Intraspinal synovial cysts. Magnetic resonance evaluation

Effectiveness and Safety of CT-Guided Facet Joint Cyst Rupture for Radicular Pain as First Choice Therapy: A Retrospective Analysis

OBJECTIVE

To evaluate effectiveness and safety of computed tomography (CT)-guided cyst rupture with intraarticular contrast-enhanced injection of steroid and local anesthetic as first choice therapy in patients with facet joint cyst-induced radicular pain.

DESIGN

Retrospective data set analysis.

SETTING

University hospital.

SUBJECTS

One hundred and twenty-one patients suffering from radicular pain attributable to facet joint cysts were included.

METHODS

The rate of patients without following surgery was assessed and defined as surrogate to measure effectiveness. Patients' characteristics, procedure-associated complications, technical aspects, and imaging findings on magnetic resonance imaging (MRI) were analyzed. A subgroup of 65 patients (54%) underwent telephone interview to assess pain relief and clinical outcome measured by Numeric Rating Scale and Oswestry Disability Index. Analyses between the groups with and without surgery were performed by Fisher exact test and two-sample unpaired t-test, respectively.

RESULTS

The effectiveness of CT-guided cyst rupture was found to be 66.1%. Procedure-induced pain yielded in premature abort in two cases (1.7%). The detection of epidural contrast agent was statistically significantly associated with no need for surgery (P = .010). The cyst level was associated with the status of following surgery (P = .026), that is, cysts at lower lumbar spine were easier to rupture than cysts at other locations (cervical, thoracic, or upper lumbar spine). No further significant association was found.

CONCLUSIONS

CT-guided cyst rupture as the first-choice therapy in patients with cyst-induced radicular pain was safe and effective. Successful cyst rupture was associated with no need for surgery. Cysts at lower lumbar spine revealed the highest success rate.

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.

Acute lumbosacral hemorrhagic ganglion cyst after transforaminal epidural steroid injection

Epidural steroid injection is one of the most commonly used non-surgical treatments for degenerative lumbar vertebral disease. Its use has increased as degenerative lumbar vertebral disease has increased in frequency. Concomitant complications are being reported more often. In this report, we report a rare case of iatrogenic hemorrhagic cyst following epidural steroid injection. The patient underwent operative treatment with complete resolution of his symptoms

Association of Lumbar Synovial Cysts with Facet Effusion

To show the frequent association of synovial cysts and facet effusion.

MR studies of 26 patients with lumbar synovial cysts were reviewed for sex/age incidence, anatomic location, multiplicity of cysts and associated pathologies. All studies were reviewed for presence of facet effusion.

26 patients had 39 MRI documented synovial (17 females, 9 males). Age distribution: 41 – 79 years. Location of cysts: L4/5 = 29, L3/4 = 6, L5/S1 = 3, L1/2= −;1. 36 synovial cysts showed facet effusion. 19 patients also had facet effusions at adjoining motion segments or at contralateral joints. Synovial cysts were found in anterior (n=20), posterior (n=13), anterior-posterior (n=3) positions. 18 patients had cysts localized to one single facet joint, 8 patients showed synovial cysts at multiple facet joints.

The frequent coexistence of synovial cysts and facet effusion in our material suggests a causal relationship. External herniation of synovium from a fluid expanded joint space appears to be the most plausible pathologic mechanism.

A case of cervical juxtafacet cyst with extensive rim enhancement on Gd-DTPA MRI

The authors reported a case of cervical juxtafacet cyst with extensive rim enhancement on gadolinium-diethylenetriamine pentaacid magnetic resonance imaging. Operative finding revealed the epidural space around the mass filled with abundant venous plexus. Histological examination demonstrated that cyst wall was composed of the well-vascularized fibrous connective tissue with some inflammatory changes. We speculate that extensive rim enhancement of juxtafacet cyst may be attributed not only to the chronic inflammatory changes of cyst wall, but to engorged venous plexus within the widened epidural space.

Extradural cyst causing spinal cord compression in osteoporotic compression fracture

Intraspinal cystic lesions with different pathogeneses have been reported to cause neurological deficits; however, no one has focused on the intraspinal extradural cysts that develop after osteoporotic compression fracture. The reported case features a 66-year-old woman presenting with progressive neurological deficit, back pain, and no history of additional trauma after undergoing conservative treatment for an osteoporotic fracture of L-1. The authors present serial radiographs and MR images demonstrating an epidural cyst successfully treated via a single posterior approach. This appears to be the first such case reported in the literature.

