Synovial cysts of the lumbar spine: CT evaluation

Long-Term Effectiveness of Direct CT-Guided Aspiration and Fenestration of Symptomatic Lumbar Facet Synovial Cysts

BACKGROUND AND PURPOSE

Lumbar facet synovial cysts are commonly seen in facet degenerative arthropathy and may be symptomatic when narrowing the spinal canal or compressing nerve roots. The purpose of this study was to analyze the safety, effectiveness, and long-term outcomes of direct CT-guided lumbar facet synovial cyst aspiration and fenestration for symptom relief and for obviating an operation.

MATERIALS AND METHODS

We retrospectively reviewed the medical records and imaging studies of 64 consecutive patients between 2006 and 2016 who underwent 85 CT-guided lumbar facet synovial cyst fenestration procedures in our department. We recorded patient demographics, lumbar facet synovial cyst imaging characteristics, presenting symptoms, change in symptoms after the procedure, and whether they underwent a subsequent operation. We also assessed long-term outcomes from the medical records and via follow-up telephone surveys with patients.

RESULTS

Direct CT-guided lumbar facet synovial cyst puncture was technically successful in 98% of procedures. At first postprocedural follow-up, 86% of patients had a complete or partial symptomatic response. During a mean follow-up of 49 months, 56% of patients had partial or complete long-term relief without the need for an operation; 44% of patients underwent an operation. Patients with calcified, thick-rimmed, or low T2 signal intensity cysts were less likely to respond to the procedure and more likely to need an operation.

CONCLUSIONS

CT-guided direct lumbar facet synovial cyst aspiration and fenestration procedures are safe, effective, and minimally invasive for symptomatic treatment of lumbar synovial facet cysts. This procedure obviates an operation in a substantial number of patients, even at long-term follow-up, and should be considered before surgical intervention.

Long-term outcomes of percutaneous lumbar facet synovial cyst rupture

OBJECTIVE

To evaluate the therapeutic value, safety, and long-term clinical outcomes of percutaneous lumbar facet synovial cyst (LFSC) rupture.

MATERIALS AND METHODS

Our study was institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant. The study group comprised 71 patients (44 women, mean age: 65 ± 17 years) who underwent CT- or fluoroscopy-guided percutaneous LFSC rupture. The technical success of LFSC rupture, the long-term clinical outcome, including repeat procedures or surgery, and imaging findings on MRI and CT were recorded.

RESULTS

Seventy-nine LFSC ruptures were performed in 71 patients. CT guidance was used in 57 cases and fluoroscopy guidance in 22 cases. LFSC rupture was technically successful in 58 out of 79 cases (73 %). Mean injection volume for cyst rupture was 3.6 ± 2.2 mL and a combination of steroid and anesthetic was injected in all cases. Over a mean follow-up time of 44 months, 12 % of patients underwent repeat cyst rupture, and 46 % eventually underwent surgery, whereas the majority of patients (55 %) experienced symptomatic relief and did not undergo surgery. There was no significant association between a successful outcome and age, sex, level, or size of LFSC (p > 0.1). LFSCs with T2 hypointensity were more likely to require surgery (p = 0.02). There was one complication, a bacterial skin infection that completely resolved following antibiotic therapy.

CONCLUSION

Percutaneous LFSC rupture is an effective and safe nonsurgical treatment option for LFSC. More than half of treated patients were able to avoid subsequent surgery. Therefore, percutaneous LFSC rupture should be considered before surgical intervention.

Microsurgical excision without fusion as a safe option for resection of synovial cyst of the lumbar spine: long-term follow-up in mono-institutional experience

