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

Outcomes and adverse events for spinal synovial cysts surgical treatment: a systematic review and meta-analysis

BACKGROUND

Spinal synovial cysts (SSCs) are a rare cause of nerve root and spinal cord compression. Surgical excision of SSCs remains the mainstay of treatment in the presence of unremitting symptoms or neurological deficits, but the choice of the surgical approach remains controversial. The goal of this study was to compare clinical outcomes and adverse events associated with traditional approaches (interlaminar or laminectomy/hemilaminectomy) and minimally invasive approaches (microsurgical tubular approaches or endoscopic approaches) for SSCs.

METHODS

Studies reporting surgical management of SSCs were searched in three online databases (PubMed, the Cochrane Library, and Web of Science). This meta-analysis was reported following the PRISMA Statement. It was registered at the International Prospective Register of Systematic Reviews (CRD42021288992). The Cochrane Collaboration's Risk of Bias in Nonrandomised Studies-of Interventions (ROBINS-I) was used to evaluate bias. Extracted research data were statistically analyzed using Stata 16 and SPSS statistics 25.

RESULTS

A total of 22 related relevant studies were included. Meta-analysis revealed no statistically significant difference in dural tear, residual cyst, recurrence, reoperation, and operation time between minimally invasive approaches and traditional approaches (p > 0.05), but minimally invasive approaches had a good functional improvement (p = 0.004). Postoperative length of hospital stays and intraoperative bleeding in traditional approaches were also higher than in minimally invasive approaches (p < 0.05).

CONCLUSION

Based on the available evidence, minimally invasive approaches may be better than traditional approaches in the treatment of SSCs. Minimally invasive approaches had the advantages of improving clinical satisfaction, with a similar complication rate to traditional approaches. Moreover, endoscopic and microsurgical tubular approaches had similar outcomes.

Spontaneous Resolution of Symptomatic Synovial Cysts of the Lumbar Spine: A Comprehensive Review with Two Illustrative Cases

Although lumbar synovial cysts (LSCs) are frequently described in the literature, they are a relatively uncommon cause of low back and radicular leg pain. Furthermore, their spontaneous resolution is an even rarer event. The standard treatment of the lumbar synovial cyst is surgical excision. Spontaneous resolution in the literature is a sporadic event. In our experience, we have had two cases where the lumbar synovial cyst disappeared spontaneously. To date, only nine cases of spontaneous resolution of synovial cysts have been documented in the literature. In this discussion, we highlight a pathology that typically suggests surgical intervention, yet conservative treatment can be a viable alternative. We present two cases of large synovial cysts that were initially scheduled for surgery but ultimately resolved spontaneously without any treatment. While the spontaneous resolution of lumbar synovial cysts is extremely rare, conservative strategies are an option that should not be overlooked. Our cases contribute to the growing body of evidence on the spontaneous regression of symptomatic LSC, potentially enhancing the understanding of the disease's natural progression in the future.

Percutaneous Epidural Neuroplasty for Symptomatic Lumbar Juxtafacet Cysts

Background and Objectives: The term "Juxtafacet cyst" refers to both synovial cysts and ganglion pseudocysts associated with the lumbar facet joint. As conservative treatment for the juxtafacet cyst has a minimal effect, complete excision through surgery is considered the first choice of treatment. In this study, we retrospectively reviewed the clinical outcomes of percutaneous epidural neuroplasty for symptomatic lumbar juxtafacet cysts. Materials and Methods: We conducted a retrospective review of 34 patients with symptomatic juxtafacet cysts who visited a single institute from January 2010 to September 2023. Patients who received conservative treatment for at least 6 weeks but experienced no or insufficient effects were eligible for this study. After neuroplasty, a medical history check and neurological examination were performed during follow-up at 2 weeks, 1 month, 2 months, 3 months, 6 months, and once a year thereafter. Results: The pain improved for all patients to a VAS score of 3 or less immediately after neuroplasty; however, four of those patients (11%) had pain that worsened eventually to the same level as before the procedure and required surgery. The results showed that, regardless of cyst size, in cases with severe stenosis of the spinal canal, the outcome of neuroplasty was poor and often eventually required surgery. The cyst size was not associated with the procedure results. In addition, if the cyst was present at the L4-L5 level, or if diabetes mellitus was present, the likelihood of future surgery was significant (p-value = 0.003). Conclusions: Percutaneous neuroplasty showed a better success rate than other non-surgical treatments. In addition, severe spinal stenosis (Schizas grade C or higher), L4-L5 level, or diabetes mellitus produced a high possibility of surgery due to recurrence.

CT-guided lumbar facet cyst rupture and corticosteroid injection: technique, approach, and procedural and clinical success rates

PURPOSE

To evaluate success rates of computed tomography (CT)-guided lumbar facet synovial cyst (LFC) rupture.

MATERIALS AND METHODS

We retrospectively reviewed all LFC ruptures performed by a single musculoskeletal radiologist with > 10 years of experience, using posterior facet approach and/or direct puncture by ipsilateral/contralateral interlaminar, or transforaminal approach. All patients also received a corticosteroid injection. Rupture rates were calculated, and clinical success rate was determined through medical record review. Pre-procedure magnetic resonance imaging (MRI) images and CT procedure images were also reviewed for LFC and facet joint imaging features that may predict rupture.

RESULTS

There were 37 patients, 17 (46%) female and 20 (54%) male, ages 62 ± 12 (range 39-87) years. Thirty-four (92%) of LFC were successfully ruptured, 17 (50%) by facet approach and 17 (50%) by direct cyst puncture. At least one direct puncture approach was possible in 35 (95%) patients. No MRI or CT LFC or facet joint features predicted cyst rupture. Thirty-one (91%) of patients reported immediate pain relief, and 19 (53%) did not have further intervention for LFC-related pain. Sixteen (84%) of these patients remained pain-free for an average follow-up time period of 28 months. Fourteen (39%) of patients required surgical intervention. There were no complications.