Cisto intraespinal em comunicação com o disco intervertebral na coluna lombar: relato de um caso e revisão da literatura

A hérnia discal lombar é causa importante bem como a mais freqüente de lombalgia e ciática. Muitos dos casos podem prontamente ser diagnosticados através do simples exame semiológico. A ressonância nuclear magnética (RNM) estabelece um diagnóstico definitivo mesmo em bases ambulatoriais. Diversos tipos de cistos intraespinais com diferentes patogenias foram descritos no passado como cistos perineurais, cistos sinoviais, cistos aracnóides e cistos ganglionares, que são doenças difíceis de diferenciar da hérnia de disco lombar. Os autores observaram recentemente um caso de cisto intraespinal comunicante com o disco intervertebral correspondente, apresentando sinais e sintomas e mesmo alguns achados radiológicos indistinguíveis daqueles da herniação discal lombar. O diagnóstico foi estabelecido pela RNM e confirmado no momento da cirurgia. Este artigo descreve as características dessa entidade clínica, incluindo quadro clínico, aparência radiográfica e achados histológicos, a fim de discutir possíveis patogenias e tratamento.

Lumbar diskal cyst containing intervertebral disk materials

The diskal cyst is a relatively new clinical entity and develops clinical symptoms of a unilateral single nerve root lesion. Although many cases of diskal cyst have been reported, the pathogenesis of diskal cyst remains unclear, and several theories regarding the pathogenesis have been proposed. This article presents 2 cases of diskal cyst communicating with an adjacent herniated disk. Magnetic resonance imaging findings showed diskal cysts in the epidural space of the lumbar spine. Surgical resection was performed, and apparent connections between the corresponding disk and cysts were found. Histopathologic examinations of the cyst wall demonstrated cartilaginous tissue including nucleus pulposus and annulus fibrosis. These patient's symptoms improved remarkably postoperatively, and there was no recurrence of diskal cyst.The hypothesis supported by many authors is hemorrhage from the epidural venous plexus. Diskal cysts arise first from an underlying intervertebral disk injury that causes an annulus fibrosis fissure in the posterior intervertebral disk. Hemorrhage from the epidural venous plexus with a rich blood flow then occurs in the space between the peridural membrane and vertebral body. However, in our cases, we confirmed that the diskal cyst could have developed from the resorption process of an intervertebral disk herniation. Only 5 cases of diskal cyst demonstrating the presence of cartilaginous tissue in the cyst have been reported. Our 2 cases are rare and support the hypothesis of resorption of intervertebral disk herniation.

Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a clinical outcome study

BACKGROUND CONTEXT

Lumbar zygapophyseal joint (Z-joint) synovial cysts can cause low back pain (LBP), spinal stenosis, and lower extremity radiculopathy. In the literature, there are several minimally invasive techniques described with mixed results. Typical recommended treatment is surgical resection of the cyst. Currently, there is little information available concerning the efficacy and outcome with treatment of Z-joint synovial cyst by percutaneous, fluoroscopic, contrast-enhanced distention, and rupture.

PURPOSE

To evaluate the therapeutic value and safety of Z-joint cyst rupture in symptomatic patients.

STUDY DESIGN/SETTING

Retrospective cohort study in an academic outpatient physiatric spine practice.

PATIENT SAMPLE

Thirty-two patients with moderate-to-severe LBP and leg pain (18 women and 14 men with an age range of 46-86 y; mean age, 66 y) with an average preprocedure symptom duration of 5 months. The patient's clinical symptoms correlated with magnetic resonance imaging studies documenting the presence of a synovial cyst at the corresponding level and side of symptoms. Patients had at least 6 months follow-up (range, 6-24).

OUTCOME MEASURES

Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, North American Spine Society four-point patient satisfaction survey, recurrence of synovial cyst requiring repeat rupture, and need for surgical intervention.

METHODS

Patients with symptomatic lumbar Z-joint synovial cyst were identified and their charts were reviewed. Patients included in the study either had symptomatic lumbar LBP or LBP with associated lower extremity radiculopathy. All patients in the study had magnetic resonance imaging's documenting Z-joint synovial cyst that corresponded with the patients' clinical symptoms. All patients received fluoroscopically guided, contrast-enhanced, percutaneous facet cyst distention and rupture followed by an intra-articular facet joint injection of 1 cc kenalog and 1 cc of 1% lidocaine. Seventeen of the patients also received a transforaminal epidural steroid injection just before facet cyst rupture. Telephone follow-up was conducted on all patients.

