Commentary on: "Lumbar Intervertebral Discal Cyst: A Rare Cause of Low Back Pain and Radiculopathy. Case Report and Review of the Current Evidences on Diagnosis and Management".

Abstract

An intradiscal cyst is one of the least common etiologies of lumbar radicular pain. Although it may appear that the pathophysiology is self-explanatory, the formation and natural historyof the condition continues to eludesurgeonsbecause of its infrequency.Thus,literatureandresearchregarding thetopicis limited, making the developmentofanaccurate understanding regarding the treatment of the discs quite challenging. Certo et al illustrate a case of an intervertebral discal cyst that presented with lumbar pain and radiculopathy. Their report included an in-depth review of the literature with a total of 105 cases regarding management of these rare cysts. Prior to considering surgical intervention, understanding of the formation and composition of the cysts is crucial to determining the best treatment modality. The authors discuss several instances in the literature that have attempted to define the consistency, as well the characteristics, of such cysts. Chiba et al have given a very thorough descriptive evaluation of such cysts, including location, symptomatology (unilateral nerve root), fluid content, and lack of disc material within the cystic lesion. However, in 2010, Kobayashi et al 1 argued that in their two cases the histological features of the cyst were similar to the absorption process of a disc herniation, and the presence of residual herniated tissues was confirmed in the cyst wall. Thus, the actual pathological features regarding these lesions continue to remain elusive. Despitequestionsregarding theformationandcomposition of the cyst, the diagnosis can be made and confirmed with magnetic resonance imaging (MRI) with and without contrast enhancement. OnMRI, the cyst wall is contrast-enhancing and is connected to the disc space. We agree with the authors that MRI is the essential tool in the diagnosis of the discal cyst, but we do not find much added value to doing discography followed by a computed tomography (CT) scan as it would not significantly alter the management of the patient. Ultimately, the most important part to learn from this review is how to manage such a patient if one presents himself to your office. In our opinion, the symptoms should determine the treatment. If the patient presents with tolerable pain without neurological deficits, conservative medical therapies and management should be the first line in management.Aydin etal 2 discuss medicaltherapies, and although the failure rate was 62.5% with the ultimate result of surgery, there is value to conservatively managing a patient given the