Cervical and thoracic juxtafacet cysts causing neurologic deficits

Waste not, want not: Report of a completely calcified C1-C2 juxtafacet cyst and literature review

Background

Calcified juxtafacet cysts in the cervical spine are extremely rate. Such symptomatic cysts commonly cause neck pain, radiculopathy, or even myelopathy. MR and CT studies typically document cord/ root compression. On occasion, some of these cysts will spontaneously regress, while many others may warrant surgical removal.

Case Description

A 70-year-old male presented with a 2-year history of a progressive tetraparesis. The preoperative MR/CT studies showed a C1-C2 left extradural mass occupying more than half of the spinal canal. On MR, it was homogeneously hypointense on both T1- and T2-weighted images, while the CT showed a calcified cyst. Intraoperative and histopathological findings documented a calcified cervical juxtafacet cyst (i.e. ganglion subtype) that was fully excised without sequelae.

Conclusion

C1-C2 juxtafacet cervical cyst should be considered when a patient presents with myelopathy due to a calcified MR/CT documented paraspinal lesion contributing to significant cervical cord/root compression.

Spinal ganglion cyst presenting with radiculopathy: diagnostic challenges and differential

INTRODUCTION

Ganglion cysts are benign soft tissue lesions, usually arising from periarticular connective tissue. These are very rarely reported in the spine, but when seen can cause radiculopathy or myelopathy.

CASE PRESENTATION

A 68-year-old female patient presented with worsening radiculopathy and right foot drop and imaging noted a right L5-S1 foraminal mass. The lesion was gross totally resected. Histological analysis revealed myxoid degeneration and inflammation, without a synovial lining, consistent with ganglion cyst.

DISCUSSION

While uncommon, intra-foraminal ganglion cysts can be distinguished from synovial cysts through imaging and histology and are typically amenable to surgical resection. Greater knowledge and insight about differentiating ganglion versus synovial cyst may prevent resection of facet joints and prevent a fusion procedure.

Rapid Neurologic Deterioration due to an Enlarging Thoracic Spine Synovial Cyst: A Case Report

CASE

We present the case of a 69-year-old man arriving to our clinic after a previous outside hospital recommendation of L1-S1 fusion due to degenerative scoliosis. A thoracic spine synovial cyst was identified through magnetic resonance imaging. The patient had rapid progression of his neurologic deficit due to cyst enlargement. We elected to perform cyst decompression and instrumented fusion of the involved thoracic segment. The patient rapidly regained full neurologic function. After the one-year follow-up, he remained asymptomatic with no progression of thoracolumbar degeneration.

CONCLUSIONS

Thoracic spine synovial facet cysts are uncommonly encountered. Decompression alone or decompression and fusion are both viable treatment options depending on the surgeon's assessment of spine stability after decompression. This diagnosis should be considered in patients presenting with unilateral lower extremity upper motor neuron findings.

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.

Sudden Onset of Paraparesis Caused by a Hemorrhagic Thoracic Synovial Cyst

BACKGROUND

Hemorrhage is a rare presentation of spinal synovial cysts, which are usually located in the lumbar spine. They may cause an epidural hematoma and compression of the cauda equina. Infrequently, they may be located in the thoracic spine.

CASE DESCRIPTION

We present a case of sudden onset paraparesis caused by hemorrhage in a synovial cyst at a midthoracic level. Clinical, radiologic, and histologic findings are described.

CONCLUSIONS

This report describes a unique case of hemorrhagic synovial cyst at the mid-thoracic spine. These lesions are rarely located in the cervico-thoracic spine but should be included in the differential diagnosis of myelopathy.

