Classification of Lumbar Facet Joint Cysts Using the NeuroSpine Surgery Research Group (NSURG) Grading Score and Correlation with Recurrence and Clinical Outcomes

The effect of integrative Korean medicine treatment on symptomatic lumbar facet joint cysts: A case series

OBJECTIVE

The optimal treatment for facet joint cysts (FJCs) has remained controversial. Despite a higher success rate than the conservative option, surgical treatments may pose risks of postoperative complications and comorbidities may make the surgical approach difficult. Thus, this study reports four cases of pain amelioration and resorption of FJCs through noninvasive integrative Korean Medicine treatment.

METHODS

For intervention, four patients with symptomatic FJCs underwent integrative Korean medicine treatment with acupuncture, herbal medicine, pharmacopuncture, and Chuna manual therapy; after completion of the series of treatment sessions, patients were re-examined with magnetic resonance imaging (MRI).

RESULTS

Pain disappeared within 2 months for all four patients; the amelioration of pain was sustained for more than 6 months. Furthermore, the disappearance of FJCs was confirmed by MRI after a certain period from the time of pain disappearance.

CONCLUSIONS

This study reported the effectiveness of non-invasive, integrative Korean medicine treatment for patients with FJCs; this method shows promise as a conservative treatment option for patients with FJCs.

Percutaneous uniportal full-endoscopic surgery for treating symptomatic lumbar facet joint cysts under local anesthesia combined with monitored anesthesia care: a preliminary report of eight cases with at least 1 year follow-up

Background

Lumbar facet joint cysts (FJCs) are a relatively rare clinical pathology that can result in radiculopathy or neurogenic claudication. Various treatments such as percutaneous aspiration and surgery have been reported to have good clinical outcomes. However, few clinical studies have aimed to treat symptomatic lumbar FJCs by using uniportal full-endoscopic (UFE) surgery. This study aimed to investigate the preliminary clinical outcomes of UFE surgery for the treatment of lumbar FJCs under local anesthesia combined with monitored anesthesia care (MAC).

Methods

Eight patients (five males and three females) with symptomatic lumbar FJCs who underwent UFE surgery under local and MAC anesthesia were enrolled in this study between January 2018 and April 2022. The clinical characteristics, radiological features, operative information, visual analog scale (VAS) score, Oswestry disability index (ODI), and overall outcome rating based on the modified MacNab criteria were retrospectively analyzed.

Results

Of the eight patients, four underwent a transforaminal approach and four underwent an interlaminar approach. Postoperatively, the mean VAS score for leg pain decreased from 6.1 before surgery to 0.6 after surgery, and the ODI decreased from 74.5% to 14.7%. All patients were followed up for more than 1 year, and the good-to-excellent rate based on the modified MacNab criteria remained 100% at the last follow-up. No complications occurred during the follow-up period.

Conclusion

Lumbar FJCs can cause severe radiating leg pain and/or neurogenic claudication due to the dural sac compression and nerve roots. As an alternative treatment, UFE decompression under local and MAC anesthesia may provide effective clinical outcomes for symptomatic lumbar FJCs.

Awake transforaminal endoscopic lumbar facet cyst resection: technical note and case series

OBJECTIVE

The aim of this study was to describe a minimally invasive transforaminal surgical technique for treating awake patients presenting with lumbar radiculopathy and compressive facet cysts.

METHODS

Awake transforaminal endoscopic decompression surgery was performed in 645 patients over a 6-year period from 2014 to 2020. Transforaminal endoscopic decompression surgery utilizing a high-speed endoscopic drill was performed in 25 patients who had lumbar facet cysts. All surgeries were performed as outpatient procedures in awake patients. Nine of the 25 patients had previously undergone laminectomies at the treated level. A retrospective chart review of patient-reported outcome measures is presented.

RESULTS

At the 2-year follow-up, the mean (± standard deviation) preoperative visual analog scale leg score and Oswestry Disability Index improved from 7.6 ± 1.3 to 2.3 ± 1.4 and 39.7% ± 8.1% to 13.0% ± 7.4%, respectively. There were no complications, readmissions, or recurrence of symptoms during the 2-year follow-up period.

