Lumbar intraspinal synovial and ganglion cysts (facet cysts). Ten-year experience in evaluation and treatment

STUDY DESIGN

This study analyzed the clinical history, physical examination, diagnostic studies, and operative and histologic findings in 19 patients with lumbar intraspinal synovial and ganglion facet cysts evaluated and treated over a 10-year period.

OBJECTIVES

The results were correlated to provide a greater understanding of lumbar facet cysts and rationale for conservative or surgical treatments.

SUMMARY OF BACKGROUND DATA

The 19 patients included 13 women and 6 men ranging in age from 38 to 79 years. 84.4% of the patients presented with radicular pain. 26.3% had significant motor deficit. 68.4% of the facet cysts were found at L4-L5, 21.1% at L5-S1, 5.2% at L1-L2, and 5.2% at L2-L3.

METHODS

The clinical history and findings on physical examination, standard radiography, myelography, computed tomography-myelography, facet arthrography, post-facet arthrograph computed tomography, magnetic resonance imaging with and without contrast, and computed tomography scans were reviewed.

RESULTS

Bilobed cysts were found on both dorsal and ventral aspects of the involved facet joints within and outside of the spinal canal on facet arthrography, computed tomography, magnetic resonance imaging, and at the time of surgery in more than 60% of the patients. Significant facet degeneration was found in 75% of standard radiographs, and on all of the magnetic resonance imaging and computed tomography scans. In six patients, symptoms improved with rest, medication, and bracing. Epidural corticosteroid injections provided short-term relief in three out of four patients. Facet corticosteroid injections provided good relief in one, partial relief in one, and no relief in one patient. Surgical decompression in eight patients resulted in three excellent, four good, and one fair outcome.

CONCLUSIONS

Most of the lumbar intraspinal facet cysts were associated with significantly degenerated facet joints. Patients with intraspinal facet cysts may respond to conservative treatments if there is no significant neurologic deficit. Surgical decompression and removal of large facet cysts usually are successful in relieving symptoms.

Ganglion cyst of the hallux: an aberrant presentation

Ganglion cysts are benign, thin walled, fluid-filled lesions commonly occurring in the distal extremities. Although widely debated in the literature, a true, identifiable etiology has remained elusive. The authors report on a ganglion cyst with a unique presentation on the hallux, and a review of the literature.

[Adventitia resection in cystic degeneration of the popliteal artery]

Adventitial cystic disease is a rare form of non-atherosclerotic stenosis of the popliteal artery. It is caused by synovial-like cysts in the subadventitial tissue layer of the arterial wall causing compression of the lumen. The cysts contain mucinous material similar to that found in joint-ganglia. Popliteal artery stenoses causing claudication in young patients is the leading symptom of this disease. The classical therapy is the surgical excision of the diseased artery and interposition grafting with saphenous vein. As an alternative method we present the technique of complete circumferential resection of the diseased adventitia to decompress the lumen of the artery by removing the cysts completely. This technique is called exarterectomy and has been applied in 2 patients. In both cases we could remove the cysts completely without opening the arterial lumen. Intraoperative arteriography documented complete decompression of the arterial lumen. Both patients presented with excellent results 6 months postoperatively without any symptoms or signs of recurrence. Late results of exarterectomy ar not yet available.

Extradural synovial thoracic cyst

SUMMARY OF BACKGROUND DATA. Case studies documenting the incidence of thoracic intraspinal, extradural synovial cysts are limited. The occurrence of synovial cysts is associated with varied symptoms that differ among cervical, thoracic, and lumbar regions. The clinical appearance may be similar to other spinal diseases. METHODS. This report describes symptoms exhibited by and care provided for a patient with extradural synovial thoracic cyst.

Intramuscular ganglion of the biceps muscle

Ganglia are reported to have arisen in association with bursa or connected to synovial joints. We report a patient with a ganglion within the biceps muscle most likely to have evolved from an embryological arrest.

Soft-tissue and bone tumors about the foot and ankle

The development of primary and malignant tumors of the soft tissues and bones of the foot and ankle are uncommon. A potential for misdiagnosis and increased morbidity exists for those patients who do indeed have a malignancy. This article illustrates the proper steps in staging lesions and the appropriate techniques for biopsy. This will help physicians to avoid undertreating malignant lesions, and, conversely, overtreating benign lesions.