Bilateral Ganglion Cysts of the Ligamentum Flavum in the Cervical Spine Causing a Progressive Cervical Radiculomyelopathy and Literature Review

Here we report a unique case of bilateral ganglion cysts originating from the ligamentum flavum in the cervical spine. Degenerative cysts of the ligamentum flavum are rare lesions, and most had been reported in the lumbar spine. Its occurrence in the cervical spine is extremely rare: only eight have been reported. A 66-year-old male patient presented with progressive paraparesis, pain, and paresthesia in his bilateral T1 dermatomes that had lasted for three weeks. Magnetic resonance imaging of the cervical spine demonstrated a well-demarcated cystic lesion in the bilateral dorsolateral aspects of the C7/T1 segment and significant compression of the cervical cord. All case reports of ganglion cysts of the cervical ligamentum flavum including the present one showed characteristic symptoms and signs of myelopathy such as paraparesis or quadriparesis associated with varying degrees of paresthesia or pain in the upper extremities. Ganglion cysts of the cervical ligamentum flavum are considered a cause of cervical radiculomyelopathy due to cervical intraspinal cystic lesions. Bilateral occurrence and associated subluxation of the involved cervical segments again support the degenerative pathogenesis of ganglion cysts of the ligamentum flavum in the cervical spine.

The role of spinal fusion in the treatment of cervical synovial cysts: a series of 17 cases and meta-analysis

Object

This study was undertaken to compare surgical outcomes between patients with atlantoaxial versus subaxial cervical synovial cysts (CSCs) and to compare outcomes between patients who underwent decompression alone versus decompression and fusion for the treatment of CSCs.

Methods

The authors present a series of 17 cases involving patients treated at their institution and report the surgical outcomes. Due to the rarity of CSCs, a meta-analysis was conducted, and results of the literature search were combined with the case series to enhance the power of the study.

Results

Seventeen patients underwent surgical treatment for CSCs at our institution: 3 patients (17.6%) had atlantoaxial cysts and 14 (82.3%) had subaxial cysts. Of the 17 patients, 16 underwent a decompression and fusion; most patients experienced symptom resolution at last follow-up, and there were no cyst recurrences. A total of 54 articles (including the current series) and 101 patients were included in the meta-analysis. The mean age at presentation was 64 ± 13.9 years, and the most common symptoms were motor and sensory deficits. Forty-one patients (40.6%) presented with atlantoaxial cysts, and 60 (59.4%) with subaxial cysts. There were no significant differences between groups in terms of presenting symptoms, Nurick scores, surgical treatment, or surgical outcomes. Fifty-two patients (51.4%) underwent surgical decompression without fusion, while 49 patients (48.6%) underwent fusion. The preoperative Nurick scores were significantly lower in the fused group (p = 0.001), with an average score of 1.32 compared with 2.75 in the nonfused group. After a mean follow-up of 16.5 months, a difference of means analysis between final and preoperative Nurick scores revealed that patients who received a decompression alone improved on average 1.66 points (95% CI 1.03–2.29) compared with 0.8 points (95% CI 0.23–1.39) in the fused group (p = 0.004). However, there was no statistically significant difference in symptom resolution between the groups, and the rate of cyst recurrence was found to be 0%.

Conclusions

In this study, patients with CSCs had similar outcomes regardless of cyst location and regardless of whether they underwent decompression only or fusion. In the authors' institutional experience, 16 of 17 patients underwent fusion due to underlying spinal instability. While there were no reports of cyst recurrence in their series or in the literature in patients who only received decompression, this is likely due to the limited follow-up time available for the study population. Longer follow-up and prospective and biomechanical studies are needed to corroborate these findings.

Synovial cysts of the cervicothoracic junction causing myelopathy: report of 3 cases and review of the literature

Synovial cysts are uncommon pathological entities in patients with cervical degenerative spinal disease, and there are only a few reports in the literature. Treatment typically involves decompression; however, biomechanical data indicate that laminectomies in the cervical spine also result in cervical instability, specifically within the cervicothoracic junction, supporting the use of fusion as well. The authors describe the use of fusion with decompression in the treatment of 3 patients with cervicothoracic synovial cysts that presented in an acute fashion with associated myelopathy and neurological decline, and they review the diagnostic elements, histopathology, and treatment of these cysts. All 3 of the patients did well with decompression via a posterior approach with a single-level instrumented fusion from C-7 to T-1. Each patient regained complete neurological function and had no residual neurological deficits. These results are promising, although the sample size of 3 cases is too small to make any conclusive evaluations. Future studies incorporating Class I and Class II data are imperative to make firm conclusions regarding general management of this rare entity.

