Microsurgical treatment of juxta facet cysts of the lumbar spine

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.

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.

Microsurgical Resection of a Lumbar Synovial Cyst: 2-Dimensional Operative Video

Lumbar spine synovial cysts develop from degenerated zygapophyseal joints. Symptomatic patients present with radicular pain and weakness or neurogenic claudication.1 In the absence of significant concomitant degenerative spondylolisthesis, symptomatic patients can be managed with a laminectomy and microsurgical resection of the cyst, without the need for instrumented fusion.2,3 In this video, we present the microsurgical resection of a left-sided L4-5 synovial cyst in a 68-yr-old man with radicular pain refractory to conservative management. The radiographical features, relevant surgical anatomy, and salient operative steps are reviewed, and strategies for preventing cyst recurrence are emphasized. There were no complications, the postoperative course was unremarkable, and the patient was discharged on postoperative day 1 with significant improvement in his presenting symptoms. No identifying information is present, and patient consent was obtained for the procedure and for publishing the material included in this video.

[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.

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.

Percutaneous Translaminar Facet Cyst Rupture and Epidural Access-Description of a Novel Technique

Synovial cysts of the lumbar zygapophysial joints can be treated by percutaneous injection of corticosteroids, with distension and rupture of the cyst. Some cysts can be difficult to access, particularly when they lie deep in relation to the lamina. This technical report describes a fluoroscopy-guided technique for accessing sublaminar pathology. Crucial to the safety of the technique is visualization of the ventral margin of the lamina using a contralateral oblique view, and controlling and limiting the insertion of the needle such that only its tip passes the lamina.

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.

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.

Contralateral Juxtafacet Cyst Development after the Spontaneous Resolution of a Previous Facet Cyst

Juxtafacet cysts are implicated in neural compression. Thus far, it is known that surgical removal is the definitive treatment for symptomatic juxtafacet cyst because spontaneous regression is rare, and the failure rate of conservative treatment is high. We have reported a rare case of right-sided juxtafacet cyst development after the spontaneous resolution of contralateral left-sided facet cyst. The left-sided facet cyst resolved spontaneously without surgical treatment, but a juxtacyst developed on the contralateral facet on the right side, as illustrated on 4-year follow-up magnetic resonance images. To the best of our knowledge, this is the first report of newly developed contralateral juxtafacet cyst after spontaneous regression. Herein, we have discussed the natural history and the management of this rare case.

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.

Lumbar intraforaminal synovial cyst in young adulthood: case report and review of the literature

Study Design Case report. Objective Lumbar juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Most patients with lumbar cysts are in their sixth decade of life and have significant facet joint and disk degeneration. Lumbar synovial cysts (LSCs) are extremely rare in adolescence and young adulthood, and to our knowledge, only two pediatric cases of LSC have been reported in the literature. We aim to prove the existence of LSC in adolescent patients as a real entity that causes low back and radicular complaints and to discuss the possibility of traumatic injury as a pathogenic cause of LSC formation in adolescence. A case of an 18-year old patient with LSC is presented. We report the clinical presentation, management, outcome, and review of the literature, focusing on issues that remain debatable. Methods The case is presented together with its clinical course, the diagnostic techniques, the surgical findings, histologic results, and the treatment outcome. Results After surgical treatment, the patient's complaints were alleviated and almost no complaints were registered during the next 6 months' follow-up. Conclusions LSCs are extremely rare in adolescence, but they could be considered in the differential diagnosis in adolescent patients with low back pain and radiculopathy. Surgical removal of LSC could be considered as a treatment option to provide immediate and safe symptomatic relief.

Operation of Lumbar Zygoapophyseal Joint Cysts Using a Full-Endoscopic Interlaminar and Transforaminal Approach

In appropriate situations, extensive decompression with laminectomy often continues to be described as the method of choice for operations involving lumbar zygoapophyseal joint (z-joint) cysts. Tissue-sparing procedures are nevertheless becoming more common. Endoscopic techniques have become the standard procedures in many areas because of the advantages they offer in terms of surgical technique and in rehabilitation. One key aspect in spinal surgery was the development of instruments for sufficient bone resection carried out under continuous visual control. This enabled endoscopes to be used when operating on z-joint cysts. The objective of this prospective study was to examine the technical possibilities for the full-endoscopic interlaminar and transforaminal technique in lumbar z-joint cysts. A total of 74 patients were followed up for 2 years. The results show that 85% of the patients no longer have any leg pain or that the pain had been almost completely eliminated, and 11 % experience occasional pain. The complication rate was low. The full-endoscopic techniques brought advantages in the following areas: operation, complications, traumatization, and rehabilitation. The recorded results show that full-endoscopic resection of a z-joint cyst using an interlaminar and transforaminal approach provides an adequate and safe supplement, and is an alternative to conventional procedures when the indication criteria are fulfilled. It also offers the advantages of a minimally invasive intervention.

