- Email: [email protected]
Surgical Treatment of Extraforaminal Gas-Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endoscopy
Accepted Manuscript Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report Jin-Woo An, MD, Chul-Woo Lee, MD, PhD PII:
S1878-8750(19)30058-0
DOI:
https://doi.org/10.1016/j.wneu.2018.12.186
Reference:
WNEU 11136
To appear in:
World Neurosurgery
Received Date: 11 December 2018 Accepted Date: 22 December 2018
Please cite this article as: An J-W, Lee C-W, Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2018.12.186. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report
1
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Jin-Woo An, MD1, Chul-Woo Lee, MD, PhD2
Department of Orthopedic Surgery, Bur-Team Hospital, Suwon, Korea Department of Neurosurgery, St. Peter’s Hospital, Seoul, Korea
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2
Corresponding author: Chul-Woo Lee, MD, PhD
Department of Neurosurgery, St. Peter’s Hospital,
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914-2 Dogok-dong, Gangnam-gu Seoul, 135- 809, Korea
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Phone: +82-1544-7522
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Fax: +82-2-574-9414 Email: [email protected]
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Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report ABSTRACT
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Backgound: Most gaseous lumbar pseudocysts have been previously reported to be located in the spinal canal and successfully treated by several therapeutic methods. By comparison, a gas containing pseudocyst in lumbar extra-foraminal area is very rare. Here, the authors report a
ed with unilateral biportal endoscopic (UBE) surgery.
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case of symptomatic gas containing cyst located in lumbar foramen. It was successfully treat-
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Case description: a 75-year-old man presented with severe left leg pain and tingling sensation refractory to conservative treatment that aggravated with weight bearing and position change. Computed tomography and magnetic resonance imaging showed a gas containing cyst compressing the left L5 nerve root ganglion in the foramina area at L5-S1 level. Gaseous extra-
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foraminal pseudocyst was successfully removed by UBE surgery via para-spinal approach. Vivid and clear endoscopic operative imaging of pseudocyst in detail was obtained during operation. The patient’s symptom was significantly improved after the operation.
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Conclusions: Gas containing pseudocyst in lumbar foraminal area is not common. Combined use of pre-operative MRI and CT can help diagnose gaseous pseudocyst and differentiate oth-
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er pathologies. UBE technique which provides good operative visualization and delicate operative manipulation is a less invasive therapeutic method to treat foraminal gas containing pseudocyst.
Keywords: Gas pseudocyst, Lumbar foramen, Percutaneous endoscopic, Unilateral Biportal Endoscopy
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INTRODUCTION Intraspinal gas containing pseudocysts are rare causes of lumbar radicular pain.1–10 Pathogenetic mechanisms of pseudocyst remain unknown. It has been suggested that they are associ-
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ated with the intervertebral vacuum phenomenon.9,11,12 Most epidural gas-containing cysts coexist with disc fragment.13,14 They are found in the spinal canal. However, an isolated gas cyst, so called ‘pseudocyst’, located in the foraminal and/or extraforaminal zone causing radicular
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compression is extremely rare.6,8
Gas containing cysts are easy to be misdiagnosed as simple herniated discs. Sometimes they
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could be missed intraoperatively due to premature rupture. Therapeutic options for gas containing cysts range from nonoperative to operative, depending on clinical symptoms presented. Several authors have reported that surgical excision is the optimal treatment for symptomatic gas pseudocyst.4,9,15,16 Nowadays, endoscopic spinal operation has become the standard to
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treat various lumbar spinal diseases using various accesses and techniques.17–22 The purpose of this report was to present a symptomatic foraminal gas containing cyst that was removed by unilateral biportal endoscopy (UBE) technique. The process of removal of
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cyst with vivid endoscopic intraoperative illustration was also presented in this report. To the best of our knowledge, this is the first case report of a pseudocyst developed in lumbar foram-
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inal area and treated by UBE surgery via paraspinal approach.
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CASE REPORT History and clinical manifestations A 75-year-old man presented with severe left leg radiating pain and tingling sensation. Stand-
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ing and walking would exacerbate the patient’s symptoms while bed rest could only partially alleviate it. On neurological examination, left big toe dorsiflexion weakness (motor power:
grade 4) and sensory impairment in L5 dermatome were observed from the patient. He denied
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therapy, and a series of root block were ineffective.