Symptomatic facet cysts of the subaxial cervical spine

Subaxial cervical facet cysts are uncommon. We report two patients with intraspinal, extradural, subaxial cervical spinal facet cysts, and review the literature to describe the epidemiology, clinical presentation, imaging findings, and treatment options for these lesions. Intraspinal, extradural, cervical spinal cysts should be considered as part of the differential diagnosis in patients presenting with clinical signs of cervical radiculopathy or myelopathy.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cervical degenerative intraspinal cyst: a case report and literature review involving 132 cases

Intraspinal and extradural cysts in the cervical spine are rare disorders that may cause myelopathy or radiculopathy. A synovial cyst or ganglion derived from the facet joint and that from a ligamentum flavum have been reported. We report a surgical case of degenerative intraspinal cyst, causing cervical myelopathy. MRI of a case revealed cystic lesion at C4-5. Spinal cord was compressed by cyst and symptoms of myelopathy were also observed. The patient with cervical spinal canal stenosis underwent laminoplasty and excision of the cyst. The patient recovered well immediately after the surgery. Literature review showed that 133 patients have been reported, including the present case. Previous reports indicated that most cysts occurred in old patients and at the atlanto-axial or C7-T1 junction, and laminectomy or laminoplasty with excision of the cyst gave good results in most cases.

Management of lumbar spine juxtafacet cysts

OBJECTIVE

We review a series of 21 patients with lumbar juxtafacet cysts (LJFCs) treated in two institutions.

METHODS

The charts of 21 patients with a diagnosis of LJFCs during a 6- year period, January 2001 to December 2006, treated at Hamad Hospital, Doha, Qatar, and El Ribat University Hospital, Khartoum, Sudan, were reviewed. Demographic data, clinical and imaging findings, management, and outcome were reviewed.

RESULTS

Twenty-one patients with 23 LJFCs were identified (14 men, 7 women) with a mean age of 54 years. All presented with back pain and radicular symptoms. Ten patients presented with neurogenic claudication due to spinal canal stenosis. All had magnetic resonance imaging and dynamic spine radiographs. Fourteen LJFCs were found at L4-5 level, 8 at L5-S1 level, and 1 at L3-4 level. Three patients had sustained improvement with conservative treatment and 17 patients underwent surgical management, mainly through a microsurgical approach. Nine of 10 patients with lumbar canal stenosis underwent decompressive laminectomy; one patient refused treatment. One patient with bilateral LJFCs and mobile spondylolisthesis underwent spinal fusion. All patients, except one, were followed up for a period of 12-72 months.

CONCLUSIONS

LJFCs may lead to symptoms similar to degenerative disc disease. Surgery is reserved for symptomatic patients who do not improve satisfactorily with conservative treatment. The microsurgical approach is our preferred surgical method and spinal fusion should be reserved for patients with spinal instability. Long-term outcome with surgical treatment appears satisfactory.

Juxtafacet cysts of the lumbar spine: a positional MRI study

BACKGROUND/AIMS

Juxtafacet cysts (JFC) are related to facet joint degeneration. Supine MRI is routinely used to evaluate JFC. However, some JFC are missed and found only intraoperatively. The present study addresses positional MRI features and factors leading to variation in the size of JFC.

METHODS

Fifty patients in whom positional MRI had been performed were investigated retrospectively and 67 distinct intraspinal or intraneuroforaminal were JFC found. Signal intensity, size of the JFC, the presence and variance of a vertebral slip and the angular movement of affected segments were assessed in supine, neutral sitting, flexion (sitting) and extension (standing). The overall movement of the spine and the lordosis angle in different positions were measured.

RESULTS

JFC varied in size in segments with unstable slip and increased angular movement (variation of the angle in the affected segment in function: 13.3 degrees compared to 8.7 degrees). JFC with bright signals tended to vary in size compared to JFC with intermediate or low signal intensity (all: p < 0.001). Joint effusion and displacement of effusion lead to formation and variations in the size of JFC. JFC were most prominent in extension: 6.7 mm, less prominent in supine: 5.5 mm and in neutral sitting position: 4.6 mm (all p < 0.05). The detection rate for JFC was 97% for extension, 89% for supine and 78% for neutral sitting.

