Retrospective study of 77 patients harbouring lumbar synovial cysts: functional and neurological outcome

Surgical excision of a Juxtafacet cyst in the lumbar spine: A report of thirteen cases with long-term follow up

CONTEXT

Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. Surgical treatment is indicated when there is failure of conservative measures. Primary spinal fusion at the time of surgical excision of the cyst is a matter of controversy. Few reports have described long-term follow-up for surgical treatment of spinal cysts.

AIM

The purpose of this study is to assess the long-term outcome of the surgical excision of a Juxtafacet cyst without spinal fusion.

STUDY DESIGN

This is a retrospective case series study, level IV evidence.

MATERIALS AND METHODS

This is a retrospective case series study on 13 patients with Juxtafacet cysts, who were treated with surgical excision of the cysts without spinal fusion. A questionnaire scoring system was used for evaluation of the surgical outcome.

RESULTS

The study was conducted on 13 patients, seven females (54%) and six males (46%), their age ranging from 38 to 69 years, with a mean age of 52 (±9.93 STD) years. The mean duration of the symptoms was 10.5 (±6.22 STD) months. All patients got benefit from surgery, with six excellent (46%), six good (46%), and one fair outcome (8%), with no surgery-related complications. The mean follow-up period of the patients at the time of this study was 4.2 years (±1.43 STD).

CONCLUSION

Long-term follow-up for surgical excision of symptomatic Juxtafacet cysts without spinal fusion revealed excellent to good results in 92% of the patients, with a satisfaction rate of 80% (±8.41 STD).

Chiropractic management of a patient with lumbar spine pain due to synovial cyst: a case report

INTRODUCTION

The purpose of this study is to report the findings resulting from chiropractic care using flexion distraction spinal manipulation for a patient with low back and radicular pain due to spinal stenosis caused by a synovial cyst.

CASE REPORT

A 75-year-old man presented with low back pain radiating to the right anterior thigh and down the left posterior leg of 3 years' duration. Physical and imaging examinations showed a synovial cyst-induced spinal stenosis at the right L3-L4 level and bilateral L4-L5 spinal stenosis.

INTERVENTION AND OUTCOMES

Flexion distraction spinal manipulation and physiological therapeutics were applied at the levels of stenosis. After 4 visits, the patient noted total absence of the right and left lower extremity pain and no adverse reaction to treatment. After 3 months of treatment and 16 visits, his low back and buttock pain were minimal; and he had no leg pain.

CONCLUSION

Lumbar synovial cyst and stenosis-generated low back and radicular pain was 80% relieved in a 75-year-old man following Cox flexion distraction spinal manipulation.

The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration

Background:

The surgical management of lumbar synovial cysts that have extruded into the spinal canal remains controversial (e.g. decompression with/without fusion).

Methods:

The neurological presentation, anatomy, pathophysiology, and surgical challenges posed by synovial cysts in the lumbar spine are well known. Neurological complaints typically include unilateral or, more rarely, bilateral radicular complaints, and/or cauda equina syndromes. Anatomically, synovial cysts constitute cystic dilatations of synovial sheaths that directly extrude from facet joints into the spinal canal. Pathophysiologically, these cysts reflect disruption of the facet joints often with accompanying instability, and potentially compromise both the cephalad and caudad nerve roots.

Results:

Aspiration of lumbar synovial cysts, which are typically gelatinous and non-aspirable, and typically performed by “pain specialists” (e.g. pain management, rehabilitation, radiologists, others) utilizing fluoroscopy or CT-guided aspiration, is associated with 50–100% failure rates. Surgical decompression with/without fusion (as the issue regarding fusion remains unsettled) results in the resolution of back and radicular pain in 91.6–92.5% and 91.1–91.9% of cases, respectively.

Conclusions:

After a thorough review of the literature, it appears that the treatment with the best outcome for patients with synovial cysts is cyst removal utilizing surgical decompression; the need for attendant fusion remains unsettled. The use of an alternative treatment, percutaneous aspiration of cysts, appears to have a much higher recurrence and failure rate, but may be followed by surgery if warranted.

Hemorrhagic synovial cyst: the possible role of initial trauma and subsequent microtrauma in its pathogenesis: case report

BACKGROUND AND IMPORTANCE

Intraspinal synovial cysts are uncommon causes of back and radicular leg pain. Usually associated with degenerative spinal disease, these juxtafacet cysts are usually located in the lumbar spine and may rarely undergo intracystic hemorrhage. The pathogenesis of these cysts are unclear, and risk factors that may contribute to hemorrhagic complications are largely unknown.