CONCLUSION

Our systematic approach to CT-guided LFC rupture is safe and has high technical and clinical success rates similar to prior studies. Since there are no definitive imaging features that determine rupture success, this procedure can almost always be attempted as a first-line treatment for LFC.

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.

Efficacy of minimally invasive tubular approaches for management of the lumbar spinal synovial cysts: a meta-analysis

The treatment of lumbar spinal synovial cysts (LSCs) which are relatively rare but can cause neurogenic dysfunction and intractable pain has been a controversial topic for many years. Surgical excision of LSCs is the standard treatment for patients in whom conservative treatment options fail. This meta-analysis was undertaken to compare clinical outcomes between minimally invasive approaches using tubular retractors (microscopic vs. endoscopic) and traditional percutaneous approaches for LSCs. Studies reporting surgical management of LSCs were searched in the Cochrane Library, PubMed and Web of Science database. This meta-analysis was reported following the PRISMA Statement, registered in Prospero (CRD42021288992). A total of 1833 patients were included from both the related relevant studies (41 studies, n = 1831) and the present series (n = 2). Meta-analysis of minimally invasive tubular approaches revealed no statistically significant difference in pain improvement, dural tear, residual cyst, recurrence and operation time between minimal groups with traditional groups (p > 0.05). Minimal groups had better Functional improvement of 100% (95% CI 1.00-1.00; p < 0.001, I2 = 75.3%) and less reoperation rates of 0% (95% CI - 0.00-0.00; p = 0.007, I2 = 47.1%). Postoperative length of hospital stay and intraoperative bleeding in minimal groups were also less than traditional groups (p < 0.05). Subgroup analysis revealed endoscopic groups had less operation time (p = 0.004), and there was no significant difference in the rest. For patients with LSCs but without obvious clinical and imaging evidence of vertebral instability, even when preoperative stable grade 1 spondylolisthesis is present, minimally invasive tubular approaches without fusion may provide the best outcome in surgical management.

Lumbar spinal ganglion cyst: A systematic review with case illustration

PURPOSE

Ganglion cysts are benign soft tissue lesions found in joints, most commonly wrists. The incidence for juxtafacet cysts, the condition under which spinal ganglion cysts are categorized, is between 0.06% and 5.8%. Spinal ganglion cysts often arise in the most mobile segment of the lumbar spine, L4-L5. Patients commonly present with pain, radiculopathy, and weakness. Conservative management is used, but surgical resection is the most common treatment modality. We aim to review the literature and present a rare case of an L2-L3 situated spinal ganglion cyst, treated with maximal safe resection.

METHODS

A systematic review of literature was conducted in accordance with PRISMA guidelines. PubMed, Web of Science, and Cochrane databases were queried using Boolean operators and search terms, "spinal ganglion cyst, lumbar ganglion cyst, and lumbar juxtafacet cyst". Presentation, surgical management, and postoperative course of a 29-year-old male with an L2-L3 spinal ganglion cyst are also described.

RESULTS

The search yielded 824 articles; 23 met inclusion criteria. These papers consisted of 27 spinal ganglion cyst cases with disaggregated patient data. 63.0% of patients were male, and 53.4 years (range: 23-86) was the average age at presentation. Mean symptom duration was 1.9 years (range: 3 days-12 years). 70.4% of patients reported complete symptom resolution. 14.8% of cases noted neural foramen involvement.

CONCLUSIONS

Spinal ganglion cysts are benign lesions typically presenting with radiculopathy. Maximal safe resection is an effective treatment modality with low complication rates. Future studies are needed to understand if neural foramen involvement leads to increased symptom severity.

Bilateral Lumbar Facet Synovial Cysts as a Cause of Radiculopathy

Remarkable advancements in endoscopic spinal surgery have led to successful outcomes comparable to those of conventional open surgery with the benefits of less traumatization and postoperative spinal instability. Bilateral lumbar facet cysts are rarely found in the spinal canal. We report a rare case of L4–L5 bilateral lumbar facet cysts compressing the nerve root in a patient who presented with L5 radiculopathy. Endoscopic decompression and removal of the cysts without fusion were performed. Histopathology revealed synovial cysts. Postoperatively, the patient showed a total resolution of symptoms with sustained benefits at the final evaluation. No recurrence of pain and no further segmental instability were observed at the 1-year follow-up.

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.

Surgically managed symptomatic intraspinal lumbar facet synovial cyst outcome of surgical treatment with resection and instrumented posterolateral fusion, a case series

Background

There is controversy regarding the treatment of symptomatic synovial cysts, specifically, the need for a concomitant fusion when surgical resection of the synovial cysts is required. We present a retrospective review of a series of patients treated for symptomatic synovial cysts of the lumbar region during the last 20 years by a single surgeon, analyzing the current available literature.

Methods

Retrospective review. The same surgical technique was applied to all patients. Demographic, clinical, surgical data and synovial cyst recurrence rate were recorded. Postoperative results reported by patients were documented according to the McNab score.

Results

Sixty nine subjects, with mean follow-up of 7.4 years. 62% (43) were female, with a mean 57.8 years at the time of surgery. In 91.3% (63), the primary management was conservative for a minimum period of 3 months. All subjects underwent surgery due to the failure of conservative treatment. The segment most operated on was L4–L5 (63.77%). 91.3% (63) of the sample reported excellent and good and 6 subjects (8.6%) fair or poor results. There was no evidence of synovial cysts recurrence at the operated level.

