Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy

Can acute radiculopathy be caused by upper lumbar hemorrhagic synovial cyst spinal compression in the elderly?

Introduction and importance

Acute radiculopathy caused by upper lumbar synovial cysts is rare. They generally present with a slow development of symptoms resulting from spinal canal involvement. Intracyst hemorrhagic synovial cysts are extremely uncommon and can manifest as radicular pain, radiculopathy or even cauda equina compression syndrome.

Case presentation

A 71-year-old woman with acute back and radicular leg pain presented with worsening symptoms after receiving 1 week of therapy to the left lower limb without trauma. Magnetic resonance imaging (MRI) showed a hemorrhagic synovial intracyst at L2-L3 on the front of the left inter-facet joint which was identified as the cause of the acute back pain and radiculopathy which required surgical removal. Post-surgery, the patient followed the rehabilitation program instructions and attended all scheduled follow-up visits. The patient was asymptomatic at the one-year follow-up.

Clinical discussion

Synovial cysts are commonly associated with degenerative changes that occur with aging, although the specific cause is unknown. Surgical removal of an upper lumbar synovial cyst gives better results than non-surgical treatments if the symptoms persist or recurrent.

Conclusion

For recurrent symptomatic upper lumbar spine synovial cysts (L2−L3), surgery is usually the best option. Surgical removal of an upper lumbar synovial cyst can result in full relief of acute symptoms and reduction of neurologic deficits.

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Intracyst hemorrhagic synovial cysts in the upper lumbar spine are extremely uncommon.

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Synovial cysts can manifest as radicular pain, radiculopathy or even cauda equina compression syndrome.

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Surgical removal of upper lumbar synovial cysts gives better results than non-surgical treatments.

Synovial facet joint cysts after lumbar posterior decompression surgery

OBJECTIVE

Numerous studies have reported on synovial facet joint cysts of the spine as a primary lesion. The exact pathogenesis of those cysts is still controversial, but degeneration and destabilization seem to be underlying mechanisms. However, only a few reports have thus far investigated synovial cysts of the spine as postoperative complications of decompression surgery. In this retrospective clinical study, the authors focused on synovial cysts of the lumbar facet joints as complications after lumbar decompression surgery, with the aim of elucidating their pathophysiology.

METHODS

A total of 326 patients with 384 segments treated with posterior decompression surgery without fusion were included in the study. Of these segments, 107 were surgically decompressed unilaterally and 277 were decompressed bilaterally. After surgery, 18 of the 384 segments developed a complication of symptomatic facet synovial cyst. The anatomical and morphological evaluations of these segments were performed using functional plain radiographs, CT scans, and MR images.

RESULTS

All of the 18 segments with postoperative lumbar facet synovial cyst were treated with bilateral lumbar posterior decompression. There was no significant radiological lumbar spinal instability in any segments, although 17 of 18 segments demonstrated facet articular spondylotic changes. Moreover, 12 of 18 patients demonstrated lumbar retrolisthesis in the neutral position.

CONCLUSIONS

Based on the authors' results, they propose that patients with lumbar degenerative disease who have a potential biomechanical lumbar instability such as disruption of the facet articular surface and hydrarthrosis or lumbar facet tropism might have a high risk for formation of lumbar facet synovial cyst after bilateral posterior decompression surgery.

Facet joint cyst haematoma: a rare cause of cauda equina syndrome

Facet joint cysts are a feature of lumbar spondylosis and are an uncommon cause of radiculopathy. Facet joint cyst haematoma is a very rare entity and has previously been reported as a subacute cause of leg pain, back pain, sensory deficit and lower limb weakness. We present the unique case of facet joint cyst haematoma presenting as cauda equina syndrome. An 81 year old lady presented with a 7 day history of back pain and left foot drop, a 1 day history of perineal numbness and urinary retention with absent rectal tone, perianal anaesthesia and left leg hypoaesthesia. Emergency MRI scan demonstrated spinal canal stenosis as the aetiology of her cauda equina syndrome. She was taken to theatre for emergency lumbar decompression. At operation a facet joint haematoma compressing the cauda equina was found and extirpated with complete resolution of symptoms. In this case, the aetiology of cauda equina compression was not demonstrated effectively on pre-operative MRI scanning.