RESULTS

Excellent long-term (average follow-up 1 y; range, 6-24 mo) pain relief was achieved in 23 (72%) of 32 patients undergoing facet cyst rupture. Twelve patients (37.5%) had synovial cyst recurrence and 11 chose to undergo repeat rupture, which resulted in 5 patients (45%) obtaining complete relief of symptoms and 6 patients (55%) requiring surgical intervention for cyst removal. Fisher exact test demonstrated that all patients who did not have a cyst recurrence were a success and obtained complete relief of symptoms (p<.0002). Patients who underwent a repeat rupture had a 50% chance of a successful outcome. There was no statistical significance between a successful outcome and level of facet cyst rupture, the presence of spondylolisthesis, sex, age, or having a transforaminal epidural steroid injection at the time of the procedure. Wilcoxon signed-rank test demonstrated that the difference in Numerical Pain Rating Scale and Roland-Morris Disability Questionnaire scores before and after the procedure was statistically significant (p<.0001). No complications were reported.

CONCLUSIONS

Fluoroscopic percutaneous Z-joint cyst rupture appears to be a safe and effective minimally invasive treatment option. This procedure should be considered before surgical intervention.

Osteolytic lumbar discal cyst: case report

A 25-year-old man presented with left lumboischialgia refractory to medical treatment. Neurological examination revealed L5 and S1 radiculopathy which rapidly worsened over a short period. Magnetic resonance imaging demonstrated disk bulging with a discal cyst at the L4-5 intervertebral space and disk herniation at the L5-S1 intervertebral space. Computed tomography showed osteolytic change of the L5 vertebral body adjacent to the cyst. Resection of the cyst and removal of the herniated disk were performed following fenestration of the L4-5 and L5-S1 interlaminar spaces. Bloody serous fluid followed by clear serous fluid was recognized during the aspiration and partial resection of the cyst at the L4-5 level. Histological examination demonstrated a cyst wall consisting of fibrous connective tissue without a single-layer lining of cells, and fibrin deposits. The patient's symptoms disappeared immediately after the operation. This osteolytic lumbar discal cyst possibly occurred subsequent to hemorrhage from the epidural venous plexus following intervertebral disk injury, hematoma encapsulation by connective fibrous tissue, and cyst wall formation in reaction to the disk injury and hemorrhage. The cyst may have enlarged due to the inflow of the serous fluid from the water-containing degenerated disk.

Discal cysts of the lumbar spine: a case report

Discal cysts--intraspinal cysts communicating with an adjacent intervertebral disc--are an uncommon cause of lumbar radiculopathy. We report a case of discal cyst of the lumbar spine. The cyst contents were bloody and clotted rapidly; no disc materials were seen. Communication between the cyst and the intervertebral disc was detected. Histopathology of the cyst wall revealed fibrous connective tissue without synovial lining cells. We hypothesise that the discal cyst was formed by haemorrhage of the epidural venous plexus caused by separation of the peridural membrane by mechanical force transmitted by an annulus fibrosis fissure. The minute segmental motion caused by the affected disc may have stimulated continuous bleeding.

Lumbar spinal 'juxtaarticular' cyst in a Gordon setter

An 11-year-old Gordon setter bitch was presented with a history of progressive weakness in the right hind limb associated with pain in the lumbar spine. Neurological deficits consisted of ataxia, monoparesis, muscle atrophy and spontaneous over-knuckling of the affected limb. A large 'juxtaarticular' cyst located in a right dorsolateral position of the intervertebral foramen at L3-L4 was diagnosed by magnetic resonance imaging. The cyst was removed through a modified laminectomy. The dog recovered quickly and returned to the owners 4 days after surgery with slight neurological symptoms. During the follow-up examination 2 and 6 months later, the Setter showed normal gait and neurological examination.

Far Lateral Extraforaminal Facet Cyst Causing L5 Radiculopathy

Most synovial cysts of the lumbar spine appear as intraspinal extradural masses adjacent to the facet joint. Almost all symptomatic synovial cysts are located within the spinal canal and or the neural foramen. To our knowledge, only 6 cases of symptomatic extraspinal synovial cysts have been described in the literature. The authors report a case of lumbar radiculopathy caused by a synovial cyst located in the far lateral extraforaminal area. The patient underwent decompression of the L5 nerve root with recapping right isthmectomy and facetectomy. Postoperative recovery was uneventful, and the patient was totally pain free with no motor deficit. Symptomatic synovial cysts are uncommon lesions that are associated with degenerative disease of the spine. Juxtafacet cysts should be considered in the differential diagnosis of space-occupying lesions at the extraforaminal areas. Recapping isthmectomy and facetectomy are useful procedures for a synovial cyst located in the far lateral extraforaminal area.

