The prevalence and pathogenesis of synovial cysts within the ligamentum flavum in patients with lumbar spinal stenosis and radiculopathy

Cysts of the ligamentum flavum are often linked to ischemic conditions: A morphological study

"Cysts of the ligamentum flavum (cysts-LF)" is the term for non-neoplastic cystic lesion involving LF. The aim of the present study was to elucidate the histopathological characteristics and pathogenesis of "cysts-LF". Herein, we defined cysts-LF as spinal cysts containing degenerative LF components. From archival cases, we investigated 18 symptomatic cysts-LF surgically removed from 18 patients (13 males and five females; median age 68.5 years [range, 42-86 years]). The elastic fibers of LF components in the wall were separated and/or torn, and cyst walls were accompanied by chondroid metaplasia (17 cases), myxoid changes (13 cases), ossification (11 cases), amyloid deposits (14 cases), hemosiderosis (six cases), granular/smudgy calcification (four cases), synovial cell linings (three cases), and severe inflammatory infiltrates (one case). These histologic features of our cysts-LF were shared by previously reported "cysts-LF." Fourteen cysts-LF demonstrated vascular stenosis/occlusion, and eight showed thick hyalinized vessels, suggesting local circulatory insufficiency. Eight cases (44%) exhibited lipomembranous fat necrosis, accompanied by hyalinized vascular changes (p = 0.003). Ischemic conditions were observed in nearly half of the present cysts-LF, and may be one of the main contributing factors for the formation of cysts-LF, via degeneration and cystic changes in the LF.

A rare gas-containing lumbar synovial cyst treated by percutaneous transforaminal endoscopic cystectomy: A case report and literature review

Spinal synovial cysts are rare entities for which standard surgical strategies are inconsistent. Here, we present an uncommon intraspinal gas-containing synovial cyst treated by percutaneous transforaminal endoscopic cystectomy. A 52-year-old man presented with radicular pain and intermittent claudication that had persisted for one month. Computed tomography revealed an intraspinal cystic lesion anteromedial to the left L4-L5 articular joint and the center of the lesion manifested gas contents. A transforaminal endoscopic procedure was performed and confirmed as a safe and minimally invasive technique for gas-containing lumbar synovial cysts. It provides a valuable substitution and supplementation to open surgery.

Gas containing intraspinal synovial cyst in the lumbar spine: Case report and literature review

Intraspinal synovial cyst (ISC) is a well-documented pathology. It is sometimes found in the degenerative lumbar spine and can result in neurological disorders. ISC typically contains xanthochromic fluid, blood, inflammatory tissue, and/or osseous structures, enclosed by fibrous tissue. Regarding the treatment modalities, the effectiveness of both nonsurgical management, such as oral analgesics, needle aspiration, and intra-articular injection of corticosteroid drugs, and surgical management, have been reported. Previous studies have described that the ISC can contain gas, which is derived from the vacuum phenomenon of an adjacent facet joint; however, this clinical condition has never been systematically investigated because of its rarity. In the present report, we describe the case of a 68-year-old male with gas-containing ISC in the lumbar spine who was successfully treated with surgical management; additionally, we performed a literature review to discuss the decision-making process for cases of gas-containing ISC. Based on our findings and previous literature, we recommend that considering the peculiarity of the content of such lesions in addition to the ball-valve effect of a synovial cyst, prompt transition to surgical management would be pertinent when nonsurgical treatment cannot achieve satisfactory outcomes in such cases.

OLIF Combined with Anterior Fixation for Lumbar Synovial Cysts with Instability

BACKGROUND

The optimal management of lumbar synovial cysts (LSCs) has always been controversial. Open or minimally invasive partial hemilaminotomy as a direct decompression approach has been widely studied, whereas to our knowledge, there has been no report of an indirect decompression method for LSC.

CASE DESCRIPTION

A 60-year-old male complained of chronic low back pain for 2 years. He reported that the pain had been getting worse and started radiating to the bilateral posterior thighs and right lateral calf for 6 months. An ovoid lesion with a hyperintense center attached to the medial side of the right facet joint at the L4-5 level, as well as L4-5 dynamic instability, were found with magnetic resonance imaging and lumbar x-ray examinations, respectively. L4-5 oblique lumbar interbody fusion combined with anterior fixation was performed. After surgery, the patient felt distinct pain relief and was discharged on the third day postoperatively. Three months later, lumbar magnetic resonance imaging and 3-dimensional computed tomography were performed again. The L4-5 disk height and foraminal height recovered from 7.1-12.3 mm and 14.8-18.5 mm, respectively. No evidence of a cyst was disclosed. The patient did not complain of any low back pain or radicular pain during the 12-month follow-up.

CONCLUSIONS

Indirect decompression surgery may be a new option for the management of LSC, especially in those with lumbar instability and that communicate with the facet joint. Further research with a larger and more comprehensive sample population is required.