Conclusion

In symptomatic synovial cysts, it seems that conservative treatment is only effective in a limited number of patients and in the short term. Thus, the recommendation of a surgical indication should proceed as soon as the conservative management fails to result in significant symptom relief. Based on our results, we recommend, together with the resection of the cyst, the instrumentation of the segment to avoid its recurrence and the management of axial pain.

Resection of Lumbar Spinal Facet Joint Cysts and Cerebrospinal Fluid Leakage: Incidence, Prognostic Parameters, and Outcome in a Single-center Series

STUDY DESIGN

Single-center series.

OBJECTIVE

Intraspinal facet joint cysts can lead to nerve root compression symptoms with severe discomfort and disability. Permanent improvement can be achieved by surgical resection of the cyst. However, cerebrospinal fluid (CSF) leakage is a common problem in resection of facet joint cyst.The aim of the study was to investigate the frequency of CSF leak after resection of a joint cyst and to determine predictive factors.

METHODS

A total of 176 consecutive patients underwent surgery for lumbar spinal facet joint cyst in our institution between 1997 and 2018. Patients with a CSF leak were compared with patients without a CSF leak (control group).

RESULTS

CSF leakage occurred in 14 patients (8.0%) In 2 of the cases (14.3%), the CSF leak was recognized only postoperatively, in 12 cases (85.7%), the CSF leak was detected intraoperatively. Despite intraoperative dura repair, 4 of these 12 patients (33.3%) presented with CSF leakage postoperatively. Altogether 6 patients had postoperative CSF leakage. Compared with patients without CSF leak, there were no differences in preoperative symptoms, surgical technique, complications, or postoperative findings. Adhesion of the cyst to the dura mater was present in all 14 patients with CSF leakage (100%), but only 61.7% of the control group ( P <0.005). All patients in the CSF leak group showed an improvement of their preoperative symptoms.

CONCLUSIONS

The rate of CSF leakage in resection of spinal facet joint cyst was 8% in the present study. The occurrence of a CSF leakage was independent of clinical factors, level, or side of the cyst, but significantly correlated to dural adhesion of the cyst.Since neither clinical recovery nor recurrence rates do depend on complete removal of the cyst, aggressive resection of dural adherend parts of the cyst wall should be avoided to prevent CSF leakage.

A Rare T2-T3 Synovial Facet Cyst Causing Progressive Myelopathy

Intraspinal extradural synovial cysts are a rare occurrence at the spinal cord level and thus a rare cause of myelopathy. Synovial cysts usually present in the more mobile lumbar and cervical parts of the spine; however, they may also arise in the thoracic spine. We present a case of a 59-year-old male with a left upper thoracic synovial cyst at T2-3 causing disabling, progressive myelopathy, and an incomplete spinal cord injury syndrome with inability to ambulate. An urgent decompressive laminectomy with bilateral facetectomies, cyst excision, and posterior fusion was performed. Subsequently, the patient recovered full function. Synovial cysts should be considered in the differential diagnosis of progressive thoracic myelopathy. This is only the sixth reported case of a synovial cyst of this kind occurring between the levels of T1 and T7. Urgent surgical decompression is the recommended treatment.

Fluoroscopy-Guided Transfacet Lumbar Epidural Steroid Injection for Symptomatic Synovial Cyst Treatment: A Case Report

We report the case of a patient with a right-sided L4 synovial cyst, which had been causing significant pain, who had a successful transfacet epidural steroid injection to rupture the cyst. Using fluoroscopy, the needle was advanced through the right L4 facet joint and the cyst was ruptured using saline. The needle was then advanced into the epidural space and a transfacet epidural steroid injection was done. The patient's symptoms resolved. Repeat magnetic resonance imaging (MRI) done 2 years later showed no recurrence of the cyst. We discuss the role of transfacet epidural steroid injection in synovial cysts treatment.

Transdural Approach to Resection of Intraspinal Extradural Ventral Cysts in the Lumbar Spine

BACKGROUND

Intraspinal extradural ventral cysts in the lumbar spine can cause back pain and neurological deficits of the lower extremities. For the resection of this type of space-occupying lesion, the transdural approach has not been reported in the literature.

CASE DESCRIPTION

A 66-year-old man presented, suffering from progressive radiation pain of his bilateral lower extremities. Imaging examination revealed a cystic lesion in ventral side of lumbar spinal canal. We conducted the excision of the cyst with the transdural approach. The symptoms of the patient disappeared immediately after the operation and recurrence of the symptoms has not been observed in the 3-month follow-up.

CONCLUSIONS

This operation approach is safe and effective. Compared with the previous surgical approach reported in the literature, by this approach surgeons could achieve less injury, shorter operation time, and the same surgical outcomes in the short term. Therefore, we would like to present this approach to provide an alternative to deal with similar lesions.

Transforaminal Epiduroscopic Laser Ablation for Removal of a Postlaminectomy Synovial Cyst: A Case Report

Background: Synovial cysts rarely occur after a laminectomy and are difficult to detect if there are no symptoms; however, they can cause lower back pain or symptoms of radiculopathy. Various methods are used to treat synovial cysts. Here, we will introduce the first case with treatment using the transforaminal epiduroscopic laser annuloplasty (TELA) system. Case report: A 64-year-old female patient visited the pain clinic with lower back pain and pain radiating from the left lower extremity. An MRI T2 image showed a synovial cyst of facet joint origin at the L4–L5 level; the patient had undergone a laminectomy 10 years ago at the same spinal level. The patient rated the pain an 8 on the numerical rating scale (NRS), and pain was reduced after epidural steroid injection, but symptoms recurred a month later. The cyst ablation was performed using the TELA system with a 1414 nm neodymium-doped yttrium-aluminum-garnet (Nd:YAG) laser, and after the procedure, pain decreased to 4 points immediately and was reduced to 2 points on the NRS after 1 week. Six months after the procedure, the pain level was measured on NRS 2 and cyst was not recurred in the additional MRI. Conclusion: We introduced the TELA system as a noninvasive therapy for treating synovial cysts. Ablation of cystic necks using a 1414 nm Nd:YAG laser could be a method to prevent cyst recurrence, but long-term follow-up and large scale control studies will be needed to verify the effectiveness of this method.