Synovial cysts associated with cauda equina syndrome in two dogs

OBJECTIVE

To report synovial cysts associated with cauda equina syndrome in 2 dogs.

STUDY DESIGN

Clinical cases.

ANIMALS

Two German Shepherd dogs.

METHODS

After magnetic resonance imaging detection, cysts were surgically removed via dorsal laminectomy.

RESULTS

Six and 8 months after surgery, both dogs were free of clinical signs and no pain was elicited on lumbosacral joint manipulation.

CONCLUSION

Although described in dogs, cysts at the lumbosacral joint might cause compression of the cauda equina nerve roots. Radical excision of the cyst capsule can result in resolution of clinical signs.

CLINICAL RELEVANCE

Synovial cysts should be considered in the differential diagnosis of dogs with cauda equina compression syndrome when lumbosacral degenerative joint disease is present.

Lumbar hemorrhagic synovial cysts: diagnosis, pathogenesis, and treatment. Report of 3 cases

BACKGROUND

To define the etiologic, clinical, histological, and surgical features of lumbar hemorrhagic synovial cysts (LHSCs). Three personal cases are reported together with a review of the pertinent literature.

METHODS

We identified 3 cases of LHSC treated in our departments and 20 cases culled from the literature.

RESULTS

A total of 23 cases of LHSC were selected. All the patients underwent surgical treatment because of untreatable radicular pain and/or neurological deficits. The amount of bleeding, either massive or minor but repeated, influenced the timing of surgery. In our cases, the histological examinations showed an inflammatory reaction within the cyst and the consequent formation of neoangiogenic vessels.

CONCLUSIONS

Hemorrhagic synovial cyst of the spine is rare and its most common localization is lumbar. Bleeding within the cyst leads to an increase of its volume, accompanied by neurological deficits and/or painful symptoms that are violent and generally intractable. In this event, surgical excision is the treatment of choice and, in some cases, emergency surgery is necessary. Hemorrhages are probably caused by the rupture of fragile neoangiogenic vessels.

Procedure-based nonsurgical management of lumbar zygapophyseal joint cyst-induced radicular pain

OBJECTIVE

To evaluate the success of fluoroscopically guided, contrast-enhanced lumbar zygapophyseal joint (Z-joint) aspiration and steroid injection combined with transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar Z-joint cyst-induced radicular pain.

DESIGN

Retrospective case series with independent follow-up.

SETTING

Institutional, referral center.

PARTICIPANTS

Twenty-three patients referred to a single provider for procedure-based management of radicular pain believed secondary to lumbar Z-joint cyst. Inclusion criteria consisted of lumbar radicular pain that was consistent with the level and side of the Z-joint cyst as a causative lesion.

INTERVENTIONS

Eighteen patients were treated with a fluoroscopically guided, contrast-enhanced Z-joint aspiration and steroid injection at the level of the causative cyst coupled with a fluoroscopically guided, contrast-enhanced TFESI over the level of the presumably irritated spinal nerve.

MAIN OUTCOME MEASURES

Patient satisfaction, and whether or not surgery was performed.

RESULTS

Fifty percent of patients treated with the procedure had significant long-term benefit and avoided surgical intervention at an average follow-up of 9.9 months.

CONCLUSIONS

Fluoroscopically guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar Z-joint cyst-induced radicular pain.

Cervical cyst of the ligamentum flavum and C7-T1 subluxation: case report

A patient with progressive gait disturbance resulting from a cyst of the cervical ligamentum flavum associated with C7-T1 listhesis is reported. Surgical removal of the cyst improved the patient's myelopathy. Intraspinal degenerative cysts are preferentially located in the lumbar region:unusual is the cervical localization. Differential diagnosis includes ligamentum flavum cyst, synovial and ganglion cysts. Association between degenerative intraspinal cysts and listhesis is discussed. To our knowledge, this is the first case of cyst of the ligamentum flavum associated with cervical subluxation.