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any history of open surgery. Conservative treatments such as the use of narcotics, physical
Imaging manifestations
A plain X-ray showed severe degenerative spondylosis with disc space narrowing in multilumbar level. However, definite instability was not seen in dynamic X-rays. Magnetic reso-
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nance imaging (MRI) demonstrated well demarcated, round shaped mass lesion with low signal intensity on both T1- and T2-weighted images, compressing the L5 root at the Left L5-S1 foramen (Figures 1A, 1B). Radiological pathologic lesion in MRI was revealed as gas which
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showed low density on computed tomography (CT) scan (Figures 2A-2C). There was intervertebral vacuum at the L5-S1 level while connection between intervertebral vacuum and gas
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containing cyst was not seen. Other possible causes such as degenerated disc or calcification suspicious from MRI examination were excluded by preoperative CT. Based on preoperative radiologic examinations, gaseous pseudocyst in extra-foraminal area was the primary impression and surgical treatment was considered.
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Treatment Unilateral biportal endoscopic (UBE) surgery with left para-spinal approach was performed to remove the gas containing cyst. The patient was operated in prone position under general an-
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esthesia. Under fluoroscopic guidance, two skin incisions of 1 cm each were made 1-2 cm lateral to the vertebral body lateral border for two portals (Figures 3A, 3B). As expected from
preoperative X-ray and CT, extra-foraminal zone in L5-S1 was nearly fused between trans-
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verse process and iliac bone due to degenerative change. There was no sufficient space to approach. Thus, a hole was made at the junction of transverse process and iliac bone by high
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speed drill. The operative space was further enlarged by circumferential drilling of bony structures considered as a lateral part of superior articular process, isthmus, and inferior part of transverse process. After confirmation of inferior margin of L5 pedicle, the intertransverse and foraminal ligament was dissected and excised. The pathologic cyst and affected L5 nerve root
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were then exposed. After delicate adhesiolysis between cyst and exiting L5 root, well-defined transparent cyst compressing L5 nerve root ganglion was found in extra-foraminal zone (Figure 4A).
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A large amount of gas bubbled up from the lacerated fissure when the cyst wall was pushed by probe. Fluid like materials were also trickled out (Figures 4B, 4C). There was no coexisting
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disc herniation. Connection with intradiscal space was not found during the removal of the cyst. Ablated remnants of soft tissues around the cyst were removed. Fully decompressed exiting L5 root was confirmed (Figure 4D, Video 1).
Postoperative course
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After the operation, the patient had complete relief of pain. His motor power and sensation were recovered to normal status by 3 months. Successful removal of gaseous cyst was confirmed by postoperative MRI (Figures 5A, 5B). The patient was discharged one day after op-
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eration. He was able to return to work. He was followed up regularly. He remained asymptomatic six months later.
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DISCUSSION
Free air in lumbar spine has been reported in various clinical situations, including epidural
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anesthesia, percutaneous spinal procedure, intestinal necrosis, pyogenic infections produced by gas-forming organisms, and osteonecrosis.11,13,23,24 Spinal surgery can be one of causes of intraspinal epidural gas (EG) formation.4,25 In most cases, reported epidural gas-containing cysts are asymptomatic and coexisted with sequestrated disc fragment. Severe radicular pain
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caused by isolated epidural gas cyst, so called gas containing pseudocyst, is extremely rare in the literature.3,5,6 Pathogenetic mechanisms of postoperative EG remain unknown. Intraspinal air has been thought to have a relationship with vacuum phenomenon by many authors.9,11,12 A
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weak point in the longitudinal ligament caused by developmental impairment has also been suggested to have a role in the formation of cyst.4,8 By using gas chromatography, Yoshida et
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al. have demonstrated that the major composition of cyst is nitrogen. They also suggested communication between the intradiscal gas and intraspinal gas pseudocyst using CT after discography which showed the flow of contrast media into the cyst.16 Usually, epidural gas is found in spinal canal, posterior lesion, or posterolateral lesion. A gas formation in foraminal or extra-foraminal zone is very rare.6,8
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Sometimes, gas containing cyst could be misdiagnosed as simple disc herniation compressing neural structure by radiologic images. The mass lesion which has low signal in T1, T2 images of Lumbar MRI should be considered first as calcification or air. In the current case, fo-
