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

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Perspective: Operate on lumbar synovial cysts and avoid ineffective percutaneous techniques

Background

Lumbar synovial cysts (LSC), best diagnosed on MR studies, may cause symptoms/signs ranging from unilateral radiculopathy to cauda equina compressive syndromes. Attempts at percutaneous treatment of LSC typically fail. Rather, greater safety/efficacy is associated with direct surgical resection with/without fusion.

Methods

Treatment of LSC with percutaneous techniques, including cyst aspiration/perforation, injection (i.e., with/without steroids, saline/other), dilatation, and/or disruption/bursting, classically fail. This is because LSCs' tough, thickened, and adherent fibrous capsules cause extensive thecal sac/nerve root compression, and contain minimal central "fluid" (i.e., "crank-case" and non-aspirable). Multiple percutaneous attempts at decompression, therefore, typically cause several needle puncture sites risking dural tears (DT)/cerebrospinal fluid (CSF) leaks, direct root injuries, failure to decompress the thecal sac/nerve roots, infections, hematomas, and over the longer-term, adhesive arachnoiditis.

Results

Alternatively, many studies document the success of direct or even partial resection of LSC (i.e., partial removal with marked cyst/dural adhesions with shrinking down the remnant of capsular tissue). Surgical decompressions of LSC, ranging from focal laminotomies to laminectomies, may or may not warrant additional fusions.

Conclusions

Symptomatic LSC are best managed with direct or even partial operative resection/decompression with/without fusion. The use of varying percutaneous techniques classically fails, and increases multiple perioperative risks.

Ankle and toe weakness caused by calcified ligamentum flavum cyst: A case report

BACKGROUND

Ligamentum flavum cysts, which are most common in mobile junctional levels of the spine, can be a rare cause of spinal stenosis. There have been several case reports of ligamentum flavum cysts. However, there is yet to be a documented case report of a calcified ligamentum flavum cyst. Herein, we report the first case of a calcified ligamentum flavum cyst causing ankle and toe weakness.

CASE SUMMARY

A 66-year-old male visited our hospital complaining of claudication as well as thigh and calf pain in his left leg, all beginning two weeks prior. Physical examination revealed motor weakness of the left ankle dorsiflexion and great toe dorsiflexion. Lumbar spinal computed tomography scans showed spinal stenosis combined with a calcified mass at the left side of the L4-5 level. Magnetic resonance imaging showed dural sac compression caused by the calcified mass at the left ligamentum flavum of the L4-5 level. We performed decompressive laminectomy and excision of the calcified mass combined with posterior lumbar interbody fusion at the L4-5 level. Intra-operatively, we found a firm and nodule like mass originating from the ventral surface of ligamentum flavum. Pathological examination suggested a calcified pseudocyst without a capsular lining. After the operation, the patient's motor weakness in the ankle and great toe improved gradually.

CONCLUSION

The patient's ankle and great toe weakness were improved successfully after surgical removal of the calcified cyst.

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

OBJECTIVE

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

DESIGN

Retrospective data set analysis.

SETTING

University hospital.

SUBJECTS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Efficacy of Percutaneous Image-Guided Rupture of Lumbar Facet Cysts: A Retrospective Study

Background

Percutaneous rupture of lumbar facet cysts (LFC) is the only nonsurgical treatment which is effective in directly reducing cysts. However, this is not yet a common procedure, and its effectiveness, including the associated complications, remains unclear. Therefore, this study aimed to evaluate the clinical outcomes of percutaneous rupture for LFC and elucidate whether this minimally invasive procedure could become an alternative to surgeries for cases resistant to conservative treatments.

Methods

This study investigated 57 symptomatic patients with LFC for whom conservative treatments were ineffective and underwent percutaneous rupture of the LFC. All patients were followed up for >2 years posttreatment. Clinical evaluations (visual analogue scale (VAS) and recovery rate calculated using the Japanese Orthopedic Association (JOA) scores) and radiographic evaluations (size of LFC based on magnetic resonance imaging (MRI)) were performed from pretreatment to the final follow-up examination.

Results

Successful LFC rupture, without hospitalization and general anesthesia, was achieved in 48 patients. No severe complications occurred during treatment through the last observation. Satisfactory clinical results with significant improvements in the VAS and JOA scores were obtained (VAS: pre/posttreatment: 80.7 mm/11.2 mm, JOA: pre/posttreatment: 15.6 points/26.7 points, and recovery rate: 82.3%). A significant reduction in the LFC was also observed in all cases based on the posttreatment MRI findings. No successful rupture cases required subsequent surgical treatments, although four cases of LFC recurrence required additional percutaneous rupture treatment.