CLINICAL PRESENTATION

A 68-year-old man presented to the clinic 4 months after a fall on ice with persistent back pain and lumbar radiculopathy. A week after the initial clinic consultation, the patient presented to the emergency room with increased pain and worsening weakness in the left foot. An emergent magnetic resonance image showed thecal sac compression secondary to a large, juxtafacet cyst that was hyperintense on T1-weighted and hypointense on T2-weighted images. Lumbar decompressive laminectomies were performed at L3 and L4 with cyst removal and stabilization.

CONCLUSION

We present the eighth reported case of a hemorrhagic juxtafacet cyst secondary to physical trauma, the second in which the patient's symptoms acutely worsened several months after the initial insult without new trauma. We also present summary statistics of the 31 cases of hemorrhagic juxtafacet cysts reported in the literature and propose a putative mechanism that may account for the development and progression of symptoms in some patients.

Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systematic review of reported postoperative outcomes

BACKGROUND CONTEXT

With improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.

PURPOSE

To determine the cumulative incidence of postoperative symptomatic relief, recurrent back and leg pain after cyst resection and decompression, and synovial cyst recurrence.

STUDY DESIGN

Systematic review of the literature.

PATIENT SAMPLE

All published studies to date reporting outcomes of synovial cyst excision with and without spinal fusion.

OUTCOME MEASURES

Cyst recurrence and Kawabata, Macnab, Prolo, or Stauffer pain scales.

METHODS

We performed a systematic literature review of all articles published between 1970 and 2009 reporting outcomes after surgical management of spinal synovial cysts.

RESULTS

Eighty-two published studies encompassing 966 patients were identified and reviewed. Six hundred seventy-two (69.6%) patients presented with radicular pain and 467 (48.3%) with back pain. The most commonly involved spinal level was L4-L5 (75.4%), with only 25 (2.6%) and 12 (1.2%) reported synovial cysts in the cervical or thoracic area, respectively. Eight hundred eleven (84.0%) patients were treated with decompressive surgical excision alone, whereas 155 (16.0%) received additional concomitant spinal fusion. Six hundred fifty-four (92.5%) and 880 (91.1%) patients experienced complete resolution of their back or leg pain after surgery, respectively. By a mean follow-up of 25.4 months, back and leg pain recurred in 155 (21.9%) and 123 (12.7%) patients, respectively. Sixty (6.2%) patients required reoperation, of which the majority (n=47) required fusion for correction of spinal instability and mechanical back pain. Same-level synovial cyst recurrence occurred in 17 (1.8%) patients after decompression alone but has been reported in no (0%) patients after decompression and fusion.

CONCLUSIONS

Surgical decompression results in symptomatic resolution in the vast majority of patients; however, recurrent back pain occurs in a significant number of patients. Cyst recurrence occurs in less than 2% of patients but has never been reported after cyst excision with concomitant fusion. The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine.

Ganglion cyst of the posterior longitudinal ligament causing lumbar radiculopathy

Degenerated conditions such as herniated disc or spinal stenosis are common etiologies of lumbar radiculopathy. Less common etiologies include spinal extradural cyst such as synovial cysts and ganglion cysts. Ganglion cyst of the posterior longitudinal ligament (PLL) of the spine is a rare entity that can result in classical sciatica. Posterior longitudinal ligament cyst has no continuity with the facet joint and has no epithelial lining. Two young male patients presented with unilateral sciatica and were found to have intraspinal cystic lesions causing lumbar radiculopathy. Magnetic resonance imaging demonstrated rounded, cystic lesions (i.e., hypointense on T1- but hyperintense on T2-weighted images) adjacent to minimally dehydrated, nonherniated disc spaces in both cases. These patients underwent posterior decompression and cysts were excised, and their sciatic symptoms were completely resolved. Histological examination showed typical features of ganglion cysts in these cases.

Diagnostic challenge: bilateral infected lumbar facet cysts--a rare cause of acute lumbar spinal stenosis and back pain

Symptomatic synovial lumbar facet cysts are a relatively rare cause of radiculopathy and spinal stenosis. This case and brief review of the literature, details a patient who presented with acutely symptomatic bilateral spontaneously infected synovial facet (L4/5) cysts. This report highlights diagnostic clues for identifying infection of a facet cyst.