Lumbar synovial cysts: a review of diagnosis, surgical management, and outcome assessment

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. Clinical findings and neurodiagnostic confirmation prompt surgical intervention consisting of varying decompressions with or without primary fusion. Most patients present in their mid-60s, with a male-to-female ratio varying from 2:1 to 1:1. Preoperative symptoms include low back pain, radiculopathy, and neurogenic claudication. Motor and sensory signs usually reflect the anatomic location of the synovial cyst and the level of resultant maximal lumbar stenosis. In descending order of frequency, they are typically found at the L4-L5, L5-S1, L3-L4, and L2-L3 levels. Lumbar synovial cyst surgery includes unilateral or bilateral laminotomies, hemilaminectomies, or laminectomies alone or in combination with in situ or instrumented fusion. Those patients undergoing decompression alone may postoperatively develop progression or the new appearance of olisthy, while those primarily fused rarely show further increase or a new onset of slip. Outcome measures spanning 1- to 2-year postoperative intervals frequently included surgeon-based rather than the current patient-based analysis, the lat-ter including the Medical Outcomes Trust Short Form-36.

Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: an outcome study

STUDY DESIGN

Surgeon- and patient-based (SF-36) outcome measures were used to assess the results of decompressive laminectomies for the excision of synovial cysts with coexistent lumbar spinal stenosis (45 patients) or for synovial cysts with coexistent lumbar stenosis and degenerative spondylolisthesis (35 patients).

OBJECTIVES

To evaluate the results following laminectomy and the excision of synovial cysts/stenosis with or without olisthy.

SUMMARY OF BACKGROUND DATA

SF-36 outcome studies evaluating these surgical results deserve further investigation.

METHODS

Before surgery, patients with synovial cysts/ stenosis (45 patients) or cysts/stenosis/degenerative spondylolisthesis (35 patients), respectively, exhibited low back pain (40 and 33 patients), radiculopathy (43 and 33 patients), and neurogenic claudication (41 and 26 patients). Surgery required average 3.8 and 3.5 level laminectomies, respectively, for patients with cysts/stenosis and cysts/stenosis and olisthy. Outcomes were assessed 2 years after surgery.

RESULTS

Five of 45 patients undergoing laminectomy alone for cysts/stenosis developed postoperative olisthy. Of 35 patients with cysts/stenosis and preoperative Grade 1 degenerative spondylolisthesis, olisthy increased after surgery to Grade 2 in 11 patients. Good/excellent results (58% and 63%) and SF-36 improvement on the Physical Function Scale (+44 and +38 points) were, respectively, documented for these two groups.

CONCLUSIONS

Using both surgeon and SF-36 outcome measures, 2 years following laminectomy for synovial cysts/lumbar stenosis with or without olisthy, patients exhibited a moderate degree of improvement. As synovial cysts reflect disruption of the facet joint and some degree of instability, primary fusion should be considered to improve operative results for patients in both categories.

Synovial cysts of the lumbar spine: surgery-related results and outcome

OBJECT

The authors conducted a study to determine the surgery-related results and outcomes in patients with synovial cysts of the lumbar spine. They emphasize several specific characteristics useful in clinical management.

METHODS

Forty-six consecutive patients with 54 lumbar synovial cysts underwent surgery between 1990 and 2001. A retrospective analysis of the clinical presentation and follow-up data, radiological findings, and surgical techniques was performed. Clinical presentation was dominated by acute or subacute sciatic pain. No specific symptom allowed differentiation of synovial cyst from a lumbar disc herniation. Computerized tomography scanning aided in establishing the correct diagnosis in 19 of 30 cases and magnetic resonance (MR) imaging did so in all cases. Three of the 46 patients presented with bilateral lumbar synovial cysts. The L4-5 level was affected in 61%, and radiological signs of disc degeneration/spondylosis were observed in 54% of the patients. Immediate symptom relief without local recurrence was obtained by complete microsurgical excision in which bipolar coagulation was used to remove the synovial membrane and in which the interapophysial joint was preserved. During the 1st postoperative year, a newly formed symptomatic synovial cyst developed on the contralateral side or at a superior vertebral level in five patients. They underwent surgery; results were good and there was no recurrence.

CONCLUSIONS

The findings in this series suggest that synovial cysts can occur at multiple lumbar sites within a short period of time and could be predisposed to developing in certain individuals, predominantly in women older than 40 years of age. Postoperative follow up is recommended and MR imaging mandatory in cases of recurrent sciatica.

An unusual presentation of a lumbar synovial cyst: case report

STUDY DESIGN

A case of intraforaminal synovial cyst is reported.

OBJECTIVES

To stress the importance of the way intraforaminal synovial cyst, a very rare condition, causes a peculiar position of the nerve root in the foramen and to describe the required surgical approach.