Clinical outcomes with endoscopic resection of lumbar extradural cysts

Background

Lumbar extradural cysts may be associated with sciatica-type back and leg pain. The symptoms of clinical pain syndrome from synovial cysts are sometimes difficult to differentiate from those of lumbar disc herniation or spinal canal stenosis and may be identified to be a pain source when visualized endoscopically. The authors analyzed the clinical outcomes with their endoscopic resection to better establish clinical indications and prognosticators of favorable results.

Methods

Two-year Macnab outcomes, VAS scores, and complications were analyzed in a series of 48 patients treated with the endoscopic removal of extradural cyst encountered during routine transforaminal and interlaminar decompression for foraminal and lateral recess stenosis causing lumbar radiculopathy.

Results

There were 26 female and 22 male patients. The extradural cysts were most commonly encountered at L4/5 level in 26 patients (72.2%) followed by the L5/S1 level in 8 patients (22.2%), and in 2 patients (5.6%) at the L3/4 level, respectively. One patient underwent T9/10 decompression. At minimum 2-year follow-up, all patients were improved. Excellent results according to the Macnab criteria were obtained in 19/48 (39.6%) patients, good in 18/48 (37.5%), and fair in 11/48 (22.9%), respectively. The average preoperative VAS score for leg pain was 8.06±1.57 and reduced at a statistically significant level (P<0.000) postoperatively to 1.92±1.49, and 1.77±1.32 at final follow-up, respectively. The percentage of patients with unlimited walking endurance had improved at a statistically significant level (P<0.0001) from 33.3% preoperatively (16/48) to 81.3% (39/48) postoperatively. One patient had a recurrent disc herniation, and another patient did not improve. Two patients underwent fusion during the follow-up period. Patients with Fair outcomes had a statistically significant association (P<0.001) with facet instability as suggested by axial T2-weighted magnetic resonance imaging (MRI) findings of thickened ligamentum flavum, facet joint hypertrophy, and bright white fluid-filled joint gap of >2 mm.

Conclusions

Endoscopic resection of extradural spinal cysts during routine decompression for symptomatic foraminal and lateral recess stenosis is feasible with favorable clinical outcomes in the majority of patients. Fair outcomes were associated with advanced instability of the involved lumbar facet joint complex.

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.

Is fluoroscopy-guided percutaneous rupture of facet cyst an alternative to surgery? A case report

Lumbar intraspinal synovial cysts (LISCs) are rare cause of the lumbosacral radicular syndrome. Fluoroscopy-guided percutaneous cyst rupture (PCR) is an option in the treatment. This report introduces long-term symptom relief after fluoroscopy-guided PCR of LISC. A 73-year-old patient presented with low back pain radiating to right leg. L5 radiculopathy was suspected by physical examination; however, an intraspinal cystic mass was visualized through imaging studies. The patient reported immediate pain relief after fluoroscopy-guided PCR, which sustained for one year. In conclusion, fluoroscopy-guided PCR appears to be a safe and effective treatment option and should be considered before surgery in patients with LISCs.

[Lumbar synovial cysts: literature review and original long-term results after microsurgical resection]

BACKGROUND

Intraspinal lumbar vertebral joint cysts are an unusual cause of nerve root compression symptoms and do not differ clinically from the symptoms of a herniated disc.

PATHOGENESIS

The cysts originate from the small vertebral joints and, depending on their size, compress the nerval structures. The affected vertebral joints typically show activated arthritic circumstances, which are associated with degenerative spondylolisthesis in about 50% of cases. In the majority of cases, MRT and CT can be used for diagnostic purposes. The exact etiology has not been fully clarified; various factors such as activated arthritis of the vertebral joints appear to be the major cause.

TREATMENT

Treatment options include conservative, semi-invasive and surgical therapy. Conservative and semi-invasive treatment methods lead to temporary improvement. The result of surgical treatment, however, is excellent in a complete resection of synovial cysts. In In rare cases, an initial fusion is necessary in rare cases.

[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.

Bilateral synovial cyst of the thoracic spine causing paraparesis

Spinal synovial cysts are degenerative extradural lesions mostly found in the lumbar region, and more rarely at cervical or thoracic levels and in a bilateral presentation. We report a patient with a history of progressive paraparesis associated with bilateral cervicothoracic synovial cysts, causing spinal canal narrowing and cord compression, ultimately resulting in myelopathy. A review of the literature summarizes previous reports on this topic. Surgical excision of the extradural mass, decompression of the spinal canal and instrumented fusion were performed, improving lower limb deficit and gait. Post-surgical MRI showed evidence of complete cyst resection, and good arthrodesis consolidation with adequate sagittal balance. Surgical excision is indicated in case of medical treatment failure or increasing symptom severity. Given the strong pathophysiological link between synovial cysts and spinal instability, concomitant instrumented fusion may help improve outcome.

The Prevalence of Incidental and Symptomatic Lumbar Synovial Facet Cysts

STUDY DESIGN

This was a retrospective cohort study from 2 affiliated tertiary care referral centers for spine disease.

OBJECTIVE

The purpose of this article was to assess the prevalence of incidental (ie, asymptomatic) and symptomatic lumbar synovial facet cysts on magnetic resonance imaging. Secondarily, we assessed whether the prevalence increases with age. In addition, we assessed differences in patient and cyst characteristics between asymptomatic and symptomatic facet cysts.