CONCLUSIONS

The detection rate of JFC improves with increasing lordosis of the spine and under weight-bearing conditions, particularly when standing. Unstable slipping or increased angular movement affects the size of JFC.

Degenerative intraspinal cyst of the cervical spine

We describe two cases of degenerative intraspinal cyst of the cervical spine that caused a gradually progressive myelopathy. One case had a cyst that arose from the facet joint and the other case had a cyst that formed in the ligamentum flavum. The symptoms improved immediately after posterior decompression by cystectomy with laminoplasty.

Cervical juxtafacet cyst after anterior cervical discectomy and fusion

Anterior cervical discectomy and fusion (ACDF) is a common neurosurgical procedure, and the benefits, long-term outcomes, and complications are well described in the literature. The development of a juxtafacet joint cyst resulting in radiculopathy is a rare outcome after ACDF and merits further description. The authors describe a patient in whom a juxtafacet joint cyst developed after ACDF procedures, resulting in surgical intervention. When a juxtafacet joint cyst develops after ACDF, symptoms can include radiculopathy, neck pain, and neurological symptoms such as paresthesias and motor weakness. The presence of a juxtafacet joint cyst implies instability in that region of the spine. Patients with this pathological entity may require decompression of neural elements and fusion across the segment involved with the cyst.

Cervical juxtafacet cyst with myelopathy due to postoperative instability. Case report

A 74-year-old man presented with a cervical juxtafacet cyst on the right side of C5-6 and prominent myelopathy. He had been treated with anterior cervical discectomy and fusion at C4-5 as well as anterior foraminotomy of the right C5-6 lesion 20 months previously. The patient underwent complete surgical excision of the lesion. The patient recovered uneventfully, and the myelopathy resolved. Reexamination of the images revealed that we failed to investigate a suspicious minimal cervical juxtafacet cyst on the initial preoperative images and that the degree of subluxation at C5-6 on flexion radiography had increased postoperatively. Therefore, the surgeon should be aware that juxtafacet cyst can be progressive in planning of cervical spinal surgery which can cause or aggravate instability in the presence of an incidental, suspicious juxtafacet cyst on preoperative imaging at the same level, even if the lesion is very small and subclinical.

[Computed tomography and magnetic resonance imaging for painful spinal column: contributions and controversies]

The use of tomographic imaging techniques, computed tomography (CT) and magnetic resonance imaging (MRI), to complement or replace plain-film radiography in the study of spine pain is becoming more and more common. The aim of this paper is to provide a general review of the CT and MRI manifestations of the wide spectrum of lesions that can cause pain in the spinal column. This spectrum includes degenerative disease, malalignment, tumors, inflammatory processes, and infectious processes. Precise knowledge and accurate reporting of the findings at CT and MRI are fundamental for clinical decision making in patients with spine pain.

Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systematic review of reported postoperative outcomes

BACKGROUND CONTEXT

With improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.

PURPOSE

To determine the cumulative incidence of postoperative symptomatic relief, recurrent back and leg pain after cyst resection and decompression, and synovial cyst recurrence.

STUDY DESIGN

Systematic review of the literature.

PATIENT SAMPLE

All published studies to date reporting outcomes of synovial cyst excision with and without spinal fusion.

OUTCOME MEASURES

Cyst recurrence and Kawabata, Macnab, Prolo, or Stauffer pain scales.

METHODS

We performed a systematic literature review of all articles published between 1970 and 2009 reporting outcomes after surgical management of spinal synovial cysts.

RESULTS

Eighty-two published studies encompassing 966 patients were identified and reviewed. Six hundred seventy-two (69.6%) patients presented with radicular pain and 467 (48.3%) with back pain. The most commonly involved spinal level was L4-L5 (75.4%), with only 25 (2.6%) and 12 (1.2%) reported synovial cysts in the cervical or thoracic area, respectively. Eight hundred eleven (84.0%) patients were treated with decompressive surgical excision alone, whereas 155 (16.0%) received additional concomitant spinal fusion. Six hundred fifty-four (92.5%) and 880 (91.1%) patients experienced complete resolution of their back or leg pain after surgery, respectively. By a mean follow-up of 25.4 months, back and leg pain recurred in 155 (21.9%) and 123 (12.7%) patients, respectively. Sixty (6.2%) patients required reoperation, of which the majority (n=47) required fusion for correction of spinal instability and mechanical back pain. Same-level synovial cyst recurrence occurred in 17 (1.8%) patients after decompression alone but has been reported in no (0%) patients after decompression and fusion.