Conclusions

Percutaneous rupture for LFC is not only a safe and minimally invasive procedure without any severe complications or requirements for hospitalization and general anesthesia but also a beneficial procedure that can eliminate the need for surgery in cases resistant to conservative treatments.

Selective Nerve Root Block in Treatment of Lumbar Radiculopathy: A Narrative Review

Selective Nerve Root Block (SNRB) is a precise local injection technique that can be utilised to target a particular inflamed nerve root causing lumbar radiculopathy for both diagnostic and therapeutic purposes. Usually, for SNRB to be therapeutic, a combination of a local anaesthetic agent and a steroid is injected under imaging guidance, whereas for diagnostic purposes, just the local anaesthetic agent is injected. While the ideal treatment strategy is to relieve the nerve root from its compressing pathology, local injection of steroids targeted at the affected nerve root can also be attempted to reduce inflammation and thus achieve pain relief. Although the general principle for administering an SNRB remains largely the same across the field, there are differences in techniques depending on the region and level of the spine that is targeted. Moreover, drug combinations utilised by clinicians vary based on preference. The proven benefits of SNRBs largely outweigh their risks, and the procedure is deemed safe and well tolerated in a majority of patients. In this narrative, we explore the existing literature and seek to provide a comprehensive understanding of SNRB as a treatment for lumbar radiculopathy, its indications, techniques, outcomes, and complications.

Incidence and pattern of epidural spread during lumbar facet joint injection: a prospective study

Background

In clinical practice, we have often observed contrast material spreading into the epidural space during lumbar facet joint injection. However, the exact incidence of epidural spread and contrast pattern have not been reported.

Purpose

To evaluate the incidence and pattern of epidural spread in lumbar facet joint injection.

Material and Methods

One hundred consecutive patients (38 men, 62 women; mean age 68 years; age range 20–88 years) who underwent lumbar facet joint injection at two sites between April 2014 and June 2014 were investigated in this prospective study. Initial oblique, final anteroposterior, and lateral fluoroscopic images were obtained and evaluated for the presence of epidural spread and its contrast pattern (based on direction and extent) with the consensus of three radiologists. The relationship between epidural spread and its potential predictors was analyzed using the chi-squared test, Fisher’s exact test, and the t-test.

Results

The incidence of epidural spread during lumbar facet joint injection was 64.6% (n=64) in 99 patients and 49.5% (n=95) in 192 procedures; ventral spread occurred in 29.2% and foraminal spread in 18.8%. When epidural spread occurred, the most commonly identified distributions were unilateral (73.7%), dorsal (92.6%), and cephalad (92.6%). Epidural spread increased significantly in the caudocephalic direction ( P < 0.0001), in men (relative risk [RR]=1.478), in the adjacency of posterior fusion level (RR=1.545), in patients with spondylolisthesis (RR=1.454), and when there was no other leakage (RR=0.334).

Conclusion

Epidural spread occurred at about half the number of lumbar facet joint injections and showed a contrast pattern similar to that seen with the interlaminar approach.

LUMBAR SPINE SYNOVIAL CYST: A CASE SERIES REPORT AND REVIEW OF SURGICAL STRATEGIES

Lumbar spine synovial cysts are benign growths adjoining the facet joints that may induce low back pain, lumbar radiculopathy and neurological deficit. However, they are not well defined concerning their origin, cause and pathology, as well as available treatment strategies. The scope of different surgical procedures includes image-guided epidural steroid injection, direct cyst puncture by percutaneous epidural needle, spinal canal decompression and cyst resection, and spinal bone fusion with/without instrumentation. Hereby, we report institutional experience and discuss surgical strategies of lumbar spine synovial cyst treatment. Presenting symptoms, imaging findings and outcomes were retrospectively analyzed in 15 patients with lumbar spine synovial cyst, operated on during a one-year period. The leading presenting symptom was lumbar radicular pain, while the most commonly involved vertebral level was L5-S1. In a great majority of patients, a single-level interlaminectomy and cyst resection were performed. Most patients recovered without postoperative neurological and functional deficit, as well as surgery-related complications. No poor outcome was noticed in our series. Concerning our results and literature review, the optimal management for patients with symptomatic lumbar synovial cyst has to be highly personalized, which is essential to achieve a favorable outcome. Nonetheless, the best treatment strategy has yet to be affirmed.