SUMMARY OF BACKGROUND

The prevalence of symptomatic and asymptomatic synovial facet cysts in the lumbar spine has been incompletely established, and, although many studies demonstrate an association with degenerative spine disease, no cumulative increase in prevalence of synovial facet cysts with increasing age has been presented.

METHODS

We included 19,010 consecutive patients who underwent a dedicated lumbar spine magnetic resonance imaging between 2004 and 2015. Our outcome measures were symptomatic and asymptomatic facet cysts. A symptomatic cyst was defined as a cyst with symptoms of radiculopathy on the same side as the cyst.

RESULTS

The overall synovial facet cyst prevalence was 6.5% [95% confidence interval (CI), 6.1-6.8]; 46% of the facet cysts were incidental and 54% were symptomatic. Increased age was independently associated with a higher likelihood of having a synovial facet cyst [odds ratio (per 10 y), 1.24, 95% CI, 1.20-1.29; P<0.001]. Large cyst size (odds ratio, 1.64; 95% CI, 1.23-2.20; P=0.001) and anterior location (odds ratio, 1.39; 95% CI, 1.08-1.79; P=0.010) of the synovial facet cyst were the only factors independently associated with having radiculopathy.

CONCLUSIONS

Approximately 1 in 15 patients have at least 1 synovial facet cyst. Having a facet cyst-symptomatic and asymptomatic-is strongly associated with increased age supporting the theory that degenerative disease underlies its development. Large cyst size and anterior location of the cyst are associated with an increased likelihood of having neurological symptoms.

LEVEL OF EVIDENCE

Level III, diagnostic study.

NeuroSpine Surgery Research Group (NSURG) Classification System for Grading Lumbar Synovial Cysts

To classify facet joint cysts (FJC) which will assist in identification of patient groups to best fit with a particular intervention. Sagittal T₂ -weighted magnetic resonance images (MRI) of these patients are used to measure cyst size, while axial T₂ -weighted MRI are used to determine the percentage of the vertebral canal occupied by the cyst. The degree of spondylolisthesis is also measured through standing X-rays or sagittal MRI. The proposed grading system is as follows. Grade I includes cysts that occupy less than 25% of the canal diameter that usually present with unilateral radiculopathy. Grade II includes cysts that occupy less than 50% of the canal diameter and may present with radiculopathy, with or without claudicant symptoms. Grade III cysts may present with radiculopathy and claudication with bilateral leg symptoms, along with facetogenic pain symptoms. Grades IV and V include potential instability as defined by greater than 15% spondylolisthesis in addition to either less than or greater than 50% canal stenosis. With higher grade cysts, presentation may include: facetogenic back pain, radiculopathy and claudicant pain in variable degrees of severity. The optimal classification system grades FJC from I to V on the basis of canal compression and degree of spondylolisthesis. Prospective studies are required to confirm the validity of this grading scale for long-term use.

Comparison of Decompression With and Without Fusion for Patients With Synovial Facet Cysts

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

To compare (1) recurrence of radiculopathy and (2) back pain after decompression with and without fusion for patients with a symptomatic synovial cyst.

BACKGROUND

Previous work described favorable outcomes following cyst excision with and without fusion. Because of the association of facet cysts with spinal instability it is hypothesized that a decompression with fusion will lead to better outcomes. However, previous studies present contradicting results.

METHODS

We included 314 consecutive patients that underwent operative treatment for a facet cyst between 2003 and 2013 at 2 tertiary spine referral centers: 224 (71%) underwent decompression without fusion (35% spondylolisthesis), 90 (29%) underwent decompression with fusion (63% spondylolisthesis). Baseline data were compared between the groups. Bivariate log-rank analysis was used to compare outcomes between groups, followed by multivariable Cox regression analysis accounting for differences in baseline characteristics.

RESULTS

Patients undergoing decompression with fusion presented with a higher incidence of back pain (P=0.004) and spondylolisthesis (P<0.001), had more often bilateral decompressions (P<0.001), more facetectomies (P<0.001), and more levels of decompression (P=0.004) than those who underwent decompression alone. We found a difference in recurrence of radiculopathy (no fusion: 25% vs. fusion: 9.4%, P=0.029) in bivariate analysis. However, this difference did not hold when accounting for confounders (hazard ratio, 0.50, 95% confidence interval, 0.19-1.31, P=0.16). There was no difference in recurrence of back pain in bivariate (no fusion: 29% vs. fusion: 22%, P=0.51) and multivariable analysis (hazard ratio 0.51, 95% confidence interval, 0.23-1.14, P=0.10).

CONCLUSIONS

We found, with the numbers evaluated, no difference in recurrence of radiculopathy or back pain between patients undergoing decompression with or without fusion after accounting for confounders. The decision for fusion should be considered in light of the extent of decompression and the existence of other pathology.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Surgical Treatment of Spinal Synovial Cysts in Elderly Patients: Symptoms, Treatment Course, and Outcome in Patients >75 Years of Age

BACKGROUND

With the aging of our society comes a rising number of elderly patients with progressive degeneration of the spine associated with synovial cysts. Surgical treatment may be particularly challenging in elderly patients because of comorbidities.

METHODS

Patients treated in our department between 1999 and 2014 for spinal synovial cysts were screened. The 28 patients ≥75 years old were classified as elderly and were compared with 96 patients 50-74 years old. No patient underwent fusion as part of cyst resection.