Synovial cysts and ganglia: the value of magnetic resonance imaging

Synovial and ganglion cysts commonly present in close proximity to joints and skeletal structures in rheumatic disorders. Familiarity with the presentation of these soft tissue masses can facilitate timely diagnosis and effective management, thus avoiding costly and potentially high-risk procedures to patients. Management usually consists of local, nonsurgical approaches. A patient with chronic joint deformities and clinical features primarily consistent with mixed connective tissue disease is described. Multiple localized masses developed at her right elbow and were identified on T2-weighted magnetic resonance imaging as multiloculated cysts that dissected from the elbow joint. The cysts were treated successfully by needle aspiration and intraarticular corticosteroid injection. The clinical associations, diagnosis, treatment, and management of synovial cysts and ganglions are reviewed.

Experience with symptomatic spinal epidural cysts

Epidural cysts, either synovial or ganglion, are an unusual cause of epidural compressive syndromes. We report a series of 26 patients with cysts, including 1 cervical, 2 thoracic, and 23 lumbar. Complaints at the time of admission and findings were similar to those associated with other epidural lesions at the same locations. The surgical technique is similar to that for other spinal lesions, with a wide exposure to enable a clear view of the cyst and surrounding structures, and is governed by imaging studies. Patients with cervical and thoracic lumbar cysts were free of symptoms and signs postoperatively. Of the 23 patients with lumbar cysts, 15 were free of symptoms after an operation, 7 had symptomatic improvement but had some pain and neurological findings, and 1 patient had no improvement. Computed tomography and magnetic resonance imaging permit accurate preoperative evaluation.

Pisotriquetral joint ganglion

Physical examination of a woman with painful swelling about the ulnar side of her dominant right wrist but no history of trauma revealed a freely mobile soft-tissue mass on the ulnar aspect of the wrist. Radiographs of the wrist were normal. At surgery, a 1 cm x 1 cm ganglion immediately adjacent to the hypothenar muscles was dissected circumferentially and found to have a stalk originating from the ulnar aspect of the pisotriquetral joint. This report suggests that ganglions arising from the medial side of the pisotriquetral joint should be included in the differential diagnosis of ulnar wrist pain.

Calcium pyrophosphate arthropathy of the spine: case report and review of the literature

Calcium pyrophosphate deposition disease is a relatively uncommon arthropathy characterized by the clinical features of pseudogout, the radiographic manifestations of chondrocalcinosis, and the pathological deposition of calcium pyrophosphate crystals in both hyaline and fibrocartilage. Symptomatic involvement of the spine by calcium pyrophosphate deposition disease is rare except by nodular deposition in the ligamentum flavum and atlanto-occipital ligament. We report a 50-year-old woman who presented with an acute herniated disc syndrome secondary to an intraspinal inflammatory calcium pyrophosphate deposition disease mass at the level of the L4-L5 interspace. The magnetic resonance image and histopathological features of the case are also discussed.

The histopathology of fibrous flexor sheath ganglia

In order to determine if fibrous flexor sheath ganglia had any histological features that could distinguish them from other ganglia, wer reviewed 50 consecutive ganglia treated by surgical excision. Of these, eight were fibrous flexor sheath ganglia. They did not have any specific features to distinguish them from the other ganglia. Furthermore, an absence of true synovial lining in them refutes the theory that they may result from synovial herniation around the A1 pulley.

An intramuscular ganglion presenting as a thenar mass

Soft-tissue masses in the hand are frequently due to ganglion cysts. We report a ganglion originating from a common location, the volar wrist, but presenting in a unique fashion as a thenar mass. This case helps demonstrate why ganglion cysts should be considered in the differential diagnosis of any soft-tissue hand mass.

Ganglion cysts of the anterior cruciate ligament: a case report and review of the literature

Ganglion cysts on the anterior cruciate ligament (ACL) should be suspected in any patient having pain and clicking sensation during terminal knee extension. Previous investigators have reported incidental findings of ganglion cysts on the ACL. However, we report a symptomatic case of a ganglion cyst on the ACL that was treated successfully with arthroscopic debridement.

