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CLINICAL NOTE

A Ganglion Cyst Causing Lumbar Radiculopathy in a Baseball Pitcher: A Case Report Joe Lee, MD, RonaM J. Wisneski, MD, Gregory E. Lutz, MD

ABSTRACT. Lee J, Wisneski RJ, Lutz GE. A ganglion cyst causing lumbar radiculopathy in a baseball pitcher: a case report. Arch Phys Med Rehabil2000;8 I :837-9.

This report describes a case of a professional baseball pitcher who developed acute left lumbar radicular symptoms after a baseball game and was subsequently sidelined for the rest of the season. Physical examination revealed depressed reflexes in the left posterior tibialis and left medial hamstring muscles, mild weakness in the left extensor hallucis longus. and positive dural tension signs. Magnetic resonance imaging demonstrated an ovoid mass at the L4-L5 level, causing compression of the dura. Surgical resection of the mass resulted in resolution of his symptoms. Pathology revealed that the mass was a ganglion cyst. A ganglion cyst is a rare cause of lumbar radiculopathy and should be considered in the differential diagnosis if a patient with lumbar radiculopathy fails to respond to conserva- tive treatment.

Key Words: Radiculopathy, lumbar; Ganglion cysts; Reha- bilitation.

0 2000 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation

T HE INCIDENCE OF back pain in athletes varies depend- ing on the sport and has been reported to occur from I. 1%

to 30%.’ The incidence of lumbar radiculopathy in athletes has not been well studied. Baseball players have been identified as at risk for spine injuries, but this problem has not been thoroughly investigated.2 Lumbar radicular pain can often be attributed to a discogenic source in these patients, but a ganglion cyst is a rare cause of lumbar radicu10pathy.3-6 The diagnosis of ganglion cyst causing lumbar radiculopathy cannot be easily distinguished from discogenic disease based on physical examination alone. Ganglion cysts that originate from the posterior longitudinal ligament are very rare. There have been only I2 reported cases in the literature,3,6 but magnetic resonance imaging (MRI) can help distinguish this cause of lumbar radiculopathy from a discogenic source.

CASE REPORT A 27-year-old professional baseball player presented with

low back pain, which radiated into his left leg. He had no back problems until 5 weeks before his presentation. At that time, he had performed two sets of IO squat lifts of 225 pounds and afterward pitched 6 innings. Within hours, he developed an

From the Departmenr of Physical Medicine and Rehabilitation (Lee. LUIZ) and Department of Orthopedic Surgery (Wisneski). Hospital for Special Surgery. New York.

Submitted February 17. 1999. Accepted in revised form July 23, 1999. No commercial party having a direct financial interesl in the results of the research

supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated.

Reprint requests to Gregory E. LUIZ. MD, Hospital for Special Surgery, 535 East 70th Streel. New York, NY 10021.

ooO3-9993/00/8106-5472$3.00/O doi: 10,1053/apmr.2000.378I

acute onset of low back pain with radiation into the posterolat- era1 aspect of his left leg. The symptoms were persistent and limited his ability to pitch. He was also unable to sit or flex forward without pain. The pain was relieved with recumbency and was not associated with any progressive neurologic or constitutional symptoms.

His team physician treated him with ibuprofen and hydro- codone bitartrate with acetaminophen, but none of the drugs relieved his pain. The patient could not recall the exact dosage and frequency. Physical therapy involving McKenzie exercises and activity modification were also prescribed but did not provide him with any significant relief for 5 weeks.

MRJ of the lumbosacral spine was performed and read at an outside facility. The study demonstrated small central disc protrusions at L3-L4 and at L5-S 1 (fig 1A). At the L4-L5 level, the images were read as a mild to moderate broad-based central disc protrusion. An ovoid epidural density measuring 10 X 5mm could be seen inferior to the intervertebral disc space producing dural compression (figs lA, 1B). The signal within the density was higher than that of cerebral spinal fluid on TI-weighted scans and showed very bright signal intensity on T2-weighted images. This mass was interpreted as a large free extruded disc fragment on the left. No degenerative changes were noted in the zygapophyseal joints. There was no obvious attachment to the zygapophyseal joints in the adjacent regions. The patient was referred for further treatment because he was not improving.

Physical examination revealed a well-developed man in mild distress. Lumbosacral range of motion was restricted to 10” of forward flexion secondary to the pain in his lower back and left leg. Extension was mildly painful but full. Hip active range of motion was full and pain free. Sensation in both lower extremities was intact. Reflexes were l+ in the left posterior tibialis and left medial hamstrings. Otherwise reflexes were 2+ in the lower extremities. Strength was 4+/5 in tire left extensor hahucis longus, but otherwise was 5/5. Supine straight leg raise bilaterally at 30” worsened his pain in his lower back and left leg. Bilateral sitting straight leg raises and provocative maneu- vers including compression of nerves in the left popliteal fossa with dorsiflexion also exacerbated his pain.

The MRI study was reviewed and determined to be consis- tent with what was described by the radiologist. The mass at the LA-L5 level appeared to be a disc protrusion with an extrusion of a disc fragment on the left.

Because of the severe refractory radicular pain, bilateral positive dural tension signs, the atypical MRJ features, as well as the patient’s desire to return to pitching by spring training of the next baseball season, surgical intervention was recom- mended. He underwent a left L4-L5 larninectomy, lateral recess decompression, and excision of this mass. The medial aspect of the left L4-L5 facet joint was removed to visualize the left L5 nerve root. Significant amounts of adhesions were noted along the lateral border of the dural sac just proximal to the take-off of the left L5 nerve root. The nerve root was found deviated dorsally and laterally, not by an extruded disc fragment, but rather by a large cystic mass in the lateral recess. The mass was at the junction of the transverse anastomosis with the anterior

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838 LUMBAR GANGLION CYST, Lee

Fig 1. Magnetic resonance imaging: (A) Sagittal view of lumbar spine mass (arrow). (B) Axial view of L5 vertebral level showing epidural mass in the region of the posterior longitudinal ligament (arrow).

internal vertebral vein on the left. No connection to the zygapophyseal joints was noted. The lesion was rubbery in consistency and cystic. It was partially filled with blood in some chambers and clear fluid in other chambers. The surgeon believed that the mass was a possible hemangioma.