SUMMARY OF BACKGROUND DATA

Intraforaminal synovial cyst is a highly unusual finding. The existence of this rare entity raises the problem of differential diagnosis with other space-occupying lesions of the neural foramen, such as herniated disc, neurinoma, neurofibroma, and metastatic lesions

METHODS AND RESULTS

A 64-year-old woman suffered a right L4 radiculopathy with motor deficit. Computed tomography showed a space-occupying lesion in the L4-L5 foramen isodense with the disc. Magnetic resonance images showed a right intraforaminal cystic lesion at the L4-L5 level with no enhancement after intravenous infusion of gadolinium. A 3-cm cystic lesion, which appeared to arise from the L4-L5 facet joint without direct communication, was excised from the L4-L5 foramen. In contrast with intraforaminal disc herniation, downward displacement of the L4 nerve root was observed. Two months after surgery, the patient was pain-free and neurologic examination revealed no motor deficit.

CONCLUSIONS

An unusual intraforaminal presentation of a lumbar synovial cyst demonstrates the importance of considering this entity and of adapting the surgical technique to avoid injury to the nerve root.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Intraspinal cyst communicating with the intervertebral disc in the lumbar spine: discal cyst

STUDY DESIGN

A retrospective case study of patients with intraspinal cyst having a distinct connection with the corresponding intervertebral disc.

OBJECTIVES

To propose a new clinical entity, "discal cyst," by clarifying the clinical, radiographic, and histologic aspects of the disease.

SUMMARY OF BACKGROUND DATA

Several types of intraspinal cysts with different pathogenesis, causing symptoms indistinguishable from those of lumbar disc herniation, have been reported, such as perineural cysts, synovial cysts, and ganglion cysts. However, to the authors' knowledge, no detailed analysis has been made of cysts that have a distinct connection with the corresponding intervertebral disc.

METHODS

Clinical pictures, radiographic findings, and surgical and histologic findings in eight surgically treated patients with intraspinal cyst having a distinct connection with the intervertebral disc were reviewed. Possible pathogenesis and a proposal for nomenclature were also discussed.

RESULTS

This disease can be characterized by (1) clinical symptoms indistinguishable from those of typical disc herniation, manifesting as a unilateral single nerve root lesion; (2) incidence at slightly younger age and at upper intervertebral levels than with typical disc herniation; (3) T1 low signal and T2 high signal intensity, round to oval mass lesion on magnetic resonance imaging, compatible with a liquid-containing cyst; (4) minimal degeneration of the involved disc, either on discography/computed tomographic discography or magnetic resonance imaging; (5) a connection between the cyst and the corresponding intervertebral discs on discograms with severe radiating pain in the affected leg at the time of injection; (6) immediate relief of symptoms after simple removal of the cyst; (7) cyst wall consisting of dense fibrous connective tissue containing bloody to clear serous discharge; and (8) absence of disc materials and a specific lining cell layer on histologic examination. Although the exact cause is unknown, underlying minor disc injury may serve as a basis for cyst formation.

CONCLUSION

Eight cases of intraspinal cysts communicating with the intervertebral disc presenting symptoms identical to those of disc herniation are presented. Because all cysts were connected to the corresponding disc and the development of the cyst was assumed to be related to underlying disc injury, it is proposed to name this clinical entity discal cyst.

MR imaging findings in a dog with lumbar ganglion cysts

Intraspinal cysts of the L6-L7 and L7-S1 articular process joints in a six-year-old neutered female German Shepherd Dog were diagnosed using magnetic resonance (MR) imaging. Histopathology provided a diagnosis of ganglion cysts. Clinical, laboratory, radiographic and MR imaging findings are described. Briefly, radiographic findings revealed lumbarization of the first sacral vertebra, and fusion of the first caudal vertebra to the sacrum. In addition, spondylosis and articular process osteoarthrosis occurred at L6-L7 and L7-S1. MR imaging revealed multiple, well encapsulated structures ranging in size from 3-10 mm in diameter which were found to arise from the L6-L7 and L7-S1 articular process joints. These cysts had signal intensities that varied from hyperintense to the cerebrospinal fluid (CSF) on T1 weighted images to isointense to CSF on T2 weighted images. Decompressive surgery in conjunction with arthrodesis of these joints resulted in resolution of clinical signs. The dog remained pain-free 1 1/2 years following surgical therapy.

Nonsurgical treatment of zygapophyseal joint cyst-induced radicular pain

OBJECTIVE

To evaluate the role of fluoroscopically guided injection procedures in the nonsurgical treatment of zygapophyseal joint cyst-induced radicular pain.