Percutaneous CT-guided facet joint synovial cyst rupture: Success with refractory cases and technical considerations

Percutaneous image-guided rupture of lumbar facet synovial cysts can improve clinical outcomes and obviate the need for open surgery. This series describes eleven patients who had successful CT-guided lumbar facet synovial cyst ruptures, 82% of which experienced excellent pain relief at a minimum of one-year follow-up. Of the five patients who failed prior fluoroscopic-guided synovial cyst rupture, 80% had a successful CT-guided rupture and one-year sustained pain relief. These findings reinforce minimally invasive CT-guided treatment as an excellent option to improve patient symptoms and potentially avoid open surgery.

Targeted Radiofrequency Ablation as an Adjunct in Treatment of Lumbar Facet Cysts

Lumbar facet cysts are frequently found in patients with facet degeneration and segmental instability. When the facet cyst is localized in the neural foramina and lateral recess or becomes large, it can cause radiculopathy or neurogenic claudication. These symptomatic cysts are typically treated interventionally with drainage and a corticosteroid injection or attempts via overinflation to rupture the cyst; however, these procedures have a significant recurrence rate (up to 50%) and often need to be repeated or lead to lumbar surgery if unsuccessful.  

This is the first report of using targeted radiofrequency (RF) current as an adjunct to cyst drainage. Although RF has been used for years to treat facet pain indirectly by targeting the medial facet nerve branches, with this technique, under image guidance, the actual cyst is percutaneously drained and then cauterized along with the associated facet capsule, where the original cyst developed. This has improved overall results with less cyst recurrence than previous percutaneous methods and was documented with both intermediate and long-term followup clinically and with magnetic resonance imaging (MRI) scans. This report reviews the underlying anatomy and pathology of the facet joint relating to the development of facet cysts and how current percutaneous treatments for lumbar facet cysts can be supplemented and improved by adding targeted RF ablation to the percutaneous options available to treat a lumbar facet cyst.

Spinal Injections for Pain Management

Image-guided spinal injection is commonly performed in symptomatic patients to decrease pain severity, confirm the pain generator, and delay or avoid surgery. This article focuses on the radiologist as spine interventionist and addresses the following four topics relevant to the radiologist who performs corticosteroid injections for pain management: (a) the rationale behind corticosteroid injection, (b) the interaction with patients, (c) the role of imaging in procedural selection and planning, and (d) the pearls and pitfalls of fluoroscopically guided injections. Factors that contribute to the success of a pain management service include communication skills and risk mitigation. A critical factor is the correlation of clinical symptoms with magnetic resonance (MR) imaging findings. Radiologists can leverage their training in MR image interpretation to distinguish active pain generators in the spine from incidental abnormalities. Knowledge of fluoroscopic anatomy and patterns of contrast material flow guide the planning and execution of safe and effective needle placement. ^© RSNA, 2016 Online supplemental material is available for this article.

Long-term outcomes of percutaneous lumbar facet synovial cyst rupture

OBJECTIVE

To evaluate the therapeutic value, safety, and long-term clinical outcomes of percutaneous lumbar facet synovial cyst (LFSC) rupture.

MATERIALS AND METHODS

Our study was institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant. The study group comprised 71 patients (44 women, mean age: 65 ± 17 years) who underwent CT- or fluoroscopy-guided percutaneous LFSC rupture. The technical success of LFSC rupture, the long-term clinical outcome, including repeat procedures or surgery, and imaging findings on MRI and CT were recorded.

RESULTS

Seventy-nine LFSC ruptures were performed in 71 patients. CT guidance was used in 57 cases and fluoroscopy guidance in 22 cases. LFSC rupture was technically successful in 58 out of 79 cases (73 %). Mean injection volume for cyst rupture was 3.6 ± 2.2 mL and a combination of steroid and anesthetic was injected in all cases. Over a mean follow-up time of 44 months, 12 % of patients underwent repeat cyst rupture, and 46 % eventually underwent surgery, whereas the majority of patients (55 %) experienced symptomatic relief and did not undergo surgery. There was no significant association between a successful outcome and age, sex, level, or size of LFSC (p > 0.1). LFSCs with T2 hypointensity were more likely to require surgery (p = 0.02). There was one complication, a bacterial skin infection that completely resolved following antibiotic therapy.