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raminal gas containing pseudocyst was radiologically illustrated by CT and MRI. Combined use of CT and MRI could help diagnose gaseous cyst in the foraminal area and differentiate it from other pathological lesions as mentioned in some previous reports.4,11,23
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Symptomatic gas containing cyst has been reported to have variable therapeutic modalities such as medication, nerve block, needle aspiration under fluoroscopic guidance, and surgical
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removal.3,4,6,8,14,15 Conservative treatment or percutaneous aspiration is the most common treatment. However, it has poor pain relief effect with a high recurrence rate. Open surgery has good clinical outcomes by totally removing the cyst wall. However, it can cause significant soft tissue injury.3,4,8,26
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Today, endoscopic spinal surgery has become one of standard treatments for degenerative lumbar diseases. It has shown many surgical advantages such as no need for general anesthesia, small skin incision, less soft tissue trauma, and postoperative fast recovery. Not only sim-
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ple contained disc, but also complicated cases such as highly migrated disc herniation and other pathology combined with bony degeneration to produce foraminal and canal stenosis can
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now also be treated with full-endoscopic surgery using various accesses and techniques.17,18,27– Zhu et al. have reported a case of a intracanal giant gas-containing pseudocyst successfully
removed by transforaminal endoscopic approach.2 Unilateral Biportal Endoscopy (UBE) has been suggested as an alternative treatment option to solve various spinal diseases. It has favorable surgical outcome and clinical feasibility in
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various clinical situations.20,30,31 However, there has been no report of gas containing cyst in lumbar area treated by UBE until now. To the best of our knowledge, this is the first report to present pseudocyst developed in lumbar foraminal area and successfully treated by UBE sur-
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gery via paraspinal approach.
In the current case, we could find many advantages of endoscopic spinal surgery as the therapeutic modality for gas containing pseudocyst. UBE surgery showed the same efficacy as pre-
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vious microscopic surgical method such as sufficient decompression and targeted resection of the cyst wall to avoid recurrence. Simultaneously, UBE surgery was proved to have merits of
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MIS surgery such as less muscle trauma and less soft tissue dissection, leading to patient’s short hospital stays (one day) and postoperative immediate return to normal activity. The wall of gas containing cyst is very thin and easy to be burst by intraoperative manipulation. Sometimes, an operator could miss the gaseous cyst and have difficulties to find the exact
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pathology when the cyst is premature ruptured by careless operative maneuver. In the current case, the gas containing cyst could be exposed without premature rupture during operation. This was possible because all procedures near the cyst were performed in very delicate man-
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ner with magnified endoscopic view. We also could acquire vivid endoscopic operative illustration of the cyst after careful dissection between the cyst and peri-cystic structures such as
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exiting root, ligament flavum, and disc annulus. The diagnosis of gas containing cyst was confirmed by bubbles from incision site of cyst in water medium when the cyst wall was incised and pushed with a probe. Such benefits of UBE surgery including easy discrimination of anatomical structures, delicate manipulation of pathology with magnified endoscopic view, and
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detailed operative information might have contributed to the successful result in the current case.
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CONCLUSION
Gas containing pseudocyst in lumbar foraminal area is not common. Combined use of pre-
operative MRI and CT can help diagnose gaseous pseudocyst and differentiate other patholo-
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gies. UBE technique which provides good operative visualization and delicate operative ma-
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nipulation is a less invasive therapeutic method to treat foraminal gas containing pseudocyst.
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Yasuoka H, Nemoto O, Kawaguti M, Naitou S, Yamamoto K, Ukegawa Y. An Unusual Case of Nerve Root Compression by Intradiscal Gas Pseudocyst of the Lumbar Spine.
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Zhu B, Jiang L, Liu XG. Transforaminal Endoscopic Decompression for a Giant
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Lee C-W, Yoon K-J, Ha S-S, Kang J-K. Radicular compression by intraspinal epidural gas bubble occurred in distant two levels after lumbar microdiscectomy. J Korean Neurosurg Soc. 2014;56(6):521-526.