Hemorrhagic Lumbar Synovial Cyst after Microscopic Discectomy

Intraspinal synovial cysts are rare but they are being documented with increasing frequency due to improvements in radiological imaging. However, hemorrhage into synovial cysts is uncommon, and affected patients may present with acute onset radiculopathy. This type of hemorrhage is known to result from rupture of fragile neoangiogenic vessels in the cyst wall, due to a traumatic event or anticoagulant therapy. Here, the authors present a rare case of hemorrhagic lumbar synovial cyst caused by spinal instability after microscopic discectomy. To the best of the authors’ knowledge, this is the first report of hemorrhagic lumbar synovial cyst caused by spinal instability following microscopic discectomy in the absence of a traumatic event or anticoagulant therapy. We discuss the pathophysiological mechanism of this uncommon entity and provide a review of the literature.

Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature

A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications.

Haemorrhagic lumbar juxtafacet cyst with ligamentum flavum involvement

Juxtafacet cysts are an uncommon cause of radiculopathy. They occur most frequently in the lumbar region, and their distribution across the spine correlates with mobility. Haemorrhagic complications are rare and may occur in the absence of any provocation, although there is some association with anticoagulation and trauma. We present a case of acute radiculopathy due to an L5/S1 juxtafacet cyst with unprovoked haemorrhage which was found to extend into ligamentum flavum. The patient underwent uncomplicated microscope assisted decompression with excellent results. The demographics, presentation, aetiology, and management of juxtafacet cysts are discussed.

Histopathological findings of hemorrhagic ganglion cyst causing acute radicular pain: a case report

Although juxtafacet cysts of the lumbar spine are being reported with increasing frequency, hemorrhage from a ganglion cyst is rare, and the pathophysiologic mechanism of the hemorrhage from the cyst is still unclear. A 75-year-old male presented with sudden radicular leg pain caused by hemorrhage from the ganglion cyst. Computed tomography revealed bony erosion of vertebral body and multiple punched-out lesions on facets. Magnetic resonance imaging showed the neural structure was compressed by a sharply delineating mass. Capsule and old hematoma with elastic consistency that extended to the epidural space were removed through a paramedian transforaminal approach, which led to the resolution of the patient's symptoms. Histopathologically, chronic inflammation with neovascularization and myxoid degeneration were present in the capsule. Alcian blue staining demonstrated the mixture of mucin and hematoma. The probable pathogenesis of hemorrhage from the cyst was discussed from the unique histopathological findings of surgical specimen.

Intradural intraneural hemorrhagic cyst resulting in progressive cauda equina syndrome after anticoagulation therapy

STUDY DESIGN

Case report.

OBJECTIVE

To report a case of lumbar intraneural hemorrhagic cyst after anticoagulation therapy that caused progressive radiculopathy and cauda equina syndrome. The possible pathogenic mechanism, associated diseases, and treatment options are discussed.

SUMMARY OF BACKGROUND DATA

Various pathological processes can cause progressive cauda equina syndrome. However, there have been no reports of progressive cauda equina syndrome due to compression from an intraneural hemorrhagic cyst after anticoagulation therapy.

METHODS

A case of lumbar intradural intraneural hemorrhagic cyst with progressive cauda equina syndrome after anticoagulation therapy is presented.

RESULTS

A 42-year-old-female patient complained at presentation of progressive bilateral lower extremity radiating pain, numbness, and urinary difficulty during the previous 2 months. Lumbar magnetic resonance imaging revealed an L1 cystic lesion with marked mass effect on the surrounding nerve roots. Complete drainage and excision of the lesion was performed, which resulted in excellent postoperative symptoms relief. Pathological examination revealed no definite neoplastic process except some nerve fibers with hemosiderin stain along the cyst wall. On the basis of a combination of intraoperative findings and pathology, an intradural intraneural hemorrhagic cyst that developed after systemic anticoagulation therapy was diagnosed.

CONCLUSION

This is the first report of an intradural intraneural hemorrhagic cyst causing progressive cauda equina syndrome due to anticoagulation therapy. Surgical excision of the cyst is the definite treatment of choice.

LEVEL OF EVIDENCE

N/A.

Synovial cysts of the lumbar spine

BACKGROUND AND PURPOSE

Synovial cysts of the spine occur most frequently in the lumbosacral region. Methods of treatment vary, but in cases of chronic pain or neurological deficits surgical intervention is undertaken. The aim of this paper is to present indications, surgical technique and efficacy of surgical treatment in patients with synovial cyst of the spinal canal.