CONCLUSION

Percutaneous LFSC rupture is an effective and safe nonsurgical treatment option for LFSC. More than half of treated patients were able to avoid subsequent surgery. Therefore, percutaneous LFSC rupture should be considered before surgical intervention.

Intraspinal Lumbar Juxtaarticular Cyst Treatment Through CT-Guided Percutaneus Induced Rupture Results in a Favorable Patient Outcome

Juxta-articular cysts are synovial cysts originating from the facet joints or the flava ligaments. If they grow intra-spinally they can compress nervous structures and cause a variety of symptoms. Micro-neurosurgery is usually the treatment of choice. Alternatively to surgical treatment the cyst can be approached and treated with a CT guided percutaneous injection inducing rupture. After fulfilling strict selection criteria twenty patients (25% of all treated lumbar synovial cyst patients), were treated minimally invasive by this method from 2010-2016. The facet joint was punctured under CT guidance and a mixture of a local anesthetic and contrast liquid was injected until the cyst was blasted. The mean follow-up period was 1.1 years (range 2 weeks - 5 years).

Fifteen of twenty procedures were successful and cyst rupture was confirmed by CT-scans. Twelve of these fifteen patients experienced a significant improvement of their symptoms and needed no further intervention or surgical procedure up until now, three patients showed no clinical improvement and were treated surgically within one week after cyst rupture. In five patients it was technically not possible to rupture the cyst. These patients were treated microsurgically by cyst resection and dynamic stabilization or fusion procedures. The percutaneus rupture of juxtaarticular cysts has fewer risks and is cost effective compared to microsurgical resection. It may be an alternative to surgical treatment for a selected group of patients. However there are some limitations to the procedure though, such as difficult patient selection, unpredictable outcome or technical problems due to highly degenerated facet joints.

Minimally invasive surgery for lumbar synovial cysts with coexisting degenerative spondylolisthesis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A novel approach to symptomatic lumbar facet joint synovial cyst injection and rupture using iGuide navigational software: A case report and review

Spinal synovial cysts are benign protrusions of facet joint capsules caused by degenerative spondylosis, most frequently involving the L4-5 level, and commonly lead to symptoms of back pain, radiculopathy and neurogenic claudication. Although percutaneous treatment via facet joint steroid injection with cyst rupture can provide significant symptom relief, cyst rupture is not always achievable via an indirect trans-facet approach due to limited access from severe degenerative changes. In this case, we describe a successful approach to direct cyst access using a laser-guided navigational software in a patient with severe facet joint osteophytosis. We provide a brief review of literature.

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

OBJECT

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Percutaneous Rupture of a Symptomatic Facet Joint Synovial Cyst Using 2-Needle Distention

OBJECTIVE

This case report calls attention to an alternative approach for management of a symptomatic facet joint synovial cyst. We describe a patient with a symptomatic facet joint synovial cyst who failed an attempted percutaneous rupture using a single-needle technique. This patient was subsequently successfully managed with percutaneous rupture using a 2-needle technique.

CASE REPORT

A 60-year-old woman presented with low back pain, right lower extremity pain, and paresthesias. Magnetic resonance imaging revealed a right L5-S1 facet joint cyst, which compressed the right L5 nerve root. Before presentation, the patient failed an attempted single-needle percutaneous rupture. The decision was made to proceed with percutaneous rupture using a 2-needle technique. A 22-gauge needle was inserted into the right L5-S1 facet joint, and a Tuohy needle was inserted directly into the cyst through an interlaminar approach. A solution of methylprednisolone and hyaluronidase was simultaneously injected through both needles, and the cyst was continuously distended until rupture was achieved. Rupture was confirmed by injecting contrast into the facet joint and visualizing a normal epidurogram. The patient reported significant pain relief immediately after the procedure. At 4-month follow-up, the patient reported continued pain relief and denied any radicular symptoms.

CONCLUSIONS

Percutaneous rupture of a symptomatic facet joint synovial cyst using a single-needle technique has been validated as an efficacious form of management. In a select group of patients who fail single-needle percutaneous rupture, a 2-needle approach for percutaneous facet cyst rupture may be considered as an option for management.