Vaquero J, Parajón A. Lumbar radiculopathy due to gas-containing pseudocyst. J
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Bosser V, Dietemann JL, Warter JM, Granel de Solignac M, Beaujeux R, Buchheit F. L5 radicular pain related to lumbar extradural gas-containing pseudocyst - Role of CTguided aspiration. Neuroradiology. 1990;31(6):552-553. Demierre B. Radicular Compression Due to Lumbar Intraspinal Gas Pseudocyst: Case Report. Neurosurgery. 1988;22.
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Gulati AN, Weinstein ZR. Gas in the spinal canal in association with the lumbosacral
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vacuum phenomenon: CT findings. Neuroradiology. 1980. 12.
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Yun SM, Suh BS, Park JS. Symptomatic Epidural Gas-containing Cyst from
doi:10.14245/kjs.2012.9.4.365 13.
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Intervertebral Vacuum Phenomenon. Korean J Spine. 2012;9(4):365-368.
Mortensen WW, Thorne RP, Donaldson WF. Symptomatic gas-containing disc herniation: Report of four cases. Spine (Phila Pa 1976). 1991. doi:10.1097/00007632-
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Pak KI, Hoffman DC, Herzog RJ, Lutz GE. Percutaneous Intradiscal Aspiration of a Lumbar Vacuum Disc Herniation: A Case Report. HSS J. 2011. Righini A, Lucchi S, Reganati P, Zavanone M, Bettinelli A. Percutaneous treatment of
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gas-containing lumbar disc herniation. Report of two cases. J Neurosurg. 1999. Yoshida H, Shinomiya K, Nakai O, Kurosa Y, Yamaura I. Lumbar nerve root
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1976). 1997.
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Kim HS, Paudel B, Jang JS, et al. Percutaneous Full Endoscopic Bilateral Lumbar Decompression of Spinal Stenosis Through Uniportal-Contralateral Approach: Techniques and Preliminary Results. World Neurosurg. 2017;103:201-209. Hwang JH, Park WM, Park CW. Contralateral Interlaminar Keyhole Percutaneous
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Endoscopic Lumbar Surgery in Patients with Unilateral Radiculopathy. World Neurosurg. 2017;101:33-41.
Lee CW, Yoon KJ, Jun JH. Percutaneous Endoscopic Laminotomy with Flavectomy by
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Uniportal, Unilateral Approach for the Lumbar Canal or Lateral Recess Stenosis. World
Eum JH, Heo DH, Son SK, et al. Percutaneous biportal endoscopic decompression for lumbar spinal stenosis: a technical note and preliminary clinical results. J Neurosurg Spine. 2016;24(4):602-607. 21.
Lee CWC-W, Ph D, Yoon KJK-J, et al.
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Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy: Technical note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy. J Korean Neurosurg Soc.
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Oertel JM, Burkhardt BW. Endoscopic Surgical Treatment of Lumbar Synovial Cyst:
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Detailed Account of Surgical Technique and Report of 11 Consecutive Patients. World Neurosurg. 2017.
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Ilica AT, Kocaoglu M, Bulakbasi N, Kahraman S. Symptomatic epidural gas after open
diskectomy: CT and MR imaging findings. Am J Neuroradiol. 2006.
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24.
Charles RW, Mody GM, Govender S. Pyogenic infection of the lumbar vertebral spine due to gas-forming organisms. Spine (Phila Pa 1976). 1989. Tsuji H, Handa N, Handa O, Tajima G, Mori K. Postlaminectomy ossified extradural pseudocyst. Case report. J Neurosurg. 1990;73(5):785-787.
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Sasani M, Ozer AF, Oktenoglu T, Cosar M, Karaarslan E, Sarioglu AC. Recurrent
literature review. Spine (Phila Pa 1976). 2007. 27.
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radiculopathy caused by epidural gas after spinal surgery: Report of four cases and
Heo DH, Son SK, Eum JH, Park CK, Surgery S. Fully endoscopic lumbar interbody
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fusion using a percutaneous unilateral biportal endoscopic technique: technical note and preliminary clinical results. Neurosurg Focus. 2017;43(2):E8. 28.
Kim HS, Patel R, Paudel B, et al. Early outcomes of endoscopic contralateral foraminal and lateral recess decompression via an interlaminar approach in patients with unilateral
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radiculopathy from unilateral foraminal stenosis. World Neurosurg. 2017;108:763-773. Choi K-C, Lee DC, Shim H-K, Shin S-H, Park C-K. A Strategy of Percutaneous Endoscopic Lumbar Discectomy for Migrated Disc Herniation. World Neurosurg.