CONCLUSIONS

A minimally invasive awake procedure is presented for the treatment of lumbar facet cysts in patients with lumbar radiculopathy. Approximately one-third of the treated patients (9 of 25) had postlaminectomy facet cysts.

High Rate of Revision Surgery After Limited Decompression of Lumbar Facet Cysts

INTRODUCTION

The surgical treatment of lumbar facet cysts has long been debated. Some surgeons elect for limited decompression of such cysts while other surgeons elect for primary decompression and fusion over concerns for recurrence and instability. Previous studies have suggested the rate of revision surgery after facet cyst excision to be as low as 1%, whereas others have reported this rate to be markedly higher. In this study, we examined revision surgery rates and patient-reported outcomes and conducted a radiographic analysis to identify predictors of failure after limited decompression of lumbar facet cysts.

METHODS

A retrospective review of the electronic medical records of patients treated at our institution using the Current Procedural Terminology code 63267 before January 2018 was conducted. The primary outcome measure was revision surgery at the index level for recurrence or instability or a minimum 2-year follow-up without revision surgery. Secondary outcome measures include radiographic assessments of preoperative and postoperative spondylolisthesis and patient-reported outcome measures. Using preoperative MRI studies, an analysis of facet angles at the surgical level was conducted and the presence, location, and amount of facet fluid were calculated.

RESULTS

A total of 162 patients met inclusion criteria. Of these, 93 patients had a minimum 2-year follow-up. Of these, 19 had undergone a revision surgery at the index level for cyst recurrence or instability. The revision rate for this group was 20.4%. The median time to initial revision surgery was 2.2 years. The median time from index operation to last follow-up was 3.8 years. No differences were observed between the groups regarding the presence of preoperative spondylolisthesis, age, sex, body mass index, blood loss, or patient demographics. 60.2% of all procedures were done at the L4-5 level, but this level accounted for 73.7% of primary failures. A radiographic analysis showed facet angle >45° at L4-5 to be associated with risk of failure of primary decompression. The presence and absolute amount of fluid in the facets were not associated with risk of failure at the L4-5 level.

DISCUSSION

Our revision rate of 20.4% is higher than what is commonly reported in the literature. The radiographic analysis shows that at the L4-5 level, a facet angle of >45° is associated with failure of primary decompression.

Five-Year Outcomes After Decompression and Fusion Versus Decompression Alone in the Treatment of Lumbar Synovial Cysts

BACKGROUND

Spinal synovial cysts are acquired, fluid-filled lesions of the facet joint that most commonly occur in the lumbar spine. They are thought to arise from degenerative changes and to result from segmental instability. Although the treatment of these lesions has been studied, the long-term implications and effects of the different strategies for surgical intervention (i.e., decompression and fusion vs. decompression alone) have not yet been elucidated or established.

METHODS

Using an all-payer database with 53 million patient records (MARINER-53), patients with a diagnosis of lumbar synovial cysts were identified. Patients who had undergone lumbar fusion versus laminectomy were matched 1:1 using binomial and gaussian logistic regression models to evaluate the need for future lumbar surgery within 5 years after their index procedure.

RESULTS

No statistically significant differences were noted between the 5-year rates of subsequent intervention, additional laminectomy, or fusion among patients who had undergone index decompression and fusion (n = 51; 10.5%) versus decompression alone (n = 43; 8.8%; P = 0.39). Furthermore, no significant differences were found in the odds of intervention type after index decompression and fusion versus decompression alone (subsequent laminectomy: odds ratio, 0.59; 95% confidence interval, 0.32-1.09; subsequent fusion: odds ratio, 1.14; 95% confidence interval, 0.64-2.02).

CONCLUSIONS

Patient-specific factors and surgeon-patient-shared decision-making should be used when planning interventions for these lesions. However, synovial cysts might not require a fusion procedure for presumed instability. Further investigation is required, using randomized and prospective studies, to further evaluate the effective treatment of this entity.