Lumbar discal cyst: Diagnostic discography followed by therapeutic computed tomography-guided aspiration and injection

Discal cysts are extradural masses that communicate with the intervertebral disk and are a rare cause of lower back pain and lumbar radiculopathy. This case report describes a lumbar discal cyst, the diagnosis of which was confirmed on conventional discography, and which was treated with computed tomography-guided aspiration and steroid injection. Several reports have described this procedure, but only one in the radiology literature, and thus the purpose of this report is to remind the radiology community of the existence of this entity and propose a minimally invasive means of treatment.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Ligamentum flavum cyst of lumbar spine: a case report and literature review

Ligamentum flavum cysts have rarely been reported and known to be the uncommon cause of spinal compression and radiculopathy. A 63-year-old man presented right sciatica lasting for 1 month. Lumbar computerized tomography and magnetic resonance imaging demonstrated an extradural cystic mass adjacent to the L5-S1 facet joints. Partial hemilaminectomy and flavectomy at the L5-S1 space were performed, and then the cystic mass was excised. Histopathology confirmed a connective tissue cyst, which is consistent with the ligamentum flavum. Microscopic examination of the cyst wall revealed that it is closely packed collagen fibril. The symptom of patient was improved after surgery. Because of rarity of ligamentum flavum cysts and nonspecific clinical and radiologic findings, the preoperative diagnosis is not easy. The histologic features of ligamentum flavum cysts are distinct from other cystic lesion of lumbar spine. This study presents a case and literature review of ligamentum flavum cyst. We summarize the pathophysiology, occurrence, differential diagnosis of rare ligamentum flavum cyst, especially on lumbar spine.

Minimally invasive CT guided treatment of intraspinal synovial cyst

Background

Intraspinal synovial cysts of vertebral facet joints are uncommon cause of radicular pain as well as neurological deficits. They can be managed both conservatively and surgically.

Case report

A 77-year old polymorbid patient presented with bilateral low back pain which worsened during the course of time and did not respond to the conservative treatment. A diagnosis of intraspinal synovial cyst was made using the magnetic resonance imaging (MRI). Percutaneous computed tomography (CT) guided injection with installation of local anesthetic together with corticosteroid and rupture of the cyst was successfully used. A month after the procedure his pain improved, the usage of analgesics diminished and his over-all quality of life improved.

Conclusions

Percutaneous CT guided lumbar synovial cyst treatment is safe and reliable alternative to the surgical treatment in polymorbid patients with radiculopathy who are not able to tolerate general anesthesia and operation.

Intraosseous ganglion cyst within the L4 lamina causing spinal stenosis

BACKGROUND CONTEXT

There are rare reports of intraosseous ganglion cysts in the cervical spine. However, to our knowledge, there are no previous reports of these cysts occurring in the lumbar spine.

PURPOSE

To report a case of symptomatic lumbar spinal stenosis caused by an intraosseous ganglion cyst of the L4 lamina that communicated with the spinal canal.

STUDY DESIGN

Case report.

METHODS

An 86-year-old woman was referred to our spine service for a 2-year history of anterior thigh and leg pain. Magnetic resonance imaging revealed a benign-appearing intraosseous cyst in the left L4 lamina communicating with a posterior epidural cyst at L4-L5 causing marked spinal stenosis. The patient was treated successfully with a laminectomy and resection.

RESULTS

The patient underwent partial laminectomies of L4 and L5 preserving the interspinous ligaments between L5-S1 and L3-L4. The cyst was removed en bloc without violation of the cyst wall. Histopathologic examination revealed focal myxoid changes without a cellular lining of the cyst wall, confirming the diagnosis of intraosseous ganglion cyst.

CONCLUSIONS

This is the first report to describe an intraosseous ganglion cyst occurring in the lumbar spine. Although spinal stenosis is commonly a result of degenerative joint or disc disease, it occasionally may result from more obscure causes. This case illustrates a patient with an intraosseous ganglion cyst within the spinal lamina resulting in spinal stenosis, treated successfully with a laminectomy and resection.

Percutaneous aspiration of lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance -A case report-

A 51-year-old man with a 1-month history of lower back pain and radiating pain visited to our pain clinic. A magnetic resonance imaging (MRI) scan demonstrated a cyst like mass at the level of the L4-5 interspace and compression of the thecal sac and the nerve root on the right side. We performed percutaneous needle aspiration of the lumbar zygapophyseal joint synovial cyst under fluoroscopic guidance. The patient felt an immediate relief of symptoms after the aspiration, and had no signs or symptoms of recurrence at the follow-up 6 months later. No demonstrable lesion was found in the 6 months follow-up MRI.

