1307 - Micystaken Identity of Osteomyelitis for Radiculopathy: A Case Report

54-year-old female presented with lumbar pain radiating down to the left lateral calf with paresthesias for seven months. She was discharged from acute care for similar symptoms two months prior. Imaging revealed possible osteomyelitis at T12/L1 and a synovial cyst impinging on the left L5 nerve root. She had no surgical intervention and was discharged on six weeks of IV antibiotics which did not improve her pain or functional status. 

Physical exam was consistent with left L5 radiculopathy. Given location of the facet cyst and associated impingement of the L5 nerve at the foramen, instead of a typical L5-S1 facet joint, she underwent left L5-S1 Transforaminal Epidural Steroid Injection with cyst aspiration. Upon two month follow-up, she reported 80% improvement in her axial back pain with no radiculopathy symptoms. She completed physical therapy, returned to her active lifestyle, and successfully weaned herself off all neuropathic, anti-inflammatory and anti-spasmodic medications.

Discussions: Degenerative changes of the facet leads to increased synovial fluid production, forming a cyst that can compress onto adjacent structures. Treatment involves conservative therapy including physical therapy, anti-inflammatory medications, and fluoroscopy guided steroid injections then surgical intervention with laminectomy with cyst excision once conservative measures fail. Given her presentation and imaging, standard interventional approaches may not have been an appropriate course for the patient’s symptoms and underlies the need to evaluate imaging for appropriate pre-procedural planning.

Conclusions: The hyperfixation over the osteomyelitis overshadowed the synovial cyst that was the root cause of the patient’s presenting symptoms leading to unnecessary antibiotics with delay in her care. It underscores the need to correlate clinical presentation with imaging findings and usage of imaging for appropriate targeted treatment plans.