine all participants provided written informed consent. and 1500 IU hyaluronidase. Contrast media were ad- ministered using an epiduroscopic catheter after the Inclusion and exclusion criteria mass was sufficiently decompressed, which indicated fa- Participants were eligible to participate in the study if vorable outcomes due to patency of nerve decompres- they exhibited single-lesion, low back and/or radicular sion and mobility. The small insertion point was pain, with clear evidence of cystic lesions on magnetic treated with a reinforced skin closure (Steri-strip®, 3M resonance imaging (MRI), and correlated back and/or Inc., Maplewood, MN, USA) without sutures. leg radiating pain which had not responded to conserva- tive treatment (medication and physiotherapy) within Outcome measures 6 weeks. Participant age (in years), sex (male/female), Changes in back and leg pain following surgical decom- and estimated duration of pain (in months) were col- pression of cysts using ENLD were evaluated using a lected during epiduroscopic video recording. Exclusion 1–10 visual analog scale (VAS). Improvement in func- criteria for the study included (1) evidence of intradural tion following surgery was evaluated using the Oswentry mass lesion or suggestive malignant lesions, (2) presence Disability Index (ODI) . of multiple cystic lesions or metastatic lesions on cross-sectional MR images, and (3) pain due to infection, Statistical analyses instability, herniated lumbar disc, and spondylolisthesis. All parameters were analyzed statistically. Data are pre- sented as mean and standard deviation (mean ± SD). Dif- Surgical procedure ferences between pre- and post-operative VAS pain scores All surgical procedures were performed in the prone and ODI scores were compared non-parametrically using position on a radiolucent spine table. After aseptic drap- separate Wilcoxon signed-rank tests. Differences were ing in the usual manner, local anesthesia (lidocaine 1%, considered statistically significant if p values were less 10 mL), intravenous analgesia (pethidine, 100 mg/2 mL), than 0.05. Kim et al. Journal of Orthopaedic Surgery and Research (2018) 13:136 Page 3 of 7 Fig. 1 a Operating room arrangement. b After the epiduroscope is positioned at a suitable site with a C-arm, laser vaporization is performed under high-definition video monitoring. c Local anesthesia is applied to the skin and tissues surrounding the sacral hiatus (arrow). d A tapered cannula is inserted into the epidural space for epiduroscopy (arrow). e Schematic illustration of epiduroscopic ruptures according to the type of cyst. f Anterior-posterior X-ray image distinguishes the location of the lesions. g The lateral radiograph shows the epiduroscopic location, differentiating between ventral and dorsal positions Table 1 Patient characteristics Results Characteristics Mean (SD) All ten patients underwent minimally invasive cyst Age, mean (in years) 46.6 ± 14.2 rupture using ENLD technique with Holmium: YAG Sex (%) Male 6 (60.0) laser. The average duration of follow-up for partici- pants in the study was 12.6 ± 1.0 months. The average Female 4 (40.0) duration of cyst surgery was 21.3 ± 3.0 min. The aver- Type of symptom, N (%) Pain only 5 (50.0) age length of participants’ hospital stay was 1.5 ± 0.5 days Pain and 5 (50.0) (Table 1). weakness Analysis of VAS scores revealed significant improve- Symptom duration 4.7 ± 0.7 ment in both back and leg pain from pre- to post-surgery (months) (Table 2). Mean VAS scores for back pain decreased from Follow-up duration 12.6 ± 1.0 4.7 ± 0.7 to 1.8 ± 0.8 on the last follow-up (p < .001). (months) Mean VAS scores for leg pain decreased from 5.8 ± 1.2 Operation time 21.3 ± 3.0 (minutes) to 1.6 ± 0.7 (p < .001). Mean ODI scores (%) decreased from 27.2 ± 10.7% to 14.6 ± 7.7% post-surgery (p < .001). Hospital stay (day) 1.5 ± 0.5 There were no significant complications, such as post- Type of cyst (based on Discal cyst 2 (20.0) operative infection or hematoma, or a need for a repeat radiologic findings), N (%) Facet cyst 4 (40.0) surgery. During the follow-up period, there was no symp- Pavlov cyst 4 (40.0) tom recurrence that warranted a repeat surgery. Kim et al. Journal of Orthopaedic Surgery and Research (2018) 13:136 Page 4 of 7 Table 2 Clinical outcomes of the study group Case 2 A 52-year-old woman presented at the hospital on Octo- Pre-operative Post-operative p value scores scores ber 21, 2017, with a 12-month history of low back pain Visual analog scale 4.7 ± 0.7 1.8 ± 0.8 0.001 and right leg numbness. Her back pain had increased back pain progressively, and she had developed radiating pain in Visual analog scale 5.8 ± 1.2 1.6 ± 0.7 0.001 her right leg along with hypoesthesia. Physical examin- leg pain ation showed normal motor strength and deep tendon re- Oswentry Disability 27.2 ± 10.7 14.6 ± 7.7 0.001 flexes. There was no related past or familial history. She Index (%) was initially prescribed non-steroidal anti-inflammatories Differences between pre- and post-operative visual analog scale pain scores (NSAIDs) for more than 6 months, but her symptoms did and Oswentry Disability Index scores (%) were compared non-parametrically using Wilcoxon ranked-sum tests (α = 0.05) notimprove,atwhich point she was transferred to our clinic. The MR images