Spinal synovial cysts are cystic dilatations of the synovial membrane that may arise at all levels of the spine. We describe our experience, paying attention to diagnosis, surgical treatment, and long-term follow-up. Between 1995 and 2007, 18 patients were surgically treated. Of these, three patients were excluded from the study because they presented spinal instability at pre-operative assessment. All patients were evaluated pre-operatively with CT, MRI, and dynamic X-rays, and underwent surgery for removal of the cyst by hemilaminectomy and partial arthrectomy. All patients were evaluated with early MRI and had a minimum 2-year follow-up by dynamic X-rays. None of the patients required instrumented fusion due to the absence of radiological signs of instability on the pre-operative dynamic tests. In all patients, there was an immediate resolution of the symptoms, with evidence of complete removal of the cysts on post-operative MRI. At 2-year follow-up, all patients underwent dynamic X-rays and responded to a questionnaire for evaluation of outcome. None of them showed signs of relapse. The gold standard for treatment is surgery, even though other conservative treatment regimens have been proposed. Correct surgical strategy relies on pre-operative assessment of biomechanical stability for deciding whether patients need instrumented fusion during cyst removal. Patients with no instability signs are suitable for hemilaminectomy with partial arthrectomy, preserving 2/3 of the medial portion of the articular facet, because this represents a valid option of treatment with a low risk of complications and a low rate of relapse.

Percutaneous therapy for symptomatic synovial cysts

Synovial cysts have long been known to create radicular pain in the spine, with the clinical effect mimicking a disk herniation. These cysts have traditionally been treated with open surgical therapy. Now a minimally invasive, image-guided approach to treatment is available to relieve this problem, using a simple percutaneous needle stick and injection. This article describes the technical aspects and precautions needed for this intervention.

Lumbar intraspinal synovial cysts: conservative management and review of the world's literature

BACKGROUND CONTEXT

Lumbar intraspinal synovial cysts are an important cause of axial and radicular spine pain. Controversy about nonsurgical versus surgical treatment persists.

PURPOSE

To evaluate the efficacy of nonsurgical management of symptomatic lumbar intraspinal synovial cysts (LISCs).

STUDY DESIGN/SETTING

Retrospective review set in outpatient physiatry office.

PATIENT SAMPLE

Ten patients (8 women, 2 men; average age, 60 years) with LISCs and average symptom duration of 7.9 months.

OUTCOME MEASURES

Numerical pain rating scale (NRS-11), Roland-Morris disability outcome measure, patient satisfaction, and surgery.

METHODS

Patients with LISCs were identified and their charts were reviewed. Those patients whose symptoms correlated with the level of LISC-induced extradural compression were eligible. All patients received conservative care and a fluoroscopic-guided lumbar spine injection. The primary author conducted telephone follow-up.

RESULTS

All 10 patients had unilateral radicular pain. Seven had stable neurologic deficits. Magnetic resonance imaging and computed tomography/myelography, respectively, identified a LISC in 8 and 2 patients. Five patients had cyst aspiration followed by steroid instillation; 5 patients had cyst aspiration followed by a transforaminal epidural steroid injection. Average length of follow-up was 50.4 weeks. Only 1 patient had sustained benefit. One patient had no benefit and refused surgery. Eight patients underwent surgery and had a good result.

CONCLUSION

In our opinion, nonsurgical management in patients with LISC-induced radicular pain does not appear to be as successful as surgery.

Lumbar facet joint synovial cyst: percutaneous treatment with steroid injections and distention--clinical and imaging follow-up in 12 patients

PURPOSE

To determine the imaging characteristics of lumbar facet joint synovial cysts after percutaneous treatment with steroid injections and distention of the cyst and to correlate these findings with the clinical outcome.

MATERIALS AND METHODS

Clinical outcome and imaging findings were retrospectively studied in 12 patients (four men, eight women) aged 45-79 years (mean, 60 years) with a symptomatic lumbar facet joint synovial cyst treated with percutaneous steroid injections. At varying times after the procedure, patients were contacted for clinical follow-up, and repeat imaging was performed to verify the status of the cyst.

RESULTS

Excellent pain relief was achieved in nine (75%) of 12 patients. At follow-up imaging, the cyst completely regressed in six (67%) of these nine patients, partially regressed in two (22%) patients, and was unchanged in one (11%) patient. One (8%) of the 12 patients had transient pain relief, with recurrence of symptoms at short intervals after each of three injections. No pain relief was achieved in two (17%) of 12 patients.

CONCLUSION

Image-guided percutaneous steroid injections are often effective in the treatment of lumbar facet joint synovial cysts and may result in complete regression of the cyst.

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.