MATERIAL AND METHODS

The retrospective analysis included 11 patients, aged from 47 to 72 years, treated at the Department of Neurosurgery and Neurotraumatology, Poznan University of Medical Sciences, between 2004 and 2009. The length of medical history ranged from 2 months to 6 years. Conservative treatment applied before surgery was not effective. Neurological examination revealed unilateral or bilateral sciatica, superficial sensory disturbance or lower limb paresis.

RESULTS

Synovial cysts were located mainly at the L4-L5 level (9 cases). Magnetic resonance imaging (MRI) of the spine was performed in all patients and showed the cystic lesion attached to the intervertebral joint. Surgical treatment consisted of a unilateral fenestration using microsurgical techniques in most cases. Back pain relief was observed in 9 cases. In 10 patients, symptoms of sciatica disappeared. Neurological deficits disappeared in 5 patients.

CONCLUSIONS

Surgical treatment of spinal synovial cysts is safe, effective and ensures a long-lasting effect. Surgical treatment is indicated in patients in whom the clinical symptoms correlate with the presence of synovial cyst in imaging studies and do not resolve after conservative treatment.

Subaxial cervical juxtafacet cysts: single institution surgical experience and literature review

OBJECTIVES

Juxtafacet cysts (JFCs) of the subaxial cervical spine are rare causes of neurological deficits. Their imaging characteristics, relationship to segmental instability, and potential for inducing acute symptomatic deterioration have only been described in a few case reports and small case series. The objective of the current study was to review the surgical experience at our center and across the literature to better define these variables.

METHODS

A single-institution, multisurgeon series of 12 consecutive patients (mean age 63.4 years, range 52-83 years) harboring 14 JFCs treated across 9 years was retrospectively reviewed. Clinical history, neurological status, preoperative imaging, operative findings, pathology, and postoperative outcomes were obtained from medical records. The mean follow up was 9.2 ± 7.8 months. A literature review identified 35 studies with 89 previously reported cases of surgically treated subaxial cervical JFCs.

RESULTS

Consistent with previously reported cases, most JFCs in our series involved the C7/T1 level. Nine patients reported axial neck pain, 12 patients had radicular symptoms, four patients had myelopathy, and one patient experienced rapid neurological decline attributable to cystic hemorrhage. Cyst expansion without hemorrhage caused subacute deterioration in one patient. All patients experienced sensory and/or motor improvement following surgical decompression. Preoperative axial neck pain improved in eight of nine patients (89 %). Seven out of 12 patients (58 %) underwent fusion either at the time of decompression (six patients) or at a delayed timepoint within the follow-up period (one patient). Prior history of cervical instrumentation, hypermobility on dynamic imaging, and other risk factors for segmental instability were more common in our series than in previous reports.

CONCLUSIONS

Our findings lead us to advocate for early decompression rather than prolonged conservative treatment, for pre- and postoperative dynamic imaging, and for fusion in selected cases as an initial surgical consideration.

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.

Spontaneous hemorrhage in an upper lumbar synovial cyst causing subacute cauda equina syndrome

Lumbar spine synovial cysts are becoming more frequent, and they are generally associated with degenerative lumbar spinal disease. They are common in lower lumbar lesions but rare in upper lumbar lesions. Several cases of hemorrhage into lower lumbar juxtafacet cysts after trauma or anticoagulation therapy have been reported in the literature. This article describes a case of subacute cauda equina syndrome resulting from spontaneous hemorrhage into an upper lumbar synovial cyst. A 65-year-old man presented with a 3-month history of intermittent bilateral lumbar pain. One week before, he experienced a sudden exacerbation of lumbar pain and began falling frequently; he also reported weakness and tingling in his lower limbs. A hematic collection associated with a large juxtafacet cyst at L2-L3 was suspected on magnetic resonance imaging. He underwent surgical decompression, and the cyst was resected. Microscopic examination was consistent with the diagnosis of a synovial cyst. Two days postoperatively, he was walking independently. Although several descriptions exist of hemorrhagic lumbar juxtafacet cysts after trauma or anticoagulant therapy, to the authors' knowledge, this is the first documented case of hemorrhage in an upper lumbar synovial cyst with no previous traumatic event or medication use. Magnetic resonance imaging was essential in making the preoperative diagnosis. Surgical removal of the cyst was an effective treatment.

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.

Factors associated with recurrent back pain and cyst recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of one hundred sixty-seven consecutive cases

STUDY DESIGN

Retrospective study.

OBJECTIVE

Compare outcomes of different treatment methods for intraspinal synovial cysts.