showed a single fluid-containing le- Report of the cases sion at the L5–S level measuring 12 × 8 mm and origin- Case 1 ating from the right interarticular facet of the lesion A 26-year-old man visited the hospital on August 21, (Fig. 3a). The L5 and S1 root were compressed by the 2016, with a 6-month history of pain in his right leg. cystic mass. After adequate positioning of the epiduro- The pain had a radiating quality and had not been re- scope, the mass was identified under video monitoring. lieved by medication. On examination, the patient ex- Stimulation and laser fenestration were performed as de- hibited monoparesis of the sacral (S) 1-innervated scribed in case 1. Epiduroscopic images showed multiple gastrocnemius muscle, with difficulty in pushing the ruptures in the cyst and cyst decompression (Fig. 3b). foot, revealing a lower right limb power of 4/5. Other Steroid and normal saline irrigation were performed neurological parameters were within normal limits. before the incision closure. The patient’s pain and There was no related familial or past history. Results of neurological symptoms improved in the first 2 weeks MRI performed on August 23 showed a single fluid- post-procedure. In addition, MR images of the lesion ac- containing lesion at the lumbar (L) 4–5level measuring quired 2 weeks post-procedure showed a deflated cyst 8×6 mm (Fig. 2a); the nerve root traversing L5 could measuring 6 × 6 mm (Fig. 3c). not be identified due to the mass effect of the lesion. The patient received ENLD on August 24, 2016. After Case 3 confirming adequate positioning of the epiduroscope, A 44-year-old man visited the hospital on November 27, multiple laser fenestrations (1.0 J, 10 Hz) were per- 2016, with a history of buttock and leg pain. The buttock formed. Endoscopic visualization showed decompres- pain had persisted for more than 8 months, while the sion of the cystic mass (Fig. 2b). The patient reported leg pain had presented 4 weeks ago. Physical examin- immediate improvement of his radiating pain following ation showed normal motor strength, reflexes, and sen- the procedure. The MR images acquired 2 weeks sory capability. There was no related past or familial post-procedure showed that the lesion had significantly history. He was initially managed with pain medication regressed, and post-operative MRI was now able to (NSAIDs) and physiotherapy symptomatically. Subse- identify the nerve root traversing L5 (Fig. 2c). quent MRI of the spine revealed a large cystic lesion at Fig. 2 a T2-weighted axial magnetic resonance (MR) image shows a cystic mass (arrow) originating from the disc and compressing the traversing right nerve root. b Epiduroscopic image shows the laser electrode inserted (white arrow) into the cyst (black arrow). c Post-operative T2-weighted axial MR image shows the decompressed cyst (arrow) and visualization of the L5 traversing root Kim et al. Journal of Orthopaedic Surgery and Research (2018) 13:136 Page 5 of 7 Fig. 3 a Pre-operative magnetic resonance (MR) image shows a facet-originated cyst (arrow) compressing the thecal sac sacral (S) 1 nerve root. b Epiduroscopic image shows the laser electrode inserted into the cystic mass (white arrow); the mass decreased in size (black arrow) post-surgery. c Post-operative MR image shows the decompressed cyst (arrow) and the released thecal sac and S1 nerve root the S1–2 level with T2 high signal intensity. The size of fluoroscopic imaging also showed iodine filling. The cystic mass was 50 × 45 mm; due to the mass effect of Tarlov cyst that was inflated preoperatively (Fig. 4c) the cyst, the S1 and S2 nerve roots on the left had been showed decrease in size, and the dural sac was decom- moved to the right side, and the right S1 root could not pressed (Fig. 4d). The patient’s pain and neurological be identified on imaging. When the epiduroscope was symptoms improved within the first week. advanced merely 50 mm from the sacral hiatus, we iden- tified a well-defined cystic mass at the S2 level. Cyst rup- Discussion ture was performed at a low voltage (0.6 J, 6 Hz) to Patients with degenerative changes in the lumbo-sacral protect surrounding neural structures (Fig. 4a). After region often present with pain and neurological defi- epiduroscopic confirmation of decompression (Fig. 4b), cits. However, benign cysts, such as discal, juxtafacet, Fig. 4 a Epiduroscopic image shows a laser electrode inserted into the cystic mass (white arrow) and the confirmed mass (black arrow). b Epiduroscopic image shows a laser electrode inserted into the cystic mass (white arrow); after decompression, cerebrospinal fluid was expelled and the cyst decompressed (black arrow). c T2-weighted axial magnetic resonance (MR) image shows the inflated cyst containing cerebrospinal fluid and occupying the spinal canal (white arrow). d Post-operative MR image shows the released dural sac and deflated Tarlov cyst (white arrow) Kim et al. Journal of Orthopaedic Surgery and Research (2018) 13:136 Page 6 of 7 and perineural cysts also commonly present with radi- available, allowing better visibility and neural tissue ating pain because of their anatomical location, which identification compared with the previous version; can interfere with the traversing and exiting nerve ENLD has achieved sufficient decompression