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Akbary K, Kim JS, Park CW, Jun SG, Hwang JH. Biportal Endoscopic Decompression
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of Exiting and Traversing Nerve Roots Through a Single Interlaminar Window Using a
Contralateral Approach: Technical Feasibilities and Morphometric Changes of the
Lumbar Canal and Foramen. World Neurosurg. 2018;117:153-161.
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Choi D, Jung J, Lee S, Kim Y-S, Jang H-J, Yoo B. Biportal Endoscopic Spinal Surgery for Recurrent Lumbar Disc Herniations. Clin Orthop Surg. 2016;8(3):325-329.
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Figure legends Figure 1. Preoperative Magnetic resonance imaging (MRI) showing a round shaped mass around L5–S1 extraforaminal area with low signal intensity in both axial T1&T2-weighted
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images. (A) axial T1-weighted magnetic resonance image;
Arrows: extraforaminal gas containing pseudocyst.
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(B) axial T2-weighted magnetic resonance image.
Figure 2. Preoperative Computed tomography (CT) imaging showing irregular round shaped
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mass around L5–S1 extraforaminal area with low density. (A) Coronal image; (B) Saggital image; (C) Axial image.
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Arrows: extraforaminal gas containing pseudocyst.
Figure 3. Overview of the percutaneous UBE surgery. (A) Operative position and basic surgical equipment;
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(B) Portals placement and operative target.
Figure 4. Endoscopic intraoperative illustration.
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(A) Well-defined transparent cyst compressing L5 nerve root ganglion was seen in extraforaminal zone.
Asterisk: Cyst wall;
White arrow: L5 Exiting root. (B) Air bubbles were observed from lacerated site of the cyst.
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Star: air bubbles. (C) Intracystic components were released after puncture of the cystic wall. Black arrow: fluid materials.
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(D) Fully decompressed L5 exiting root was observed after the removal of cyst and remnant soft tissues. Triangle: L5 exiting root.
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Figure 5. PostoperativeT2-weighted MRI axial image showing decompressed Left L5 exiting
(A) Axial image (L5 body level); (B) Axial image (disc level). Arrows: decompressed L5 exiting root.
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root by removal of gaseous cyst.
VIDEO 1. Video clip demonstrating the process of removing the pseudocyst in endoscopic
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ACCEPTED MANUSCRIPT A list of abbreviations
CT: Computed Tomography
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EG: Epidural Gas MRI: Magetic Resonance Imaging
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UBE: Unilateral Biportal Endosopcy
ACCEPTED MANUSCRIPT Disclosure-conflict of interest
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All authors (AJW and LCW) did not influence and receive any financial and personal relationships with other people or organizations what we wrote in the submitted work including potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.
S1878-8750(19)30058-0
DOI:
https://doi.org/10.1016/j.wneu.2018.12.186
Reference:
WNEU 11136
To appear in:
World Neurosurgery
Received Date: 11 December 2018 Accepted Date: 22 December 2018
Please cite this article as: An J-W, Lee C-W, Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report, World Neurosurgery (2019), doi: https://doi.org/10.1016/j.wneu.2018.12.186. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report
1
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Jin-Woo An, MD1, Chul-Woo Lee, MD, PhD2
Department of Orthopedic Surgery, Bur-Team Hospital, Suwon, Korea Department of Neurosurgery, St. Peter’s Hospital, Seoul, Korea
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2
Corresponding author: Chul-Woo Lee, MD, PhD
Department of Neurosurgery, St. Peter’s Hospital,
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914-2 Dogok-dong, Gangnam-gu Seoul, 135- 809, Korea
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Phone: +82-1544-7522
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Fax: +82-2-574-9414 Email: [email protected]
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Surgical Treatment of Extra-Foraminal Gas Containing Pseudocyst Compressing L5 Nerve Root by Using Unilateral Biportal Endosopy: A Case Report ABSTRACT
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Backgound: Most gaseous lumbar pseudocysts have been previously reported to be located in the spinal canal and successfully treated by several therapeutic methods. By comparison, a gas containing pseudocyst in lumbar extra-foraminal area is very rare. Here, the authors report a
ed with unilateral biportal endoscopic (UBE) surgery.