Pathology revealed that the gross specimen was an ovoid, white soft tissue mass with focal regions of brown and black pigmentation. Its greatest dimension was approximately lcm in diameter. Micro- scopic examination of the specimen revealed dense connective tissue showing mucoid and mucccystic degeneration. Within the connective tissue, there were regions of dense hemosiderosis and slight chronic inflammation. There was a lack of a distinct lining (fig 2). The final pathologic diagnosis was ganglion cyst.

Postoperatively the patient had complete relief of his symp- toms and has regained full range of motion of his lumbosacral spine. He had no dural tension signs, and a normal neurologic exam. Three months after surgery, he continued to do well, and it was anticipated that he would return to his previous level of athletic activity with no restrictions.

DISCUSSION Lumbar radicular pain can be attributed to direct irritation of

a nerve root from a variety of different causes. The most common cause is a herniated disc, but other possible causes include spinal stenosis and compression by a mass such as a tumor, a varix, a synovial cyst, or a ganglion cyst. The mass can lie within or outside the vertebral canal. In our experience, lumbar disc hemiations are the most common cause in the younger athlete, while spinal stenosis is the most common cause in athletes older than age 60. Spinal stenosis is associated with osteoarthritis of the spine and degenerative disc disease. Primary or metastatic neoplasms are less likely causes of radicular pain in a patient with no constitutional symptoms. A hemangioma is possible, and a case of chronic lumbar radiclupathy secondary to a hemangioma has been published.7 Ten cases

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of lumbar epidural varices have also been reported as causing lumbar radiculopathy.*

Ganglion cysts may develop from mutinous degeneration of periarticular connective tissue, and usually they have no direct communication with the joint. Ganglion cysts do not have a distinct lining and contain thick myxoid material.5,9 They have a thickened fibrous connective tissue lining.9

Synovial cysts have a pseudostratified columnar synovial cell lining and are supported by layers of villous nodular hyperplas- tic vascularized connective tissue. They contain thin, straw- colored fluid and may have hemosiderin without any significant inflammatory changes. They are thought to arise from periarticu- lar tissue such as synovial hemiation through weakened or destroyed facet joint capsule with continued direct communica- tion with the joint of origin.g

Intraspinal ganglion cysts and synovial cysts, are often collectively called juxtafacet cysts because they share a similar pathogenesis, patient population, and overlapping histopathol- ogy. They both can originate from the zygapophyseal joints and may be associated with lumbar spondylosis and osteoarthritis of the zygapophyseal joint. They may have a surrounding layer of calcium deposition9 There has also been an association with spondylolisthesis. The patients tend to be in their late 40s or older and may have a history of trauma. They may also have a long history of pain or a prior episode of pain that resolved, which may represent a spontaneous decompression of the cyst. Computed tomography myelogram or MRI studies would show epidural compression of the posterior or posterolateral region of the vertebral canal. High resolution imaging studies may define an attachment of the cyst to the zygapophyseal joint, but some synovial cysts may also originate from the ligamentum fla- vum.‘O The cyst may still be mistaken for an extruded herniated disc. The juxtafacet cysts can also cause significant lysis of bone and surrounding soft tissue.5 Hemosiderin within the cyst

LUMBAR GANGLION CYST, Lee 839

Fig 2. Photomicrograph of cystic mass, with red blood cells shown on the right side (hematoxylin and eosin stain; magnification, 10x; internal marker = 250pm).

indicates recent hemorrhage and has been correlated with an increase in pain or an acute onset of pain.iO

Ganglion cysts that originate from the posterior longitudinal ligament are much rarer than juxtafacet cysts. There are 12 reported cases in the literature. Eleven cases were described before 1996, according to the French medical literature.6 In 1997, a group from Japan reported a case involving a 26-year- old man.3 That patient also had no prior history of back pain or trauma. The ganglion cyst was found in the anterior aspect of the spinal canal and appeared to emanate from the vertebral rim of LA. No attachment to the zygapophyseal joint could be found on imaging or during the surgical removal of the ganglion cyst. The similarities between the two cases seem to suggest that the ganglion cyst in this reported case may very well have originated from the posterior longitudinal ligament. Surgical

removal of the ganglion cyst was effective treatment in both cases.

Although uncommon, ganglion cysts may arise from the posterior longitudinal ligament and cause lumbar radiculopa- thy. In retrospect, the striking diagnostic feature in this case was the high signal intensity on both Tl- and TZweighted MRI images, which can allow differentiation from an extruded herniated disc fragment in most instances. The high signal finding on both Tl- and T2-weighted images are suggestive of hemorrhagic cysts. The hyperintensity on Tl-weighted images could be due to the presence of methemoglobin or blood breakdown products. The finding of a hypointense rim, best seen on T2 images, may reflect a combination of the fibrous capsule, calcification, and/or hemorrhage in the cyst wall.” Because there have been few reported cases, the treatment of choice is not clear. Physicians caring for athletes with lumbar radiculopathy must recognize this as a distinct entity treated best with early surgical decompression if conservative mea- sures fail.

Acknowledgment: The authors thank Dr. Edward DiCarlo for providing the photomicrographs.

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