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

BACKGROUND

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

PATHOGENESIS

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

TREATMENT

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

The Role of Imaging in the Management of Cystic Formations of the Mobile Spine (CYFMOS)

PURPOSE OF REVIEW

The purpose of this review is to give a better understanding of the pathogenesis of cystic formations of the mobile spine (CYFMOS) and the correlating imaging findings. This would help with medical decision-making, given the plethora of conservative, interventional, and surgical treatment options.

RECENT FINDINGS

There has been a general understanding that CYFMOS are associated with degenerative spine changes. More recent articles however have suggested that identifying detailed imaging characteristics can assist in determining outcomes when CYFMOS are treated with interventional percutaneous methods or surgical decompression with or without concomitant fusion. CYFMOS although uncommon are not a rare finding seen in the spine when there is a background of degenerative spine changes. These cystic lesions are generally symptomatic by exhibiting mass effect on adjacent structure. Most treatments are aimed at decompression by interventional percutaneous or surgical means. Various imaging characteristics of these CYFMOS described in this article including their signal intensity, presence of spinal instability, particular patterns of adjacent degenerative changes, and imaging changes following interventional treatments can help guide physicians when managing these cases.

Lumbar synovial cyst with chronic viral hepatitis: A case series and literature review

Cystic dilatation of synovial sheath, one of the targets of extra-hepatic manifestations associated with liver disease, is a main pathologic finding of lumbar synovial cyst (LSC). However, LSCs are not well documented in correlation with chronic viral hepatitis. In this case series, three patients with chronic viral hepatitis presented with radiating pain in the unilateral lower extremities. On magnetic resonance imaging of the lumbar spine, all had unilateral LSCs at the facet joint of the lumbar spine. Two did not have definite spinal instability at the LSC level. Ultimately, all three showed clinical improvements following epidural spine interventions.

Development of Bilateral Facet Cysts Causing Recurrent Symptoms After Decompression and the Placement of an Intralaminar Implant: A Case Report

CASE

We report the development of bilateral symptomatic facet joint cysts in a 78-year-old man who had been treated with decompression and placement of a coflex device (Paradigm Spine) at L3-L4 and L4-L5. Preoperative imaging clearly demonstrated fluid in the facet joints without cysts. He underwent standard surgical treatment, but developed symptomatic facet joint cysts at 4 months postoperatively. The patient was treated with a revision decompression and replacement of the devices; there were no issues at the 32-month follow-up.

CONCLUSION

While the coflex device has possible long-term biomechanical advantages, vigilance with adherence to appropriate decompression surgical technique is necessary.

Midline Ligamentum Flavum Cyst of Lumbar Spine

BACKGROUND

Ligamentum flavum cysts are thought to develop due to facet joint hypermobility; however, the etiology of these lesions is not completely elucidated. These cysts may lead to compressive pathologies of the spine requiring surgical intervention.

CASE REPORT

We report the case of a 63-year-old male with chronic back pain and progressive neurogenic claudication for 6 months. He was found to have a ligamentum flavum cyst situated along the dorsal midline of the lumbar spinal canal contributing to spinal stenosis. The patient underwent a decompressive L4 laminectomy and en bloc excision of the ligamentum flavum cyst with complete resolution of his symptoms postoperatively.

CONCLUSIONS

We suggest that chronic mechanical stress leads to degeneration of the ligamentum flavum and contributes directly to cyst formation.

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.

Evaluation and Treatment of Lumbar Facet Cysts

Lumbar facet cysts are a rare but increasingly common cause of symptomatic nerve root compression and can lead to radiculopathy, neurogenic claudication, and cauda equina syndrome. The cysts arise from the zygapophyseal joints of the lumbar spine and commonly demonstrate synovial herniation with mucinous degeneration of the facet joint capsule. Lumbar facet cysts are most common at the L4-L5 level and often are associated with spondylosis and degenerative spondylolisthesis. Advanced imaging studies have increased diagnosis of the cysts; however, optimal treatment of the cysts remains controversial. First-line treatment is nonsurgical management consisting of oral NSAIDs, physical therapy, bracing, epidural steroid injections, and/or cyst aspiration. Given the high rate of recurrence and the relatively low satisfaction with nonsurgical management, surgical options, including hemilaminectomy or laminotomy to excise the cyst and decompress the neural elements, are typically performed. Recent studies suggest that segmental fusion of the involved levels may decrease the risks of cyst recurrence and radiculopathy.