Lumbar intraspinal extradural ganglion cysts

The lumbar intraspinal epidural ganglion cyst has been a rare cause of the low back pain or leg pain. Ganglion cysts and synovial cysts compose the juxtafacet cysts. Extensive studies have been performed about the synovial cysts, however, very little has been known about the ganglion cyst. Current report is about two ganglion cysts associated with implicative findings in young male patients. We discuss about the underlying pathology of the ganglion cyst based on intraoperative evidences, associated disc herniation at the same location or severe degeneration of the ligament flavum that the cyst originated from in young patients.

Lumbar synovial cyst in an adolescent: case report

BACKGROUND

Spinal extradural cysts are a rare cause of spinal cord or nerve root compression which tends to occur in the elderly but rarely reported in the under 20s.

HISTORY

A 14-year-old girl with a 9-month history of left radicular pain was found to have an intraspinal cystic lesion causing radicular compression. MRI showed a 1.1-cm extradural cystic lesion with a low signal on T1 and high signal on T2-weighted images lying in the spinal canal at the L4 vertebral body level. The patient underwent an L4 hemi-laminectomy and excision of a synovial cyst, and the radicular pain completely regressed.

DISCUSSION

We discuss the pathogenesis, radiological techniques, and management of synovial cyst in a pediatric patient.

CONCLUSION

Intraspinal ganglion cysts are extremely rare in children and only two other cases have been reported previously. They are benign lesions, frequently presenting radiculopathy, and should be considered in the differential diagnosis, in patients with low back pain and radiculopathy.

Lumbar synovial cyst in a adolescence: case report

BACKGROUND

Spinal extradural cysts are a rare cause of spinal cord or nerve root compression which tends to occur in the elderly but rarely reported in the under 20s.

HISTORY

A 14-year-old girl with a 9-month history of left radicular pain was found to have an intraspinal cystic lesion causing radicular compression. Magnetic resonance imaging showed a 1.1-cm extradural cystic lesion with a low signal on T1-weighted images and high signal on T2-weighted images lying in the spinal canal at the L4 vertebral body level. The patient underwent an L4 hemilaminectomy and excision of a synovial cyst, and the radicular pain completely regressed.

DISCUSSION

We discuss the pathogenesis, radiological techniques and management of synovial cyst in a paediatric patient

CONCLUSION

Intraspinal ganglion cysts are extremely rare in children and only two other cases have been reported previously. They are benign lesions, frequently presenting radiculopathy, and should be considered in the differential diagnosis in patients with low back pain and radiculopathy.

Spinal synovial cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review

This study is designed based on the retrospective analysis of patients treated in the Neurosurgical Department of two major hospitals and review of the literature. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic lumbar intraspinal synovial cysts. Spinal juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Although the relevant reports in the international literature are increasing, the controversy about conservative versus surgical treatment and the need for concomitant fusion still exists. Data from seven patients (age range 58-69 years, mean age 61 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concomitant local pathology, treatment and results of treatment were recorded. A follow-up of at least 6 months (range 6-48 months) was conducted and results were noted. All patients had back pain, while five also experienced unilateral radicular leg pain and one had bilateral leg pain. One patient had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. No fusion was performed. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. Review of the literature revealed a trend towards surgery, as this is correlated to a more favorable outcome compared with conservative treatment. Fusion should be performed on a case-by-case basis only. Surgery is a safe and effective treatment choice in this increasingly appearing ailment. A prospective, randomized trial should clarify issues under debate.

Lumbar Facet Joint Osteoarthritis: A Review

OBJECTIVES

The facet joints (FJ) can be a potentially important source of symptoms because of the high level of mobility and load forces, especially in the lumbar area. We reviewed the anatomy, biomechanics, and possible sources of pain of the FJ, natural history, and risk factors of lumbar FJ osteoarthritis and briefly reviewed the relevant imaging methods.

METHODS

PubMed and MEDLINE databases (1950-2006) were searched for the key words "facet joints," "zygapophyseal joints," "osteoarthritis," "low back pain," and "spondyloarthritis." All relevant articles in English were reviewed. Pertinent secondary references were also retrieved.

