The patient was a 22-year-old starting NCAA division I wide receiver. He was 6'5", weighed 225lb, and had a BMI of 26.7. After a 12-month history of intermittent low back pain, he presented to his team physician with a complaint of increasing generalized lumbar discomfort. He had been previously diagnosed with sacroiliac joint dysfunction, which had been managed with physical therapy until this recent exacerbation of symptoms. Physical examination revealed paraspinal muscle discomfort on forward flexion, tight hip flexors and hamstrings, and weak hip abductor muscles. Plain radiographs of the lumbosacral spine demonstrated six lumbarized vertebral bodies with lumbarization of S1 and mild degenerative disc changes at L4-5 (Fig. 1).
The patient was managed conservatively for almost 3 months, until he developed acute pain in his right buttock and upper posterior thigh, right-lower-leg numbness, and right-leg weakness. Physical examination revealed slightly diminished strength of knee flexion, ankle dorsiflexion, and plantar flexion in the right leg. A selective nerve-root block at L5 gave him sufficient pain relief to continue his football activities, but his leg weakness persisted over the next two months. A MRI scan demonstrated right paracentral herniation of the L4-5 disc, with a small annular tear associated with a cyst extending from the L4-5 level down to the L5-S1 level (Figure 2, Figure 3). The patient was referred for surgery.
After a right L4-5 laminotomy, lateral recess decompression, and wide foraminotomy, retraction of the L5 nerve root exposed a disc herniation with an associated large discal cyst that extended into the right neural foramen and inferiorly behind the L5 vertebral body. The cyst was decompressed; it contained very thick fluid with several fragments of disc material. After the cyst was resected, microdiscectomy revealed only small amounts of herniated disc material. The disc space was then flushed out with an antibiotic solution, and no further disc material was identified. Postoperatively, the patient's symptoms resolved, and he presented with intact motor strength at his 12-day followup visit.