The Fate of Lumbar Facet Cyst After Indirect Decompression Using Oblique Lateral Interbody Fusion in Degenerative Spondylolisthesis

Favorable clinical outcomes have been reported for oblique lateral interbody fusion (OLIF) for various lumbar degenerative diseases. However, there is only limited evidence on the safety and effectiveness of OLIF in degenerative spondylolisthesis with lumbar facet cyst (LFC), and OLIF is often regarded as a relative contraindication for these patients. The authors prospectively enrolled patients who underwent a single-level OLIF for degenerative spondylolisthesis with LFC to evaluate the morphological changes of LFC and their clinical significance following OLIF. Twenty patients with a mean age of 69.6 years (range, 65-86 years) were enrolled. At 1 week postoperative, 5 (25%) patients had a residual cyst, whereas 15 (75%) patients had completely resolved cysts on magnetic resonance imaging (MRI). No patient had a residual cyst on the 1-year postoperative MRI. Patients with cyst resolution (n=15) on the 1-week postoperative MRI had a larger slip percentage difference on the preoperative dynamic radiograph when compared with patients with no cyst resolution (n=5) (4.7%±2.8% vs 1.3%±0.3%, P=.002). The group with cyst resolution also showed a greater expansion of facet fluid width following OLIF, although this was not statistically significant (1.2±0.7 mm vs 0.7±0.5 mm, P=.098). For both groups, all preoperative clinical scores showed a significant improvement at 1 year after OLIF, but there was no significant difference between the groups at all time points. Preliminary 1-year follow-up results from this prospective series suggest that OLIF can be a useful option for fusion surgery in LFC patients with apparent segmental instability. [Orthopedics. 2021;44(5):306-312.].

Classification and Reliability of Lumbar Facet Cysts Grading Scales

BACKGROUND

The presence of symptomatic lumbar facet cysts has been associated with segmental instability. Given this association, decompression versus decompression with fusion is a frequently debated topic. Multiple grading scales have been devised to identify patients at high risk for development of cyst recurrence; however, there exists no external evaluation of these scales.

METHODS

A retrospective review of 54 patients undergoing initial treatment for lumbar synovial cysts at a single institution over the past 12 years was conducted. Surgical treatment consisted of decompression with cystectomy without fusion. Patients were assessed and classified according to the NeuroSpine Surgery Research Group (NSURG) and Rosenstock Classification systems. Five neurosurgeons reviewed the preoperative magnetic resonance images, and results were classified. Interrater reliability was assessed using both Gwet's AC1 coefficient and Krippendorff's alpha. A 1-way analysis of variance was used to evaluate predictive ability of both classification systems.

RESULTS

In total, of the 54 patients who underwent decompression, 7 had cyst recurrence. Overall cyst recurrence was most common in NSURG grade 2 cysts (3/12, 25%) followed by grade 1 cysts (4/27, 14.8%). Of the NSURG grade 3 and 4 patients, none had cyst recurrence. In the Rosenstock grades the most common recurrence was in grade 3 cysts (1/4, 25%) followed by grade 1 cysts (5/26, 19.2%). Interrater reliability demonstrated good reproducibility on Gwet's AC1 and Krippendorff's alpha on both grading scales. Neither score was predictive of cyst recurrence (P > 0.05).

CONCLUSIONS

The Rosenstock and NeuroSpine scores demonstrate good overall interrater reliability but are inconsistent in their ability to predict recurrence of lumbar facet cysts.

Comparison of Decompression versus Decompression and Fusion for Lumbar Synovial Cysts and Predictive Factors for Cyst Recurrence

BACKGROUND

The management of lumbar synovial cysts (LSC) has been a controversial topic for many years. Whereas many authors label LSC as markers of instability and thus necessitating fusion, others suggest that decompression alone without fusion is a viable initial treatment option. Our objective was to clarify outcomes in patients undergoing decompression alone and decompression with fusion for symptomatic LSC and identify factors for cyst recurrence.

METHODS

A retrospective case series was performed of all patients undergoing initial treatment for LSC at a single institution ranging from January 1999 to February 2020. Surgical treatment included either decompression with cystectomy or decompression with cystectomy and a fusion procedure. Preoperative symptoms were collected and included radicular pain, motor deficits, sensory deficits, or bowel/bladder changes. Radiographic data were calculated individually and confirmed with radiology reports. Categorical variables were assessed using χ² analysis and continuous variables were assessed with the 2-sample t test.