SC
case of symptomatic gas containing cyst located in lumbar foramen. It was successfully treat-
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Case description: a 75-year-old man presented with severe left leg pain and tingling sensation refractory to conservative treatment that aggravated with weight bearing and position change. Computed tomography and magnetic resonance imaging showed a gas containing cyst compressing the left L5 nerve root ganglion in the foramina area at L5-S1 level. Gaseous extra-
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foraminal pseudocyst was successfully removed by UBE surgery via para-spinal approach. Vivid and clear endoscopic operative imaging of pseudocyst in detail was obtained during operation. The patient’s symptom was significantly improved after the operation.
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Conclusions: Gas containing pseudocyst in lumbar foraminal area is not common. Combined use of pre-operative MRI and CT can help diagnose gaseous pseudocyst and differentiate oth-
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er pathologies. UBE technique which provides good operative visualization and delicate operative manipulation is a less invasive therapeutic method to treat foraminal gas containing pseudocyst.
Keywords: Gas pseudocyst, Lumbar foramen, Percutaneous endoscopic, Unilateral Biportal Endoscopy
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INTRODUCTION Intraspinal gas containing pseudocysts are rare causes of lumbar radicular pain.1–10 Pathogenetic mechanisms of pseudocyst remain unknown. It has been suggested that they are associ-
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ated with the intervertebral vacuum phenomenon.9,11,12 Most epidural gas-containing cysts coexist with disc fragment.13,14 They are found in the spinal canal. However, an isolated gas cyst, so called ‘pseudocyst’, located in the foraminal and/or extraforaminal zone causing radicular
SC
compression is extremely rare.6,8
Gas containing cysts are easy to be misdiagnosed as simple herniated discs. Sometimes they
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could be missed intraoperatively due to premature rupture. Therapeutic options for gas containing cysts range from nonoperative to operative, depending on clinical symptoms presented. Several authors have reported that surgical excision is the optimal treatment for symptomatic gas pseudocyst.4,9,15,16 Nowadays, endoscopic spinal operation has become the standard to
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treat various lumbar spinal diseases using various accesses and techniques.17–22 The purpose of this report was to present a symptomatic foraminal gas containing cyst that was removed by unilateral biportal endoscopy (UBE) technique. The process of removal of
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cyst with vivid endoscopic intraoperative illustration was also presented in this report. To the best of our knowledge, this is the first case report of a pseudocyst developed in lumbar foram-
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inal area and treated by UBE surgery via paraspinal approach.
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CASE REPORT History and clinical manifestations A 75-year-old man presented with severe left leg radiating pain and tingling sensation. Stand-
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ing and walking would exacerbate the patient’s symptoms while bed rest could only partially alleviate it. On neurological examination, left big toe dorsiflexion weakness (motor power:
grade 4) and sensory impairment in L5 dermatome were observed from the patient. He denied
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therapy, and a series of root block were ineffective.
SC
any history of open surgery. Conservative treatments such as the use of narcotics, physical
Imaging manifestations
A plain X-ray showed severe degenerative spondylosis with disc space narrowing in multilumbar level. However, definite instability was not seen in dynamic X-rays. Magnetic reso-
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nance imaging (MRI) demonstrated well demarcated, round shaped mass lesion with low signal intensity on both T1- and T2-weighted images, compressing the L5 root at the Left L5-S1 foramen (Figures 1A, 1B). Radiological pathologic lesion in MRI was revealed as gas which
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showed low density on computed tomography (CT) scan (Figures 2A-2C). There was intervertebral vacuum at the L5-S1 level while connection between intervertebral vacuum and gas
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containing cyst was not seen. Other possible causes such as degenerated disc or calcification suspicious from MRI examination were excluded by preoperative CT. Based on preoperative radiologic examinations, gaseous pseudocyst in extra-foraminal area was the primary impression and surgical treatment was considered.