RESULTS

Despite a significantly higher frequency of muscle reflex changes in elderly patients at presentation, symptoms, cyst levels, rate of complications, and surgical method were not different between groups. Cyst adherence to the dura and subtotal resection were observed significantly more often in the elderly group (18% vs. 3%; P < 0.05). Outcome according to the Oswestry Disability Index was classified as no disability or minimal disability in 85% of the elderly group and in 82% of the control group. Recurrent cyst and delayed fusion rates were lower in the elderly group (4% and 4%) compared with the control group (7% and 8%).

CONCLUSIONS

The clinical course of elderly patients with surgical treatment of spinal synovial cysts did not differ compared with younger patients. Good or excellent results could be achieved and persisted for a long time in most cases. Fusion should be performed only in cases of severe instability. Nonaggressive cyst removal in cases of dural attachment enables low cerebrospinal fluid fistula rates without increasing cyst recurrence rates.

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.

Imaging of Degenerative and Infectious Conditions of the Spine

: Imaging is important in the evaluation of patients with degenerative disease and infectious processes. There are numerous conditions that can manifest as low back pain (LBP) or neck pain in a patient, and in many cases, the cause may be multifactorial. Clinical history and physical examination are key components in the evaluation of such patients; however, physical examination has variable sensitivity and specificity. Although studies have demonstrated that uncomplicated acute LBP and/or radiculopathy are self-limited conditions that do not warrant any imaging, neuroimaging can provide clear anatomic delineation of potential causes of the patient's clinical presentation. Various professional organizations have recommendations for imaging of LBP, which generally agree that an imaging study is not indicated for patients with uncomplicated LBP or radiculopathy without a red flag (eg, neurological deficit such as major weakness or numbness in lower extremities, bowel or bladder dysfunction, saddle anesthesia, fever, history of cancer, intravenous drug use, immunosuppression, trauma, or worsening symptoms). Different imaging modalities have a complementary role in the diagnosis of pathologies affecting the spine. In this review, we discuss the standard nomenclature for lumbar disk pathology and the utility of various clinical imaging techniques in the evaluation of LBP/neck pain for potential neurosurgical management. The imaging appearance of spinal infections and potential mimics also is reviewed. Finally, we discuss advanced neuroradiological techniques that offer greater microstructural and functional information.

ABBREVIATIONS

ADC, apparent diffusion coefficientDTI, diffusion tensor imagingDWI, diffusion-weighted imagingDOM, diskitis-osteomyelitisLBP, low back painMRM, magnetic resonance myelographySNA, spinal neuroarthropathySPECT, single-positron emission computed tomographySTIR, short tau inversion recovery.

Should We Label All Synovial Cysts as Unstable?

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the various anatomical parameters that influence segmental stability in patients suffering from lumbar intra spinal cysts (LISCs) and to determine the outcome of microscopic unilateral laminotomy and cystectomy.

METHODS

All patients that were surgically managed for a LISC between 2007 and 2013 with more than 3 years of follow-up were reviewed. Those without associated instability were evaluated for segmental mobility, segmental angulation, facet inclination, stage of disc degeneration, and level of involvement on MRI and dynamic radiographs. Outcomes of unilateral laminotomy and cystectomy were evaluated using VAS (Visual Analogue Score), ODI (Oswestry Disability Index), and Macnabs criteria. Dynamic radiographs were performed in all cases pre- and postoperatively and at the last follow-up.

RESULTS

Thirty patients were operated for a LISC between 2007 and 2013. The levels involved were L4-5(23), L3-4(4) and L5-S1(3). The mean facet angle was 42.6 (± 6.1) degrees. The stage of disc degeneration was scattered haphazardly across all the cases (Gr 2[17]; Gr 3[1]; Gr 4[8]; Gr 5[4]). VAS and ODI scores improved significantly in all patients. Mean follow-up was 46.5 months (36-96 months). No patient developed postoperative instability at the last follow-up.

CONCLUSIONS

The coronal inclination of the facet joints, absence of radiological instability, and poor co-relation with stages of disc degeneration suggests the presence of adequate residual stability. In this study, stand-alone decompression for LISCs without instability had well sustained good/excellent outcomes. Fusion is recommended for LISCs with associated instability.

Lumbar ganglion cyst: Nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review

AIM

To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one.

METHODS

We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability.

RESULTS

The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring.

CONCLUSION

Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms “ganglion cyst” to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.

Synovial cysts of the spine: long-term follow-up after surgical treatment of 141 cases in a single-center series and comprehensive literature review of 2900 degenerative spinal cysts

OBJECTIVE Synovial cysts of the spine are rare lesions, predominantly arising in the lumbar region. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures in the spinal canal. Treatment strategies are still a matter of discussion. The authors performed a single-center survey and literature search focusing on long-term results after minimally invasive surgery. METHODS A total of 141 consecutive patients treated for synovial cysts of the lumbar spine between 1997 and 2014 in the authors' department were analyzed. Medical reports with regard to signs and symptoms, operative findings, complications, and short-term outcome were reviewed. Assessment of long-term outcome was performed with a standardized telephone questionnaire based on the Oswestry Disability Index (ODI). Furthermore, patients were questioned about persisting pain, symptoms, and further operative procedures, if any. Subjective satisfaction was classified as excellent, good, fair, or poor based on the Macnab classification. RESULTS The approach most often used for synovial cyst treatment was partial hemilaminectomy in 70%; hemilaminectomy was necessary in 27%. At short-term follow-up, the presence of severe and moderate leg pain had decreased from 93% to 5%. The presence of low-back pain decreased from 90% to 5%. Rates of motor and sensory deficits were reduced from 40% to 14% and from 45% to 6%, respectively. The follow-up rate was 58%, and the mean follow-up period was 9.3 years. Both leg pain and low-back pain were still absent in 78%. Outcome based on the Macnab classification was excellent in 80%, good in 14%, fair in 1%, and poor in 5%. According to the ODI, 78% of patients had no or only minimal disability, 16% had moderate disability, and 6% had severe disability at the time of follow-up. In this cohort, 7% needed surgery due to cyst recurrence, and 9% required a delayed stabilization procedure after the initial operation. CONCLUSIONS Surgical treatment with resection of the cyst provides favorable results in outcome. Excellent or good outcome persisting for a long-term follow-up period can be achieved in the vast majority of cases. Complication rates are low despite an increased risk of dural injury. With facet-sparing techniques, the stability of the segment can be preserved, and resection of spinal synovial cysts does not necessarily require segmental fusion.