CONCLUSIONS

Surgical decompression results in symptomatic resolution in the vast majority of patients; however, recurrent back pain occurs in a significant number of patients. Cyst recurrence occurs in less than 2% of patients but has never been reported after cyst excision with concomitant fusion. The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine.

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

STUDY DESIGN

Retrospective study.

OBJECTIVE

Compare outcomes of different treatment methods for intraspinal synovial cysts.

SUMMARY OF BACKGROUND DATA

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

METHODS

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

RESULTS

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

CONCLUSION

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

Evidence that atypical juxtafacet cysts are joint derived

OBJECT

Juxtafacet cysts (JFCs) in usual locations have recently been shown to have joint connections. The pathogenesis of JFCs in unusual locations has remained obscure. The authors hypothesize that all JFCs, including atypical ones, are joint derived.

METHODS

In this study the authors sought to explain the occurrence and formation of clinical outliers of spinal JFCs. In Part I, they performed an extensive literature search to identify case reports of spinal intraneural cysts that have been unappreciated despite the fact that they should occur. In Part II, they studied far-lateral (extraforaminal) cysts treated at their institution and reported in the literature. The presence of a joint connection was specifically looked for since this finding has not been widely appreciated.

RESULTS

In Part I, 3 isolated case reports of spinal intraneural JFCs without reported joint connections were identified: 2 involving L-5 and 1, C-8. In Part II, 6 cases involving patients with far-lateral JFCs treated at the authors' institution were reviewed and all 6 had joint connections. Two of these cases had been previously published, although their joint connections were not appreciated. In 2 of the newly reported cases, arthrography confirmed a communication between the facet and the cyst. Only 1 of 5 cases in the literature had a recognized joint connection.

CONCLUSIONS

The authors believe that all JFCs are joint derived. This explanation for intraneural and extraneural JFCs in typical locations would be consistent with the unified articular (synovial) theory and the pathogenesis for intraneural and extraneural ganglion cyst formation in the limbs. Facet joints appear no different from other synovial joints occurring elsewhere. Understanding the pathogenesis of these cysts will help target treatment to the joint, improve surgical outcomes, and decrease recurrences.

Synovial cyst of the thoracic spine causing myelopathy

STUDY DESIGN

Pre- and postoperative follow-up of a patient with progressive myelopathy caused by a thoracic synovial cyst developing within 6 months.

OBJECTIVE

To present the natural history of a developing thoracic synovial cyst and to highlight this unusual case.

SUMMARY OF BACKGROUND DATA

Thoracic synovial cysts are a rare finding and can produce myelopathy from spinal cord compression. The patient presented with progressing spasticity and sensory loss of both legs. Hereditary motor-sensory neuropathy was suspected and excluded by a molecular genetic examination. The cause of deterioration was finally found in an MRI of the thoracic spine revealing the rapid growth of a synovial cyst that had been detected in a previously performed MRI 6 months earlier.

METHODS

Clinical and MRI details are presented documenting the natural history and development of a thoracic synovial cyst causing myelopathy.

RESULTS

The thoracic synovial cyst was successfully decompressed. Stabilization and fusion were not performed. The myelopathy resolved after surgery and the patient stays well in the 6-months follow-up.

CONCLUSION

Although thoracic synovial cysts are a rare finding, they have to be considered as a source for progressive myelopathy. If an MRI of the spine does not reveal any pathologies, it should be repeated even after a short period of time if the patient's condition deteriorates, continuously to detect newly developed findings.

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.

Myelopathic presentation of cervical juxtafacet cyst: a case report

STUDY DESIGN

Case report.

OBJECTIVES

Discussion about the nature of the lesion, its various presentations, image characteristics, clinical features, surgical treatment, and patient outcome.