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Treatment Unilateral biportal endoscopic (UBE) surgery with left para-spinal approach was performed to remove the gas containing cyst. The patient was operated in prone position under general an-
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esthesia. Under fluoroscopic guidance, two skin incisions of 1 cm each were made 1-2 cm lateral to the vertebral body lateral border for two portals (Figures 3A, 3B). As expected from
preoperative X-ray and CT, extra-foraminal zone in L5-S1 was nearly fused between trans-
SC
verse process and iliac bone due to degenerative change. There was no sufficient space to approach. Thus, a hole was made at the junction of transverse process and iliac bone by high
M AN U
speed drill. The operative space was further enlarged by circumferential drilling of bony structures considered as a lateral part of superior articular process, isthmus, and inferior part of transverse process. After confirmation of inferior margin of L5 pedicle, the intertransverse and foraminal ligament was dissected and excised. The pathologic cyst and affected L5 nerve root
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were then exposed. After delicate adhesiolysis between cyst and exiting L5 root, well-defined transparent cyst compressing L5 nerve root ganglion was found in extra-foraminal zone (Figure 4A).
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A large amount of gas bubbled up from the lacerated fissure when the cyst wall was pushed by probe. Fluid like materials were also trickled out (Figures 4B, 4C). There was no coexisting
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disc herniation. Connection with intradiscal space was not found during the removal of the cyst. Ablated remnants of soft tissues around the cyst were removed. Fully decompressed exiting L5 root was confirmed (Figure 4D, Video 1).
Postoperative course
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After the operation, the patient had complete relief of pain. His motor power and sensation were recovered to normal status by 3 months. Successful removal of gaseous cyst was confirmed by postoperative MRI (Figures 5A, 5B). The patient was discharged one day after op-
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eration. He was able to return to work. He was followed up regularly. He remained asymptomatic six months later.
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DISCUSSION
Free air in lumbar spine has been reported in various clinical situations, including epidural
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anesthesia, percutaneous spinal procedure, intestinal necrosis, pyogenic infections produced by gas-forming organisms, and osteonecrosis.11,13,23,24 Spinal surgery can be one of causes of intraspinal epidural gas (EG) formation.4,25 In most cases, reported epidural gas-containing cysts are asymptomatic and coexisted with sequestrated disc fragment. Severe radicular pain
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caused by isolated epidural gas cyst, so called gas containing pseudocyst, is extremely rare in the literature.3,5,6 Pathogenetic mechanisms of postoperative EG remain unknown. Intraspinal air has been thought to have a relationship with vacuum phenomenon by many authors.9,11,12 A
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weak point in the longitudinal ligament caused by developmental impairment has also been suggested to have a role in the formation of cyst.4,8 By using gas chromatography, Yoshida et
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al. have demonstrated that the major composition of cyst is nitrogen. They also suggested communication between the intradiscal gas and intraspinal gas pseudocyst using CT after discography which showed the flow of contrast media into the cyst.16 Usually, epidural gas is found in spinal canal, posterior lesion, or posterolateral lesion. A gas formation in foraminal or extra-foraminal zone is very rare.6,8
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Sometimes, gas containing cyst could be misdiagnosed as simple disc herniation compressing neural structure by radiologic images. The mass lesion which has low signal in T1, T2 images of Lumbar MRI should be considered first as calcification or air. In the current case, fo-
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raminal gas containing pseudocyst was radiologically illustrated by CT and MRI. Combined use of CT and MRI could help diagnose gaseous cyst in the foraminal area and differentiate it from other pathological lesions as mentioned in some previous reports.4,11,23
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Symptomatic gas containing cyst has been reported to have variable therapeutic modalities such as medication, nerve block, needle aspiration under fluoroscopic guidance, and surgical
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removal.3,4,6,8,14,15 Conservative treatment or percutaneous aspiration is the most common treatment. However, it has poor pain relief effect with a high recurrence rate. Open surgery has good clinical outcomes by totally removing the cyst wall. However, it can cause significant soft tissue injury.3,4,8,26
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Today, endoscopic spinal surgery has become one of standard treatments for degenerative lumbar diseases. It has shown many surgical advantages such as no need for general anesthesia, small skin incision, less soft tissue trauma, and postoperative fast recovery. Not only sim-
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ple contained disc, but also complicated cases such as highly migrated disc herniation and other pathology combined with bony degeneration to produce foraminal and canal stenosis can
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now also be treated with full-endoscopic surgery using various accesses and techniques.17,18,27– Zhu et al. have reported a case of a intracanal giant gas-containing pseudocyst successfully
removed by transforaminal endoscopic approach.2 Unilateral Biportal Endoscopy (UBE) has been suggested as an alternative treatment option to solve various spinal diseases. It has favorable surgical outcome and clinical feasibility in
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various clinical situations.20,30,31 However, there has been no report of gas containing cyst in lumbar area treated by UBE until now. To the best of our knowledge, this is the first report to present pseudocyst developed in lumbar foraminal area and successfully treated by UBE sur-
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gery via paraspinal approach.