RESULTS

In total, 161 patients were identified as presenting with symptomatic LSC. Of these, 104 patients underwent decompression alone versus 57 who underwent decompression and fusion. In the decompression group 11 patients required reoperation at the level of the cyst compared with none in those undergoing fusion as their initial procedure (10.5% vs. 0%, P = 0.012). On subgroup analysis of those undergoing decompression as their initial procedure, patients with cyst recurrence demonstrated a statistically significant greater coronal facet inclination angle compared with those without cyst recurrence (52.4° vs. 40.6°, P = 0.02).

CONCLUSIONS

Decompression alone is a reasonable choice for the initial management of LSC, although it does carry a significant risk of same-level reoperation due to cyst recurrence and spondylolisthesis. Preoperative coronal facet inclination angle may be a useful measurement in predicting cyst recurrence following decompression.

An Unusual Case of Radicular Pain Caused by Bilateral Lumbar Synovial Cyst: A Case Report and Review of the Literature

Introduction

Spinal synovial cysts (SSCs) constitute an uncommon degenerative lesion of the spine. They are usually asymptomatic but they may also cause symptoms of variable severity. SSCs are benign growths adjoining the facet joints that may induce low back pain, lumbar radiculopathy, and neurological deficit. There are different treatment options that range from conservative management to interventions like image-guided epidural steroid injection or direct cyst puncture and finally to open or endoscopic spinal canal decompression and spinal bone fusion with/without instrumentation. A discussion of current management options for this unusual disease is presented. Material and Methods. A 52-year-old female patient presented with low back pain and left leg pain. Plain radiography demonstrated instability at the L4-L5 level. Magnetic resonance images (MRIs) revealed a bilateral cystic lesion at the L4-L5 level with associated instability and degenerative disc disease at the level L5-S1. Initially, conservative treatment was performed by aspiration of the left cyst and infiltration with corticosteroids with improvement of the pain for 1 year. After this period, the radicular and the low back pain reoccurred.

Results

Following leg pain recurrence, a hybrid L4-S1 fusion was performed. After surgery, there was clinical improvement and six months later, the patient returned to daily activities. The radiological study after five-year follow-up shows adequate implant position, without signs of loosening, compatible with solid fusion.

Conclusion

After reviewing the literature, the optimal management for patients with symptomatic lumbar synovial cyst must be very individualized, which is essential to achieve a favorable outcome.

New classification of facet joint synovial cysts

PURPOSE

Facet cysts develop due to degeneration of the zygapophyseal joints and can lead to radiculopathy and neurogenic claudication. Various surgical options are available for facet cyst excision. The aim was to facilitate surgical treatment of lumbar facet cysts based on a new classification.

METHODS

We retrospectively analyzed all patients of the last 10 years in whom a facet cyst was surgically removed (ipsilateral laminotomy, contralateral laminotomy, and segmental fusion). Several radiological parameters were analyzed and correlated with the patients' outcome (residual symptoms, perioperative complications, need for re-operation, need for secondary fusion, facet cyst recurrence).

RESULTS

One hundred eleven patients (55 women; median age 64 years) could be identified. Thirty-three (48%) of 69 cases, for which MRI data were available, were classified as medial facet cyst (compressing the spinal canal), 6 facet cysts were localized intraforaminal (9%) and 30 cases (43%) mediolateral (combination of both). The contralateral approach had the lowest rate for revision surgery (7.5%, p = .038) and the lowest prevalence of residual complaints (7.5%, p = .109). A spondylolisthesis and a higher/steeper angle of the facet joints were associated with poorer patient outcome.

CONCLUSIONS

Lateral facet joint cysts are best resected by a contralateral approach offering the best outcome while medial cysts are suitable for removal by an ipsilateral laminotomy. The approach of mediolateral cysts can be determined by the width of the lamina and the angle of the joint. Segmental fusion should be considered in cases with detected spondylolisthesis and/or steep facet joints.

The Variability of Lumbar Facet Joint Synovial Cyst Recurrence Requiring Revision Surgery After Decompression-only and Decompression/Fusion

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to evaluate lumbar spine synovial cyst recurrence rates of decompression-alone versus decompression/fusion procedures.

BACKGROUND

Improvements in imaging modalities allow for increased diagnosis and surgical treatment of symptomatic spinal juxtafacet synovial cysts. Conservative management may be used as a first-line management strategy, however rarely provides durable, effective relief of symptoms. Surgical treatment of spinal synovial cysts ranges from decompression and cyst excision to decompression with fusion procedures. Decompression procedures alone have a higher risk of recurrence of spinal synovial cysts.