SUMMARY OF BACKGROUND DATA

Juxtafacet cysts are uncommon intraspinal lesions most frequently found in the lumbar region. They usually originate as monoradicular compression syndrome mimicking disc herniation. In the cervical spine, they are rare and also have similar clinical features to intervertebral disc protrusion. However, the image findings are highly discriminative and often lead to accurate diagnosis. The cyst occupies a posterolateral position within the spinal canal, displacing the nerve root anteriorly. This situation is better seen in magnetic resonance imaging, but computed tomography scan and plain myelography also point to a diagnosis. The posterolateral site in the spinal canal can be accessed directly by a single-level laminectomy or hemilaminectomy. These are epidural lesions, usually cystic, attached to the facet joint and protruding into the intervertebral foramen. Recurrence after surgery is extremely rare and has only been reported in the lumbar spine.

METHODS

In this article, we report the case of a male patient, 64 years of age, who presented with a progressive and severe myelopathy associated with multiple mononeuropathy, which delayed the diagnosis and treatment of the main neurologic condition, a cervical spinal compressive syndrome, proven to have originated as a juxtafacet cyst. The patient underwent complete surgical excision of the lesion.

RESULTS AND CONCLUSIONS

The patient had good recovery of the myelopathy, and 6 months after surgery, he was able to walk. A follow-up of 2.5 years has not revealed any recurrence or new neurologic conditions.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN/SETTING

Retrospective review set in outpatient physiatry office.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Thoracic radiculopathy

Thoracic radiculopathy represents an uncommon spinal disorder that is frequently overlooked in the evaluation of spinal pain syndromes. Degenerative disc disease and diabetes mellitus may frequently cause radiculopathy at the thoracic level. Electromyography and magnetic resonance imaging are useful in the evaluation of radiculopathy and thoracic spinal pain syndromes. Percutaneous vertebroplasty is a procedure that may be used in the treatment of thoracic spinal pain syndromes. Surgical intervention for thoracic radiculopathy usually is reserved for patients with progressive myelopathy and neurologic compromise.

Rarer causes of radiculopathy: spinal tumors, infections, and other unusual causes

For the physiatrist practicing musculoskeletal medicine, patients with radiculopathy are a challenging and rewarding population for whom to provide care. Despite the rarity of diseases discussed in this article, at some time in his or her career every musculoskeletal physiatrist will see patients with these diagnoses as the cause of radiculopathy or back pain. A high index of suspicion is necessary to identify these rare disease processes accurately and promptly. The patient's history, examination, and plain-film radiographic evaluations remain the best tools with which to establish a differential and working diagnosis. The most important services that the physiatrist can provide to these patients are an astute application of the differential diagnosis to identify the specific etiology and the leadership required to organize a multi-disciplinary team of specialists to address all of the patient's needs.

Ganglion cyst in the ligamentum flavum of the cervical spine causing myelopathy: report of two cases

BACKGROUND

Ganglion cyst in the ligamentum flavum is commonly found in the lower lumbar region; occurrence in the cervical region is extremely rare. We report two cases of ganglion cyst in the cervical region and the clinical, pathological, and radiological findings.

METHODS

The first patient was an 81-year-old man who was admitted to our hospital with gradually progressive gait disturbance and radiating pain in both arms and legs, which was dominant on the left side. The second patient was a 65-year-old man with progressive muscle weakness of the extremities who was admitted with radiating pain in the right arm. In both cases, the cervical spinal cord had been compressed by the cystic mass with degeneration of the ligamentum flavum (the former left, the latter right) at the level of C3-4.

RESULTS

The extradural-intraspinal cystic masses, which were revealed by computed tomography (CT) and magnetic resonance imaging (MRI) to be situated antero-laterally to the cervical laminae, were removed surgically without difficulty. After surgery, the symptoms and neurologic signs improved in both cases.

CONCLUSIONS

Ganglion cyst in the ligamentum flavum of the cervical spine is a very rare lesion causing radiculo-myelopathy. In both our cases, a correct diagnosis could be established preoperatively based on CT myelogram and MRI findings, and the results of surgery were excellent.