and fen- roots [15, 16]. estration via laser vaporization for various patho- The cysts in the first case presented here originated in logical conditions . the intervertebral space. Gas-filled cysts in the interver- tebral space which share space with the posterior longi- Limitations tudinal ligaments have been previously described as a There are some limitations of this study which must cause of radiculopathy [4, 17, 18]. This pathological be acknowledged. Firstly, thedatainthisstudy wasac- condition is usually located ventrally. The vacuum quired from a small trial with no control group. phenomenon, which is caused by a reduction of discal Therefore, it is possible that the potential benefit of pressure due to flexion and traction movements , has undergoing ENLD for patients was overestimated. It is been suspected to be the cause of gas formation, which in also possible that patient selection for the study, which turn compresses the nerve root and thecal sac. included patients with symptomatic cysts, influenced The second case was that of a synovial cyst. It is one the outcomes. Secondly, remnant cysts can recur due of the most common benign extradural masses found in to the characteristics of the fenestration procedure, the spine. Synovial cysts within the facet joints have and the short follow-up duration underestimates this been reported to cause nerve compression [19, 20]. The possible complication. Despite these limitations, we last case we presented (case 3) involved a perineural believe that this study is clinically important and demon- (Tarlov) cyst. The etiology of this condition remains strates a novel minimally invasive treatment approach for unclear. Congenital formation, hemosiderin depos- benign cystic mass. ition, breakage of venous drainage, and arachnoidal proliferation around the sacral nerve root are current Conclusions hypotheses [21, 22]. The results of this study suggest that ENLD with HD Although radiologically, benign lumbo-sacral cysts are visualization and Holmium: YAG laser can be used to typically asymptomatic , some cases do produce treat benign spinal cysts safely, precisely, and effectively; symptoms. The build-up of gas in a discal cyst, overflow ENLD renders cyst fenestration via epiduroscopy pos- of synovial fluid in a facet cyst, and build-up of pulsatile sible without incision and bony destruction. Although and hydrostatic pressure in a perineural cyst are all con- this is a preliminary report for a novel technique, sidered to be likely causes for lumbo-sacral cyst forma- ENLD for symptomatic cysts may be a valuable alter- tion and symptom progression [6, 24]. Space-occupying native to surgery. Although ENLD was not associated cysts can cause neurological changes or radicular pain with post-surgical complications for any of the partici- via compression, pulling forces, or distortion . pants, careful follow-up is necessary. Large, randomized, Currently, there is no consensus regarding the best multicenter trials are needed to further explore the poten- treatment for symptomatic cystic lesions. Surgical tial of ENLD. procedures have shown favorable outcomes, but neuro- logical deterioration and sequelae of laminectomy have Abbreviations CSF: Cerebrospinal fluid; CT: Computed tomography; ENLD: Epiduroscopic also been reported . Fluoroscopic and CT-guided rup- neural laser decompression; HD: High definition; MRI: Magnetic resonance ture have an 84% success rate, but 25% of the patients imaging; NSAID: Non-steroidal anti-inflammatory drugs; ODI: Oswentry undergo subsequent surgeries due to incomplete cyst de- Disability Index; SD: Standard deviation; VAS: Visual analog scale compression during the original procedure . The Availability of data and materials trans-foraminal approach has been attempted in some All data generated or analyzed during this study are included in this cases, but this procedure can only be applied in patients published article. with intact foramen without senile changes. Authors’ contributions Epiduroscopic management using the Holmium: YAG SKK had full access to all the data in the study and takes responsibility for laser is an emerging minimally invasive procedure with- the integrity of the data and the accuracy of the data analysis. BHL designed out the risk of bone and ligament injury, compared with the study protocol. MBS performed the literature survey, summarized the previous related work, and wrote the first draft of the manuscript. SCL provided other surgical procedures, that may be applied for intellectual contribution during the revision and final approval of the manuscript. many spinal conditions. It has undergone trials for the All authors read and approved the final manuscript. treatment of herniated lumbar discs, spinal stenosis, failed-back-syndrome, and facet cysts ; ENLD Ethics approval and consent to participate Approval for the study was provided by the Institutional Review Board overseeing yields superior results relative to caudal epidural injec- research at the Himchan Hospital Health System (No. 112294-01-201801-01; date tion  and physiotherapy . Since 2007, high- 15 January 2017). 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Journal of Orthopaedic Surgery and Research
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Published: Jun 4, 2018