Lumbar Facet Cyst Presenting with S1 Radiculopathy Not Amenable to First Line Conservative Treatment Requiring Epidural Injection and Cyst Rupture: A Case Report

Case Diagnosis: Lumbar Facet Cyst Presenting as an S1 Radiculopathy

Case Description or Program Description: A 57-year-old male presented with lower back pain and right-sided radiculopathy. MRI of the lumbar spine demonstrated a 2.1 cm cyst emerging from the right L5-S1 facet causing compression of the S1 nerve root. Patient failed conservative treatment with physical therapy and oral pain medications. The patient underwent steroid injection with percutaneous rupture of the cyst with resolution of symptoms.

Setting: Outpatient pain mangement clinic

Assessment/Results: Patient received CSI followed by surgical resection of the cyst

Discussion (relevance): Lumbar facet cysts are most commonly located at the L4-L5 level (64%), followed by the L5-S1 (21%). Although rare and usually asymptomatic, if a patient develops symptoms, first line treatment currently consists of non-surgical options including physical therapy, bracing, anti-inflammatories, epidural injections and/or cyst rupture. Steroid injection alone has an approximate 33% success rate while steroid injection with percutaneous rupture has a 50% success rate. Due to high recurrence rates, surgical resection remains the gold standard with an 82% satisfactory rating. The practice to choose between injections versus surgical treatment differs vastly depending on physician preference.

Conclusions: Lumbar facet cysts are a rare cause of nerve root compression and usually located at the L4-L5 level followed by the L5-S1 level. Although surgical resection remains the golden standard once conservative management fails, we present a case in a young man who had significant relief after steroid injection with cyst rupture. Epidural injection and cyst rupture can be a great alternative in a patient with multiple comorbidities or in someone seeking to avoid surgery. It can result in quicker resolution of symptoms, shorter healing time and reduced infection risk. However, more research is needed to define the parameters in deciding between which would be more beneficial.