In the current case, we could find many advantages of endoscopic spinal surgery as the therapeutic modality for gas containing pseudocyst. UBE surgery showed the same efficacy as pre-
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vious microscopic surgical method such as sufficient decompression and targeted resection of the cyst wall to avoid recurrence. Simultaneously, UBE surgery was proved to have merits of
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MIS surgery such as less muscle trauma and less soft tissue dissection, leading to patient’s short hospital stays (one day) and postoperative immediate return to normal activity. The wall of gas containing cyst is very thin and easy to be burst by intraoperative manipulation. Sometimes, an operator could miss the gaseous cyst and have difficulties to find the exact
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pathology when the cyst is premature ruptured by careless operative maneuver. In the current case, the gas containing cyst could be exposed without premature rupture during operation. This was possible because all procedures near the cyst were performed in very delicate man-
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ner with magnified endoscopic view. We also could acquire vivid endoscopic operative illustration of the cyst after careful dissection between the cyst and peri-cystic structures such as
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exiting root, ligament flavum, and disc annulus. The diagnosis of gas containing cyst was confirmed by bubbles from incision site of cyst in water medium when the cyst wall was incised and pushed with a probe. Such benefits of UBE surgery including easy discrimination of anatomical structures, delicate manipulation of pathology with magnified endoscopic view, and
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detailed operative information might have contributed to the successful result in the current case.
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CONCLUSION
Gas containing pseudocyst in lumbar foraminal area is not common. Combined use of pre-
operative MRI and CT can help diagnose gaseous pseudocyst and differentiate other patholo-
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gies. UBE technique which provides good operative visualization and delicate operative ma-
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nipulation is a less invasive therapeutic method to treat foraminal gas containing pseudocyst.
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Figure legends Figure 1. Preoperative Magnetic resonance imaging (MRI) showing a round shaped mass around L5–S1 extraforaminal area with low signal intensity in both axial T1&T2-weighted
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images. (A) axial T1-weighted magnetic resonance image;
Arrows: extraforaminal gas containing pseudocyst.
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(B) axial T2-weighted magnetic resonance image.
Figure 2. Preoperative Computed tomography (CT) imaging showing irregular round shaped
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mass around L5–S1 extraforaminal area with low density. (A) Coronal image; (B) Saggital image; (C) Axial image.
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Arrows: extraforaminal gas containing pseudocyst.
Figure 3. Overview of the percutaneous UBE surgery. (A) Operative position and basic surgical equipment;
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(B) Portals placement and operative target.
Figure 4. Endoscopic intraoperative illustration.
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(A) Well-defined transparent cyst compressing L5 nerve root ganglion was seen in extraforaminal zone.
Asterisk: Cyst wall;
White arrow: L5 Exiting root. (B) Air bubbles were observed from lacerated site of the cyst.
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Star: air bubbles. (C) Intracystic components were released after puncture of the cystic wall. Black arrow: fluid materials.
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(D) Fully decompressed L5 exiting root was observed after the removal of cyst and remnant soft tissues. Triangle: L5 exiting root.
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Figure 5. PostoperativeT2-weighted MRI axial image showing decompressed Left L5 exiting
(A) Axial image (L5 body level); (B) Axial image (disc level). Arrows: decompressed L5 exiting root.
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root by removal of gaseous cyst.
VIDEO 1. Video clip demonstrating the process of removing the pseudocyst in endoscopic
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CT: Computed Tomography
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EG: Epidural Gas MRI: Magetic Resonance Imaging
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UBE: Unilateral Biportal Endosopcy
ACCEPTED MANUSCRIPT Disclosure-conflict of interest
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All authors (AJW and LCW) did not influence and receive any financial and personal relationships with other people or organizations what we wrote in the submitted work including potential conflicts of interest include employment, consultancies, stock ownership, honoraria, paid expert testimony, patent applications/registrations, and grants or other funding.