RESULTS

The FJ play an important role in load transmission; they provide a posterior load-bearing helper, stabilizing the motion segment in flexion and extension and also restricting axial rotation. The capsule of the FJ, subchondral bone, and synovium are richly innervated and can be a potential source of the low back pain. Degenerative changes in the FJ comprise cartilage degradation that leads to the formation of focal and then diffuse erosions with joint space narrowing, and sclerosis of the subchondral bone. Because the most prominent changes occur in bone, the best method of evaluation of the FJ is computed tomography. Risk factors for lumbar FJ osteoarthritis include advanced age, relatively more sagittal orientation of the FJ, and a background of intervertebral disk degeneration.

CONCLUSIONS

An up-to-date knowledge of this subject can be helpful in the development of diagnostic techniques and in the prevention of lumbar FJ osteoarthritis and low back pain and can assist in the determination of future research goals.

CT Guided Aspiration of a Cervical Synovial Cyst. Case Report and Technical note

SUMMARY

Synovial cysts are cystic dilations of synovial sheaths with or without anatomical continuity within a joint space that occasionally involve the lumbar spine. Image-guided aspiration has been used successfully in the management of lumbar synovial cysts. Synovial cysts of the cervical spine are rare, tend to present with myelopathic symptoms, and are classically treated using operative intervention.We report a novel approach for cervical synovial cyst aspiration under CT guidance. A 66-year-old woman presented to the clinic complaining of severe pain, tingling, and dysesthesia in her right upper extremity in the C5, C6 and C7 nerve root distribution. MR imaging of her cervical spine showed a synovial cyst within the right C6-C7 neural foramen with significant compression and obliteration of the C7 nerve root. The patient underwent CT-guided aspiration of the cyst using a double needle technique, where one needle was used to open up the epidural space while another aspirated the cyst. This was followed by epidural injection of local anesthetic and steroids. Immediately after injection, the patient experienced complete relief of her right forearm pain, tingling, and dysesthesias. The patient tolerated the procedure well and there were no postprocedure complications. At four year follow-up the patient is free of any symptoms. Image-guided aspiration of cervical synovial cysts is feasible using CT fluoroscopy. Aspiration of these cysts combined with epidural steroid injection can provide long-lasting symptomatic relief in some patients.

The MR Imaging Features and Clinical Correlates in Low Back Pain–Related Syndromes

Several distinct clinical syndromes can accompany low back pain in patients with lumbar spine abnormality. Developmental factors and any superimposed degenerative changes determine the size and configuration of the spinal canal, lateral recess, and neural foramen, and can affect the nerve roots. Somatic or referred pain may develop depending on the involved anatomic site and underlying pathology. Many times, but not always, MR imaging findings correlate with the clinical presentation. Combined analysis of the imaging and clinical findings may provide a more accurate and concise approach to the patient with low back pain.

Microdecompression for lumbar synovial cysts: an independent assessment of long term outcomes

Background

Outcomes of surgical intervention for lumbar synovial cysts have been evaluated in the short and intermediate term. Concerns regarding cyst recurrence, the development of late instability at the involved level, and instability/stenosis at adjacent levels (when concomitant) fusion is performed suggest that long term follow-up is needed. This study aims to fill that void.

Methods

Forty-six patients operated by a single surgeon not involved in the study were followed up long term at an average of 9.7 years (range 5 to 22 years) post-operatively. All patients underwent decompression (+/- concomitant arthrodesis in the presence of associated degenerative spondylolisthesis) using the operative microscope for magnification/illumination. Outcomes were assessed using a customized questionnaire evaluating: relief of pain/claudicant symptoms, numbness/parasthesias, and weakness; as well as late onset low back pain, new radicular symptoms, need for additional surgery, and patient satisfaction. Outcomes in patients with or without fusion were compared as well.

Results

87% of patients noted resolution of their pre-operative pain, numbness, and weakness. 28% of patients developed late onset low back pain. 17% developed late onset radicular symptoms in a new nerve root distribution. 15% required subsequent additional surgery. 89% of patients were satisfied with the surgical outcome. No differences were found for any outcome measure between patients undergoing concomitant fusion and those undergoing decompression alone using the two-sample t-test.

Conclusion

This study provides outcome data at an average of nearly ten years post-operative. This information should allow surgeons to provide realistic expectations for their patients regarding outcomes and should enhance the informed consent and surgical decision-making process.