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.

Spontaneous resolution of symptomatic lumbar synovial cyst

Lumbar synovial cyst arises from the facet joint and can lead to back pain, radiculopathy, neurogenic claudication or even cauda equina syndrome. Although most surgeons would consider surgery to be the treatment of choice, the natural history of the disease process remains unknown and uncertainty still exists regarding optimal management of this controversial entity. We illustrate a case of large L5/S1 synovial cyst for which surgery was initially planned. However, it resolved spontaneously without any treatment. We also provide a brief literature review regarding conservative, surgical and minimally invasive management of symptomatic lumbar synovial cyst with special reference to patient outcome.

Minimally invasive surgery for lumbar synovial cysts with coexisting degenerative spondylolisthesis

BACKGROUND

About one third of lumbar synovial cysts are associated with degenerative spondylolisthesis. Segmental instability is thought to contribute to the pathogenesis and recurrence of synovial cysts and lumbar fusion has been advocated as a treatment of choice in the presence of spondylolisthesis. In patients with spondylolisthesis, minimally invasive resection of lumbar synovial cysts, without fusion, could minimize surgically induced segmental instability while providing good pain relief.

METHODS

Clinical and radiological outcomes of lumbar synovial cyst patients with and without spondylolisthesis were retrospectively compared. Pain outcomes were assessed with modified Macnab criteria.

RESULTS

Fifty-three patients (18 with grade 1 spondylolisthesis) underwent minimally invasive synovial cyst resection and all had either excellent or good pain outcome at ≤ 8 post- operative weeks (P = 1.000, n = 53). At > 8 post-operative weeks (mean (SD) follow-up of 200 (175) weeks), excellent or good outcomes were noted in 89% of patients without spondylolisthesis and in 75% of patients with spondylolisthesis (P = 0.425, n = 40). Four patients developed a new grade 1 spondylolisthesis at a mean follow-up of 2.6 ± 2.1 years. Nine patients were assessed for spondylolisthesis measurements at 1.2 ± 1.3 years of follow up and no significant difference was observed (5 ± 0 vs 5 ± 1 mm; P = 0.791). Two patients without spondylolisthesis and none of the patients with spondylolisthesis had a synovial cyst recurrence.

CONCLUSION

Patients with concomitant lumbar degenerative spondylolisthesis and synovial cyst can have good short- and long-term clinical outcomes with minimally invasive surgery without fusion. Post-operative segmental instability does not appear to be significant in patients with spondylolisthesis. All patients included in this article signed an informed consent for the use of their medical information for research.

Lumbar synovial cysts: presentation of a series of 10 cases and literature review

INTRODUCTION

Although they are freqqently described in the literature, lumbar synovial cysts are a relative uncommon cause of low back and radicular leg pain.

OBJECTIVE

To evaluate the treatment and surgical outcomes of the lumbar synovial cysts operated on in our hospital during a 5 year period.

MATERIAL AND METHODS

A retrospective study was conducted on patients surgically treated in our department from August 2009 to September 2014, using a visual analogue scale for the clinical follow-up in the first year after surgery.

RESULTS

After the surgical treatment (surgical removal of the synovial cyst with or without instrumented arthrodesis with transpedicular screws) of 10 patients (5 female and 5 male) with a mean age of 70.2 years (range 50-80), the clinical outcome was satisfactory in 80% of the patients, with the resolving of their symptoms.

CONCLUSIONS

Lumbar synovial cysts have to be considered in the differential diagnosis in patients with low back and radicular leg pain. The majority of the patients are in their sixties and have lumbar degenerative spondylopathy. Nowadays, surgical resection of the lumbar synovial cysts and spinal fusion are the recommended treatment, because it is thought that the increased movement of the spine is one to the causes of the cyst formation. More studies are still needed, hence the relevance of this article.

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.

Juxtafacet Spinal Synovial Cysts

STUDY DESIGN

This was a retrospective study.

PURPOSE

To study the surgical outcome of synovial cysts of the lumbar spine through posterior laminectomy in combination with transpedicular screw fixation.

OVERVIEW OF LITERATURE

Synovial cysts of the lumbar spine contribute significantly to narrowing of the spinal canal and lateral thecal sac and nerve root compression. Cysts form as a result of arthrotic disruption of the facet joint, leading to degenerative spondylolisthesis in up to 40% of patients.

METHODS

Retrospective data from 6 patients, treated during the period of March 2007 to February 2011, were analyzed. All preoperative and postoperative manifestations, extension/flexion radiographs, magnetic resonance imaging, and computed tomography records were reviewed. All underwent surgery for synovial cysts with excision and decompression combined with posterior fixation. The result of surgery was evaluated with Macnab's classification. An excellent or good outcome was considered as satisfactory. Japanese Orthopedic Association Scale was used for evaluation of back pain.

RESULTS

All patients included in this study had excellent outcomes as regarding to improvement of all preoperative manifestations and returning to normal daily activities. Only 2 cases developed postoperative transient cerebro-spinal fluid leak and were treated conservatively and improved during the follow up period.