Diagnosis of ganglions in the hand and wrist by sonography

In the practice of hand surgery, imaging of soft tissue structures can provide useful information for diagnosis and preoperative planning. Sonography with high frequency technique giving high spatial resolution is especially rewarding. In a joint project of the Departments of Radiology and Hand Surgery we evaluated the diagnostic accuracy and clinical value of sonographic assessment of ganglions of the hand and wrist. The material comprises 68 soft tissue lesions clinically suspected to be ganglions. Sonography revealed a ganglion in 53 cases, 34 of which went to surgery. The diagnosis was confirmed in every case. One collapsed ganglion was missed. Nonpalpable ganglions causing clinical symptoms could be demonstrated, and a suspected ganglion could sometimes be ruled out in favor of other diagnoses. Sonography could delineate the entire ganglion and often its connection with the joint space.

Analysis of a large kindred with Blau syndrome for HLA, autoimmunity, and sarcoidosis

OBJECTIVE

To determine whether HLA and autoimmunity contribute to the pathogenesis of Blau syndrome (familial granulomatous arthritis, uveitis, and rash) and evaluate whether this condition is related to sarcoidosis.

DESIGN

Large family survey.

SETTING

General community, Green Bay, Wis, and two tertiary care medical centers in Philadelphia, Pa.

PARTICIPANTS

Thirty-six family members and spouses from a large kindred with Blau syndrome.

SELECTION PROCEDURES

Volunteer and convenience sample.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Ten affected and many unaffected subjects were personally examined. Medical records and previous biopsy reports and specimens, when available, were reviewed. Two affected subjects had skin biopsies performed and three affected adult subjects were tested with Kveim skin-test reagent. Serologic and genomic class I and class II HLA typing was performed on 27 affected and unaffected subjects. All 13 living affected subjects and the one obligate carrier had the following assays performed; antinuclear antibody titer, rheumatoid factor, serum angiotensin converting enzyme level, quantitative immunoglobulins of the IgG, IgM, and IgA classes, and clinical chemistry profiles. Several had complete blood cell counts and erythrocyte sedimentation rates performed. Four affected subjects, one possibly affected subject, and one obligate carrier were newly identified. Flexion contractures of the fingers and toes (camptodactyly) were found, for the first time, to be a phenotype characteristic. Earlier onset and worsening of symptoms in succeeding generations (anticipation) were observed. Sixteen HLA haplotypes were identified. No conclusive evidence for linkage between these haplotypes and phenotype expression could be demonstrated. All 13 affected subjects, however, carried the DR2 (DR beta 1*1501) and/or DR4 (DR beta 1*0401) allele. There was no evidence of hypercalcemia, hypergammaglobulinemia M, rheumatoid factor production, or abnormal blood cell counts. Two affected subjects had low-titer antinuclear antibody screening tests, five had mild to moderately elevated IgG and/or IgA levels, two had raised serum angiotensin converting enzyme levels, and three had mild elevation of the erythrocyte sedimentation rate. All three subjects tested with Kveim skin-test reagent showed no reactivity by visual inspection. Both subjects who had had skin biopsies performed had evidence of granulomatous inflammation.

CONCLUSIONS

This family's illness is distinct from both classic and early-onset sarcoidosis. There is minimal evidence for autoimmunity and systemic inflammation. Camptodactyly should be added to the list of syndrome-defining characteristics. Although HLA haplotypes do not appear to segregate with affected subjects, HLA-DR2 and HLA-DR4 subtypes may play a permissive role in phenotype expression. This family represents a unique opportunity to define the molecular mechanisms involved in the initiation of arthritis and uveitis in humans. Genetic linkage studies to determine the chromosomal location of the Blau syndrome gene are in progress.

