Successful percutaneous management of symptomatic central posterior epidural Baastrup cyst: a potential surgical sparing option?

BACKGROUND CONTEXT: Neurogenic claudication from posterior epidural extension of a Baastrup interspinous bursal cyst is rare. Surgical decompression is the gold standard of treatment. This case report describes successful percutaneous treatment with good early clinicoradiological outcome.

PURPOSE: This study aimed to describe the successful percutaneous treatment of a central posterior epidural Baastrup cyst causing neurogenic claudication.

STUDY

DESIGN

This is a case report study.

METHODS

A 62-year-old man presented with neurogenic claudication on a background of previous lymphoma treated with chemotherapy, chronic obstructive pulmonary disease, chronic venous insufficiency, and obesity. Conservative therapy with narcotic analgesia had failed, with new requirement of a walking aid and marked reduction in walking distance. Magnetic resonance imaging confirmed severe L3-L4 canal stenosis from central posterior epidural extension of a Baastrup interspinous bursal cyst. Under conscious sedation, initial percutaneous computed tomography (CT)-guided interspinous bursography indirectly opacified the cyst and facilitated trans-laminar direct needle access to the epidural cyst. Aspiration was performed before needle fenestration and epidural steroid injection.

RESULTS

Six-week review revealed significant improvement in pain and mobility, with no analgesic or walking aid requirement, and restoration of the patient's baseline walking distance. At 3 months, repeat magnetic resonance imaging (MRI) confirmed significant reduction in cyst size as the mediator of the treatment effect. Improvement in back and leg symptoms was durable at 24-month follow-up.

CONCLUSIONS

In selected cases, percutaneous treatment of symptomatic central posterior epidural cysts as part of Baastrup phenomena may be feasible. This treatment approach avoided general anesthesia, avoided the procedural risks of surgical decompression, and was performed in the outpatient setting, with good early clinicoradiological outcome. This may emerge to be a surgical sparing option or an alternate to continuing conservative therapy in patients who are poor surgical candidates.