CONCLUSIONS

Although this study included a small number of cases and we could not have statistically significant results, the good outcome of decompression of synovial cysts combined with posterior fixation and fusion encouraged us to recommend this approach for patients with juxtafacet synovial cysts.

Epiduroscopic Removal of a Lumbar Facet Joint Cyst

Facet joint synovial cysts are usually associated with osteoarthritis of the adjacent facet joint and/or spondylolisthesis. In between the conservative and operative ends of the treatment spectrum lie minimally invasive techniques such as cyst rupture using epiduroscopy. In this report, we describe an 82-year-old male patient presenting with low back pain radiating to his lower left extremity and associated paresthesia. Magnetic resonance imaging of the lumbar spine revealed a synovial cyst at left L4/5 facet joint. Using epiduroscopy, the cyst was mechanically ruptured by popping it with the tip of the scope. The patient remained symptom-free at his successive visits until 12 months after the procedure, and was opened for desired follow up.

Minimally invasive resection of lumbar intraspinal synovial cysts via a contralateral approach: review of 13 cases

OBJECT

The authors sought to determine patient-related outcomes after minimally invasive surgical (MIS) lumbar intraspinal synovial cyst excision via a tubular working channel and a contralateral facet-sparing approach.

METHODS

All the patients with a symptomatic lumbar intraspinal synovial cyst who underwent surgery at the University of Iowa Hospitals and Clinics with an MIS excision via a contralateral approach were treated between July 2010 and August 2014. There was a total of 13 cases. Each patient was evaluated with preoperative neurological examinations, lumbar spine radiography, MRI, and visual analog scale (VAS) scores. The patients were evaluated postoperatively with neurological examinations and VAS and Macnab scores. The primary outcomes were improvement in VAS and Macnab scores. Secondary outcomes were average blood loss, hospital stay duration, and operative times.

RESULTS

There were 5 males and 8 females. The mean age was 66 years, and the mean body mass index was 28.5 kg/m2. Sixty-nine percent (9 of 13) of the cysts were at L4–5. Most patients had low-back pain and radicular pain, and one-third of them had Grade 1 spondylolisthesis. The mean (± SD) follow-up duration was 20.8 ± 16.9 months. The mean Macnab score was 3.4 ± 1.0, and the VAS score decreased from 7.8 preoperatively to 2.9 postoperatively. The mean operative time was 123 ± 30 minutes, with a mean estimated blood loss of 44 ± 29 ml. Hospital stay averaged 1.5 ± 0.7 days. There were no complications noted in this series.

CONCLUSIONS

The MIS excision of lumbar intraspinal synovial cysts via a contralateral approach offers excellent exposure to the cyst and spares the facet joint at the involved level, thus minimizing risk of instability, blood loss, operative time, and hospital stay. Prospective randomized trials with longer follow-up times and larger cohorts are needed to conclusively determine the superiority of the contralateral MIS approach over others, including open or ipsilateral minimally invasive surgery.

Percutaneous Facet Screw Fixation in the Treatment of Symptomatic Recurrent Lumbar Facet Joint Cyst: A New Technique

We present a case of percutaneous treatment of symptomatic recurrent lumbar facet joint cyst resistant to all medical treatments including facet joint steroid injection. Percutaneous transfacet fixation was then performed at L4-L5 level with a cannulated screw using CT and fluoroscopy guidance. The procedure time was 30 min. Using the visual analog scale (VAS), pain decreased from 9.5, preoperatively, to 0 after the procedure. At 6-month follow-up, an asymptomatic cystic recurrence was observed, which further reduced at the 1-year follow-up. Pain remained stable (VAS at 0) during all follow-ups. CT- and fluoroscopy-guided percutaneous cyst rupture associated with facet screw fixation could be an alternative to surgery in patients suffering from a symptomatic recurrent lumbar facet joint cyst.

Percutaneous resolution of lumbar facet joint cysts as an alternative treatment to surgery: a meta-analysis

PURPOSE

A comprehensive review of the literature in order to analyze data about the success rate of percutaneous resolution of the lumbar facet joint cysts as a conservative management strategy.

METHODS

A systematic search for relevant articles published during 1980 to May 2014 was performed in several electronic databases by using the specific MeSH terms and keywords. Most relevant data was captured and pooled for the meta-analysis to achieve overall effect size of treatment along with 95% confidence intervals.

RESULTS

29 studies were included in the meta-analysis. Follow-up duration as mean ± sd (range) was 16±10.2 (5 days to 5.7 years). Overall the satisfactory results (after short- or long-term follow-up) were achieved in 55.8 [49.5, 62.08] % (pooled mean and 95% CI) of the 544 patients subjected to percutaneous lumbar facet joint cyst resolution procedures. 38.67 [33.3, 43.95] % of this population underwent surgery subsequently to achieve durable relief. There existed no linear relationship between the increasing average duration of follow-up period of individual studies and percent satisfaction from the percutaneous resolutions procedure.

CONCLUSION

Results shows that the percutaneous cyst resolution procedures have potential to be an alternative to surgical interventions but identification of suitable subjects requires further research.

Lumbar L4-L5 ganglion cyst with hemicauda equina syndrome. Report of a case and review of the literature

Mostly associated with degenerative facet joints and spondylolisthesis, symptomatic lumbar juxta facet cysts - ganglion and synovial cysts are uncommon lesions of the spine. They can mimic herniated discs, causing low back pain, radiculopathy or even cauda equina syndrome; also some of them are associated with spinal instability. Referring to a case with hemicauda equina syndrome where microsurgical decompression was performed with very good result; alternative treatment solutions are discussed: conservative therapy for symptomatic lesions is often unsuccessful, spinal fusion should be made for those cases with spinal instability, although there are reports of spontaneous resolution of these cysts as well as the symptoms associated with them.