METHODS

We retrospectively reviewed 87 patients undergoing surgical treatment of lumbar spinal juxtafacet synovial cysts as a single institution over 20 years. Surgical treatment consisted of either decompression versus decompression/fusion procedures. Preoperative symptoms included back pain, radiculopathy, motor deficits, or sensory deficits. The incidence of recurrence of spinal synovial cysts at the same-site or differing sites was compared between 2 categories of surgical treatment. Revision surgical procedure rates were also evaluated.

RESULTS

A total of 55 (63%) patients were treated with an index decompression-only procedure for the lumbar spinal synovial cyst compared with 32 (37%) patients treated with an index decompression and fusion procedure. Fifty-eight (68%) of the lumbar spinal cysts occurred at the L4-L5 level. There were 10 (11.5%) spinal synovial cyst recurrences in the decompression-only group, and 0 recurrences in the decompression/fusion group. Revision decompression procedures were performed in 4 of the 10 (4.6%) recurrences, and 6 of 10 (6.9%) recurrences had subsequent decompression and fusion surgery. The mean time to recurrence was 23.9±17.3 months. The mean length of follow-up was 65.1±48.6 months. Both recurrence and nonrecurrence cohorts had significant symptomatic improvement using Odom criteria.

CONCLUSIONS

Decompression and cyst excision was the more common surgical treatment of lumbar spinal synovial cysts compared with decompression/fusion procedure in our study. The rate of synovial cyst recurrence and revision surgery in patients undergoing index decompression was relatively low and comparable to current literature. Symptomatic improvement of patients undergoing decompression versus decompression/fusion was similar in our study. Although the fusion may be required for the extent of pathology or coexisting instability, decompression and excision of spinal synovial cysts provide durable, effective treatment with a known, appropriate risk of recurrence and subsequent revision surgery.

[Minimally invasive resection of spinal synovial cysts: Technical note]

Objetivo:

Presentar el algoritmo de tratamiento, técnica quirúrgica y resultados de una serie de pacientes con quistes sinoviales espinales resecados con técnica mínimamente invasiva (MIS).

Introducción:

Los quistes sinoviales espinales se originan a partir de la dilatación y potencial ruptura de la vaina sinovial de una articulación facetaria, la resección quirúrgica es considerada el tratamiento de elección en pacientes sintomáticos. La utilización de técnicas MIS podrían disminuir la disrupción de la faceta articular comprometida reduciendo el riesgo de inestabilidad postoperatoria.

Material y métodos:

Se evaluaron retrospectivamente 21 pacientes con quistes sinoviales espinales operados mediante abordaje y descompresión MIS, se analizaron los signos, síntomas, tiempo quirúrgico, estadía hospitalaria, evolución y complicaciones. Se utilizó la escala visual analógica (EVA), para evaluar el dolor y la escala de Weiner y los criterios de Macnab modificados para medir la satisfacción posoperatoria del paciente.

Resultados:

Se trataron quirúrgicamente 21 pacientes (13 mujeres, 8 hombres), el 76,2% (n = 16) de los pacientes de la serie no requirió artrodesis, el 23,8% (n = 5) restante fue fusionado. Realizamos 13 (61,9%) hemilaminectomías contralaterales, 7 hemilaminectomías ipsilaterales (33,3%) y una laminectomía en el QS S1-S2 con técnica MIS. El seguimiento promedio fue de 26 meses, el tiempo de cirugía fue de 150,33 ± 63,31 min., con una estadía hospitalaria de 2,5 ± 1,78 días. La EVA disminuyó de 8,3 preoperatoria a 2,3 postoperatoria. Siguiendo la escala de Macnab; 16 pacientes refirieron resultados excelentes, 4 buenos y 1 regular, el 95,2% de los pacientes percibió que el procedimiento tuvo mucho/bastante éxito según la escala de Weiner.

Conclusión:

El abordaje mínimamente invasivo es un procedimiento seguro y eficaz para la resección completa de quistes sinoviales espinales. Proporciona resultados clínico-funcionales excelentes preservando músculos, ligamentos y facetas articulares.