Hemorrhagic lumbar synovial facet cyst secondary to transforaminal epidural injection: A case report and review of the literature

A 64-year-old-female presented with progressive left foot weakness, low back and radicular pain after a left sided S1 transforaminal epidural steroid injection (ESI). Magnetic resonance imaging revealed left side L5-S1 large extradural heterogeneous mass with layering areas suggesting different stages of hematoma formation. Past medical history was significant for peripheral vascular disease and transient ischemic attacks, for which she took aspirin and clopidogrel (antiplatelet agent). These medications were discontinued one week prior to ESI. Although synovial cysts associated with facet arthropathy are common, hemorrhagic cyst is not. To the best of the authors’ knowledge, this is the first reported case of symptomatic hemorrhagic lumbar facet synovial cyst following ESI on a patient taking anti-platelet medications.

Professor Barrie Vernon-Roberts, AO, MD, BSc, PhD, FRCPath, FRCPA, FAOrthA (Hon), FRS.SA

This issue of Inflammopharmacology contains papers that have been submitted to commemorate the life and work of Professor Barrie Vernon-Roberts, an outstanding clinical scientist in the field of bone pathology and its pharmacological regulation. This review briefly summarizes his major works and achievements as well as a list of his publications.

Bilateral thoracic ganglion cyst : a rare case report

Ganglion cysts usually arise from the tissues around the facet joints. It is usually associated with degenerative cahanges in facet joints. Bilateral thoracic ganglion cysts are very rare and there is no previous case that located in bilateral intervertebral foramen compressing the L1 nerve root associated with severe radiculopathy. We report a 53 years old woman who presented with bilateral groin pain and severe numbness. Magnetic resonance imaging revealed bilateral cystic mass in the intervertebral foramen between 12th thoracal and 1st lumbar vertebrae. The cystic lesions were removed after bilateral exposure of Th12-L1 foramens. The result of hystopathology confirmed the diagnosis as ganglion cyst. The ganglion cyst may compromise lumbar dorsal ganglion when it located in the intervertebral foramen. The surgeon should keep this rare entity in their mind for differential diagnosis.

Clinical characteristics of intraspinal facet cysts following microsurgical bilateral decompression via a unilateral approach for treatment of degenerative lumbar disease

PURPOSE

Primary intraspinal facet cysts in the lumbar spine are uncommon, but it is unclear whether cyst incidence increases following decompression surgery and if these cysts negatively impact clinical outcome. We examined the prevalence, clinical characteristics, and the risk factors associated with intraspinal facet cysts after microsurgical bilateral decompression via a unilateral approach (MBDU).

METHODS

We studied 230 patients treated using MBDU for lumbar degenerative disease (133 men and 97 women; mean age 70.3 years). Clinical status, as assessed by the Japanese Orthopedic Association (JOA) score and findings on X-ray and magnetic resonance images, was evaluated prior to surgery and at both 3 months and 1 year after surgery. The prevalence of intraspinal facet cysts was determined and preoperative risk factors were defined by comparing presurgical findings with clinical outcomes.

RESULTS

Thirty-eight patients (16.5%) developed intraspinal facet cysts within 1 year postoperatively, and 24 exhibited cysts within 3 months. In 10 patients, the cysts resolved spontaneously 1 year postoperatively. In total, 28 patients (12.2%) had facet cysts 1 year postoperatively. The mean JOA score of patients with cysts 1 year postoperatively was significantly lower than that of patients without cysts. This poor clinical outcome resulted from low back pain that was not improved by conservative treatment. Most cases with spontaneous cyst disappearance were symptom-free 1 year later. The preoperative risk factors for postoperative intraspinal facet cyst formation were instability (OR 2.47, P = 0.26), scoliotic disc wedging (OR 2.23, P = 0.048), and sagittal imbalance (OR 2.22, P = 0.045).

CONCLUSIONS

Postoperative intraspinal facet cyst formation is a common cause of poor clinical outcome in patients treated using MBDU.

Chiropractic management of a patient with lumbar spine pain due to synovial cyst: a case report

INTRODUCTION

The purpose of this study is to report the findings resulting from chiropractic care using flexion distraction spinal manipulation for a patient with low back and radicular pain due to spinal stenosis caused by a synovial cyst.

CASE REPORT

A 75-year-old man presented with low back pain radiating to the right anterior thigh and down the left posterior leg of 3 years' duration. Physical and imaging examinations showed a synovial cyst-induced spinal stenosis at the right L3-L4 level and bilateral L4-L5 spinal stenosis.

INTERVENTION AND OUTCOMES

Flexion distraction spinal manipulation and physiological therapeutics were applied at the levels of stenosis. After 4 visits, the patient noted total absence of the right and left lower extremity pain and no adverse reaction to treatment. After 3 months of treatment and 16 visits, his low back and buttock pain were minimal; and he had no leg pain.

CONCLUSION

Lumbar synovial cyst and stenosis-generated low back and radicular pain was 80% relieved in a 75-year-old man following Cox flexion distraction spinal manipulation.

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.

Synovial cysts: to fuse or not to fuse?

Bydon A, Xu R, Parker SL, et al. Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systemic review of reported postoperative outcomes. Spine J 2010;10:820-826 (in this issue).

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.