DESIGN

Retrospective study with independent clinical review.

PARTICIPANTS

Fourteen patients (average age, 60.2 yrs), with an average symptom duration of 18.8 months, were included.

METHODS

Medical records were reviewed; patients with a radiographically observed zygapophyseal joint cyst that may have represented a compressive lesion corresponding to the patient's symptoms of radicular pain were eligible for inclusion. The level of nerve root involvement was confirmed by physical examination or electrodiagnostic findings. Patients whose root level involvement remained undetermined were required to demonstrate a positive response to a fluoroscopically guided diagnostic selective nerve root block (SNRB). Nonsurgical treatments included therapeutic SNRB, intraarticular zygapophyseal joint corticosteroid injection, and cyst puncture. Data collection and analysis were performed by an independent clinical reviewer.

OUTCOME MEASURES

Pain score, work status, medication usage, and patient satisfaction with treatment.

RESULTS

The majority of the observed cysts (71.4%) were at the L4-L5 level. Follow-up data collection was done at an average of 1.4 years after termination of treatment. An excellent outcome was observed in 4 patients (28.6%). Fifty percent of patients underwent surgery.

CONCLUSIONS

Preliminary findings suggest a role for fluoroscopically guided injection techniques in the nonsurgical treatment of zygapophyseal joint cyst-induced radicular pain, with up to one-third of patients experiencing lasting symptomatic relief.

Intraspinal synovial cysts: 10-year experience at the Ochsner Clinic

OBJECT

Although synovial cysts commonly involve the joints of the extremities, they are also found in the spinal canal. When symptomatic, they produce signs and symptoms consistent with nerve root and spinal cord compression. In this report the authors review the clinical presentations, radiological studies, and operative findings in 28 patients with intraspinal synovial cysts treated surgically at the Ochsner Clinic between 1988 and 1998.

METHODS

The medical records and radiological studies obtained in 28 patients (31 intraspinal synovial cysts) were analyzed. Twenty-nine (94%) of the cysts were located in the lumbar, one in the thoracic (T8-9), and one in the cervicothoracic (C7-T1) spine. Sixteen (57%) of the 28 patients presented with radicular pain. The remaining patients presented either with neurogenic claudication (25%) or with radicular pain and an associated neurological deficit (18%). Each cyst was located adjacent to a facet joint in which there was evidence of degenerative disease.

CONCLUSIONS

Intraspinal synovial cysts are uncommon lesions most often found in the lumbar spine at the L4-5 level. They are invariably associated with facet degeneration and respond very well to surgical therapy.

Magnetic resonance imaging of the cervical spine in 27 dogs

The cervical spine of 27 dogs with cervical pain or cervical myelopathy was evaluated using magnetic resonance imaging (MRI). Spin echo T1, T2, and post-contrast T1 weighted imaging sequences were obtained with a 0.5 Tesla magnet in 5 dogs and a 1.5 Tesla magnet in the remaining 22 dogs. MRI provided for visualization of the entire cervical spine including the vertebral bodies, intervertebral discs, vertebral canal, and spinal cord. Disorders noted included intervertebral disc degeneration and/or protrusion (12 dogs), intradural extramedullary mass lesions (3 dogs), intradural and extradural nerve root tumors (3 dogs), hydromyelia/syringomyelia (1 dog), intramedullary ring enhancing lesions (1 dog), extradural synovial cysts (1 dog), and extradural compressive lesions (3 dogs). The MRI findings were consistent with surgical findings in 18 dogs that underwent surgery. Magnetic resonance imaging provided a safe, useful non-invasive method of evaluating the cervical spinal cord.

Lumbar nerve root compression by intraspinal synovial cysts. Report of 8 cases

We evaluated the clinical appearance and results of surgical treatment in 8 patients with leg symptoms due to a lumbar intraspinal synovial cyst. The most frequent symptom was radicular leg pain due to unilateral single-root compression affecting the L5 or S1 nerve root. There were 2 cases with large cysts causing compression of the cauda equina, with spinal claudication as the main symptom. All cysts arose from arthrotic facet joints. Surgical excision gave good results and no recurrences have been noted 0.5-2 years postoperatively.

Symptomatic lumbar facet joint synovial cysts: clinical assessment of facet joint steroid injection after 1 and 6 months and long-term follow-up in 30 patients

PURPOSE

To study the results of facet joint intraarticular steroid injections in patients with symptomatic lumbar facet joint synovial cysts.