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.

The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration

Background:

The surgical management of lumbar synovial cysts that have extruded into the spinal canal remains controversial (e.g. decompression with/without fusion).

Methods:

The neurological presentation, anatomy, pathophysiology, and surgical challenges posed by synovial cysts in the lumbar spine are well known. Neurological complaints typically include unilateral or, more rarely, bilateral radicular complaints, and/or cauda equina syndromes. Anatomically, synovial cysts constitute cystic dilatations of synovial sheaths that directly extrude from facet joints into the spinal canal. Pathophysiologically, these cysts reflect disruption of the facet joints often with accompanying instability, and potentially compromise both the cephalad and caudad nerve roots.

Results:

Aspiration of lumbar synovial cysts, which are typically gelatinous and non-aspirable, and typically performed by “pain specialists” (e.g. pain management, rehabilitation, radiologists, others) utilizing fluoroscopy or CT-guided aspiration, is associated with 50–100% failure rates. Surgical decompression with/without fusion (as the issue regarding fusion remains unsettled) results in the resolution of back and radicular pain in 91.6–92.5% and 91.1–91.9% of cases, respectively.

Conclusions:

After a thorough review of the literature, it appears that the treatment with the best outcome for patients with synovial cysts is cyst removal utilizing surgical decompression; the need for attendant fusion remains unsettled. The use of an alternative treatment, percutaneous aspiration of cysts, appears to have a much higher recurrence and failure rate, but may be followed by surgery if warranted.

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.

Diagnostic challenge: bilateral infected lumbar facet cysts--a rare cause of acute lumbar spinal stenosis and back pain

Symptomatic synovial lumbar facet cysts are a relatively rare cause of radiculopathy and spinal stenosis. This case and brief review of the literature, details a patient who presented with acutely symptomatic bilateral spontaneously infected synovial facet (L4/5) cysts. This report highlights diagnostic clues for identifying infection of a facet cyst.

Spinal synovial cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review

This study is designed based on the retrospective analysis of patients treated in the Neurosurgical Department of two major hospitals and review of the literature. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic lumbar intraspinal synovial cysts. Spinal juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Although the relevant reports in the international literature are increasing, the controversy about conservative versus surgical treatment and the need for concomitant fusion still exists. Data from seven patients (age range 58-69 years, mean age 61 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concomitant local pathology, treatment and results of treatment were recorded. A follow-up of at least 6 months (range 6-48 months) was conducted and results were noted. All patients had back pain, while five also experienced unilateral radicular leg pain and one had bilateral leg pain. One patient had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. No fusion was performed. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. Review of the literature revealed a trend towards surgery, as this is correlated to a more favorable outcome compared with conservative treatment. Fusion should be performed on a case-by-case basis only. Surgery is a safe and effective treatment choice in this increasingly appearing ailment. A prospective, randomized trial should clarify issues under debate.

CT Guided Aspiration of a Cervical Synovial Cyst. Case Report and Technical note

SUMMARY

Synovial cysts are cystic dilations of synovial sheaths with or without anatomical continuity within a joint space that occasionally involve the lumbar spine. Image-guided aspiration has been used successfully in the management of lumbar synovial cysts. Synovial cysts of the cervical spine are rare, tend to present with myelopathic symptoms, and are classically treated using operative intervention.We report a novel approach for cervical synovial cyst aspiration under CT guidance. A 66-year-old woman presented to the clinic complaining of severe pain, tingling, and dysesthesia in her right upper extremity in the C5, C6 and C7 nerve root distribution. MR imaging of her cervical spine showed a synovial cyst within the right C6-C7 neural foramen with significant compression and obliteration of the C7 nerve root. The patient underwent CT-guided aspiration of the cyst using a double needle technique, where one needle was used to open up the epidural space while another aspirated the cyst. This was followed by epidural injection of local anesthetic and steroids. Immediately after injection, the patient experienced complete relief of her right forearm pain, tingling, and dysesthesias. The patient tolerated the procedure well and there were no postprocedure complications. At four year follow-up the patient is free of any symptoms. Image-guided aspiration of cervical synovial cysts is feasible using CT fluoroscopy. Aspiration of these cysts combined with epidural steroid injection can provide long-lasting symptomatic relief in some patients.