SUMMARY OF BACKGROUND DATA

Intraspinal synovial cysts are cited as an increasing cause of back pain and radiculopathy. To date, few studies have compared outcomes of differing treatment methods in patients with synovial cysts.

METHODS

We retrospectively reviewed 167 consecutive patients undergoing surgical management of 195 symptomatic synovial cysts at a single institution over 19 years. The incidence of postoperative mechanical back pain, radiculopathy, and cyst recurrence was compared between patients undergoing unilateral hemilaminectomy (n = 51), bilateral laminectomy (n = 39), facetectomy with in situ fusion (n = 18), and facetectomy with instrumented fusion (n = 56).

RESULTS

A total of 155 (97.5%) patients presented with radiculopathy, 132(82.5%) with mechanical back pain, 31 (20%) with neurogenic claudication, and 5 (3.2%) with bladder dysfunction. Most cysts occurred in the lumbar spine. After surgery, back and radicular pain improved in 91.6% and 91.9% patients, respectively. By a mean follow-up of 16 +/- 9 months, 36 (21.6%) patients developed recurrent back pain, 20 (11.8%) recurrent leg pain, and 5 (3%) recurrent synovial cysts. Patients undergoing laminectomy had a significantly increased cyst recurrence incidence compared to fusion groups via log-rank test (P = 0.042), and this risk was decreased to baseline with instrumented fusion on reoperation. Laminectomy was also associated with the highest increased risk of recurrent back pain in both log-rank test (P = 0.018) and proportional hazards regression (HR): 1.64 (1.00-3.45), P = 0.05. Instrumented fusion had the lowest risk for back pain recurrence.

CONCLUSION

Hemilaminectomy or laminectomy remains one of the mainstay surgical treatments for symptomatic intraspinal synovial cysts. Our experience shows that the majority of patients undergoing decompression/excision of synovial cysts will have immediate improvement in back and leg pain. However, within 2 years, patients receiving hemilaminectomy or laminectomy alone have an increased incidence of back pain and cyst recurrence. Decompression with instrumented fusion appears to be associated with the lowest incidences of cyst recurrence or back pain.

Facet cyst haematoma in the lumbar spine: a report of four cases

We present 4 cases of facet cyst haematoma in the ligamentum flavum of the lumbar spine. All patients presented with a one-to-3-month history of back pain or numbness in the legs, and sudden neurological deterioration. One also developed cauda equina syndrome and another developed radiculopathy. In all cases, magnetic resonance imaging showed a mass with high signal intensity on both T1- and T2-weighted images. Facet arthrography and computed tomography revealed communication between the mass and the neighbouring facet joint. The haematomas were removed en bloc with the ligamentum flavum. They were surrounded by the ligament and contained degenerated and lacerated elastic fibres but no synovial lining cells. Facet cyst haematoma is so-named because of bleeding from tissue adjacent to the facet joint into a pre-existing facet cyst.

Spontaneous hemorrhage in a lumbar ganglion cyst

STUDY DESIGN

Case report.

OBJECTIVE

To describe a case of a subacute radiculopathy resulting from a spontaneous hemorrhage into a lumbar ganglion cyst.

SUMMARY OF BACKGROUND DATA

Ganglion and synovial cysts of the lumbar spine are becoming more frequent, and they are generally associated with degenerative lumbar spinal disease. Few cases of hemorrhage into lumbar juxtafacet cysts after trauma or anticoagulation therapy have been described in the literature.

METHODS

A case of a spontaneous hemorrhage in a lumbar ganglion cyst is presented.

RESULTS

A 61-year-old man presented with a 2-month history of intermittent bilateral lumbar ache. Eight days before admission he had a sudden exacerbation of the lumbar pain and began to fall frequently and noticed weakness and tingling in his lower members, mainly in the right leg. Magnetic resonance imaging scan revealed a hematic collection associated with a large juxtafacet cyst at the L4-L5 level. He was submitted to surgery and the cyst was totally removed. Microscopic examination was consistent with the diagnosis of a ganglion cyst. Two days after surgery he had already an independent gait.

CONCLUSION

Although, there are a few descriptions of hemorrhagic lumbar justafacet cysts after trauma or anticoagulant therapy, this is the first case of a hemorrhagic ganglion cyst with no previous traumatic event or use of medication. Magnetic resonance imaging was essential for making the preoperative diagnosis. Neurosurgical cyst removal proved to be an effective treatment.