Cervical neural foraminal canal stenosis: computerized tomographic myelography diagnosis

The surgical and computerized tomographic myelography (CTM) features of 134 stenotic foraminal canals were correlated retrospectively in 95 patients. The myelographic site of stenosis was the entrance to the foraminal canal in 70 cases (52%) and the canal itself in 37 (28%); the site was not identified definitively in 27 (20%). At the entrance to the foraminal canal, encroachment on the adjacent nerve root was by a cartilaginous cap in 10 cases (8%), a bony osteophyte in 17 (13%), a synovial cyst in one (1%), and a combination of a bony and cartilaginous osteophyte in 42 (31%). The diagnostic features of stenosis within the foraminal canal were more variable. Small bone spurs arising from the uncovertebral process encroached on the anterior aspect of the foramen in 29 instances (22%), accompanied in all cases by either a congenitally narrow canal (in 16) or a diffuse osteophytically narrowed canal (in 13); osteophytes arising from the superior facet in eight instances (6%) were larger and encroached on the posterior aspect of the foramen. Diagnosis on the basis of CTM is difficult because stenosis was readily evident as a bone spur in only 13% of cases, could not be distinguished from prolapsed disc in 39%, had to be differentiated from a congenitally narrow foraminal canal in 27%, and was frankly missed in 20% of the instances of stenosis.

Intraosseous ganglion. Report of a case

We report a case of an intraosseous ganglion of the lateral malleolus of the ankle. The lesion was accompanied by a cystic bursa overlying the lateral malleolus. There were connections between the ankle joint, the intraosseous ganglion, and the overlying cyst. Radiographs of the lesion showed the cystic defect in the lateral malleolus surrounded by a sclerotic rim, suggesting that the lesion had progressed very slowly.

Isolated ganglions of the anterior cruciate ligament

We report three athletes with symptomatic isolated ganglion of the anterior cruciate ligament. The symptoms consisted of anteromedial knee pain, worse when changing direction while running, and on squatting. All gave a history of repeated minor knee trauma without a single episode of serious injury. At day-case arthroscopy, a unilobulated cystic mass arising from a clinically and arthroscopically intact anterior cruciate ligament was noted and removed in each case. No further intra- or extra-articular knee lesion was seen. Histology revealed a cystic ganglion in each case. With early physiotherapy, the patients could start gentle training 3 wk after arthroscopy, and, at 6-month review, were fully asymptomatic. A review of the literature shows that an isolated ganglion arising from the anterior cruciate ligament is exceedingly rare, with only three such ganglia having been previously reported.

[An intra-osseous synovial cyst of the carpal bones. Apropos of 3 cases]

Three additional cases of intra osseous ganglion are reported. These indicate that the carpal cysts tend to occur in young patients with no roentgen or pathological evidence of degenerative process in the neighboring joints. They arise by either intrusion of ganglion-like tissue into bone after fracture or primary skeletal metaplastic phenomenon. Conservative surgical treatment is effective.

CT findings in peripheral mononeuropathies

Thirty-six patients with a peripheral localized nerve lesion (18 of median nerve, 7 of ulnar nerve, 2 of radial nerve, 1 of lateral cutaneous brachii nerve, 1 of sciatic nerve, 5 of peroneal nerve and 2 of tibial nerve), were evaluated by Computed Tomography (CT). We used a high resolution scanner (Siemens Somatom CR) and we performed 2mm thickness slices. Sagittal and coronal reconstructed images were obtained too. Thirty-two out of 36 patients underwent surgery. CT scan was useful in all cases in defining the relationship between nerve lesions and surrounding tissues and in planning surgical procedures. The CT evaluation of tissues densities and characteristics allowed us to define the pathologic nature of the lesions in 10 cases.

[Non-discal sciatica secondary to a cystic lesion of the posterior longitudinal ligament. 10 cases]

Cyst of the longitudinal posterior ligament of the spine is a new entity described here on the basis of 10 cases. This is a lesion, perhaps of traumatic origin, which occurs in young, athletic subjects suffering from classical lumbosciatica. Computerized tomography showed an image resembling nucleus pulposus herniation. In one of our cases magnetic resonance imaging provided the preoperative diagnosis. Following surgery the outcome was favourable, with less postoperative complications than with discal herniation. The macroscopic and histological findings were the same in all cases, making the anatomico-pathological diagnosis easy.

[Intraosseous ganglion in the area of the wrist]

In the differential diagnosis of cystic lesions in bones, the intraosseous ganglion must be included. These tumor-like lesion is rare in the carpus, but often the cause of therapy-resistant pain. Four patients with intraosseous ganglion in the carpus are presented. This bone disease is treated by curettage and bone grafting. Postoperative prognosis is good.