MATERIALS AND METHODS

Data from 30 patients (age range, 44-82 years; mean age, 67 years) with nerve root pain due to a lumbar facet joint synovial cyst and treated with facet joint steroid injection were retrospectively studied. On the basis of MacNab criteria, the clinical course of nerve root pain was evaluated after 1 (n = 30) and 6 (n = 28) months. Data from long-term follow-up (mean, 26 months) were also available in 14 nonsurgically treated patients.

RESULTS

After 1 month, the nerve root pain outcome was excellent or good in 20 patients (67%) and fair or poor in 10 (33%). After 6 months, 10 (50%) of these 20 patients still had excellent or good results, and 18 (60%) of the 30 patients had a fair or poor clinical status, 14 of whom underwent surgery; two patients (7%) were lost to follow-up. Excellent and good results were maintained at further follow-up (range, 9-50 months).

CONCLUSION

One-third of patients with symptomatic lumbar facet joint synovial cysts had long-lasting acceptable benefit from facet joint steroid injections in this study. Steroid injection should be indicated before surgery.

[Differential sciatica pain diagnosis from the neurologic viewpoint]

Low back pain and sciatica with or without neurological deficits represent frequent disorders in clinical practice. Both, history and neurological examination are essential for localizing underlying lesions and initiating appropriate investigations. Pain location, sensory symptoms, motor signs and reflexes are extremely reliable in indicating which motor root(s) or peripheral nerve(s) are affected. Sometimes, pain and/or paraesthesia are the only presenting symptoms. Therefore differential diagnosis of low back pain and sciatica is various. This article summarizes the differential diagnosis of low back pain and sciatica according to the site of the lesion as follows: 1. lesions of the spinal cord, 2. lesions of the nerve roots (L4, L5, S1-S3), 3. lesions of the lumbosacral plexus, 4. peripheral nerve lesions (sciatic nerve, peroneal nerve), 5. low back pain and sciatica due to neuropathies, and 6. low back pain and sciatica as a symptom of other neurological disorders. Additionally, the status of neuroradiological procedures in establishing diagnosis is discussed.

Commented glossary for rheumatic spinal diseases, based on pathology

OBJECTIVES

To redefine and comment on terms on a pathological basis, in order to avoid the confusion due to the use of terms with different meanings, to standardise usage among clinicians, radiologists and pathologists, and to facilitate literature searches.

METHODS

Within the Committee of Pathology of the European League against Rheumatism, a study group was set up to analyse the medical literature and common practice concerning the nomenclature of rheumatic spinal diseases. The group tried to amalgamate the main trends in the field, to reconcile etymology, historical background, morphology, and common practice.

RESULTS

The group warns against use of the terms 'acquired hyperostosis syndrome', '(von) Bechterew's disease', 'Kümmel's disease', 'pseudospondylolisthesis', 'rheumatoid spondylitis', 'spondylarthropathy' in the sense of spondarthritis, and 'spondylosis'. It recommends intercorporal or interapophyseal rather than intervertebral (osteo) chondrosis, zygapophyseal diverticulum rather than cyst, disc hernia rather than prolapse, spondyloarthritis rather than spondyloarthropathy, marginal rather than anterior spondylitis, and discarthrosis. It proposes 'zygarthrosis' to designate zygapophyseal osteoarthrosis.

CONCLUSIONS

Knowledge of the pathological basis of diseases and an understanding of the original definitions given by those who coined new terms make it possible to avoid most of the confusion arising from improper use of spinal terms.

Sciatica in degenerative spondylolisthesis of the lumbar spine

Intraspinal synovial cysts are an uncommon but well recognised cause of backache and sciatica, and should be considered in patients, in particular with degenerative spondylolisthesis, who are symptomatic. MRI is the initial investigation of choice. If there is any doubt as to the diagnosis, CT with or without facet joint arthrography is helpful.

Synovial cyst of dens causing spinal cord compression. Case report

We report a rare case of synovial cyst of the dens (odontoid process) in a 61 year old women with no previous history of trauma. She had progressive symptoms of 1 year's duration due to spinal cord compression. Magnetic resonance imaging of cervical spine revealed a large mass posterior to the dens which was compressing the spinal cord near the cervicomedullary junction. This lesion was at first considered radiologically to represent an exuberant pannus formation or a meningioma of the foramen magnum, but subsequent surgical intervention and pathological examination revealed that it was a synovial cyst. Similar cases reported in the literature are reviewed and discussed.