A ganglion cyst in the second lumbar intervertebral foramen

Ganglion cysts usually arise from the tendon sheaths and tissues around the joints. It is usually associated with degenerative arthritic changes in older people. Ganglion cyst in the spine is rare and there is no previous report on case that located in the intervertebral foramen and compressed dorsal root ganglion associated severe radiculopathy. A 29-year-old woman presented with severe left thigh pain and dysesthesia for a month. Magnetic resonance imaging revealed a dumbbell like mass in the intervertebral foramen between second and third lumbar vertebrae on the left side. The lesion was removed after exposure of the L2-L3 intervertebral foramen. The histological examination showed fragmented cystic wall-like structure composed of fibromyxoid tissue but there was no lining epithelium. A ganglion cyst may compromise lumbar dorsal root ganglion when it located in the intervertebral foramen. Although it is very rare location, ganglion cyst should be included in the differential diagnosis for intervertebral foraminal mass lesions.

Technical and imaging report: fluoroscopic guidance for diagnosis and treatment of lumbar synovial cyst

Lumbar synovial cysts can be a source of low back pain with or without radiculopathy depending upon the size and location of the mass. Options for treatment range from analgesics to surgery, depending upon the degree of nerve root or spinal cord impingement. Attempts at minimally invasive treatment such as computed tomography-assisted aspiration and cyst rupture are documented in the radiology literature with varying degrees of reported success. This case report is the first to document the fluoroscopically-guided management of a lumbar synovial cyst in the pain medicine literature and highlights the knowledge and technical skills required when treating such cases.

Percutaneous therapy for symptomatic synovial cysts

Synovial cysts have long been known to create radicular pain in the spine, with the clinical effect mimicking a disk herniation. These cysts have traditionally been treated with open surgical therapy. Now a minimally invasive, image-guided approach to treatment is available to relieve this problem, using a simple percutaneous needle stick and injection. This article describes the technical aspects and precautions needed for this intervention.

Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

BACKGROUND CONTEXT

Lumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option.

PURPOSE

To profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts.

STUDY DESIGN/SETTING

Retrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts.

PATIENT SAMPLE

One hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture.

OUTCOME MEASURES

Oswestry Disability Index and numeric rating scale score for back and leg pain.

METHODS

A retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling.

RESULTS

Successful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery.

CONCLUSIONS

This study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint steroid injection with attempted cyst rupture is correlated with avoiding subsequent surgery in half of treated patients. Successful cyst rupture does not appear to have added benefit, and it was associated with worse disability 3 years postinjection. Long-term outcomes are similar, regardless of subsequent surgery.

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

BACKGROUND CONTEXT

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

PURPOSE

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

STUDY DESIGN/SETTING

Retrospective cohort study in an academic outpatient physiatric spine practice.

PATIENT SAMPLE

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

OUTCOME MEASURES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Formações císticas epidurais relacionadas a bursite interespinhosa, cisto sinovial e cisto discal

Os autores apresentam casos de cistos epidurais, dentre eles os cistos sinoviais, discais, do ligamento amarelo e relacionados a bursite interespinhosa, todas essas condições determinando compressão radicular, do saco dural ou estenose do canal vertebral. Descrevem as características de imagem e localização na ressonância magnética nessas diferentes afecções.

Spinal injection procedures: a review of concepts, controversies, and complications

The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.

Imaging the degenerative diseases of the lumbar spine

Degenerative changes of the spine may involve the disc space, the facet joints, or the supportive and surrounding soft tissues. MR imaging is ideally suited for delineating the presence, extent, and complications of degenerative spinal disease. Other imaging modalities such as radiography, myelography, and CT may provide complimentary information in selected cases. Percutaneous procedures may be used to confirm that a morphologic abnormality is the source of symptoms. Correlation with clinical and electrophysiologic data is also helpful for accurate diagnosis. Combining the information obtained from imaging studies with the patient's clinical presentation is mandatory for determining the appropriate patient management strategy, especially true in patients afflicted with any condition directly attributed to the degenerative processes of the spine.

Minimally invasive lumbar decompression

With the increasing elderly population, the number of patients presenting with symptoms secondary to lumbar stenosis can be expected to increase accordingly. Therefore, treatment of this disease process should become more prevalent, and the minimally invasive techniques offer another treatment option. As surgeons become more experienced in minimally invasive techniques, the reported advantages of the minimal access surgery, including reduction in soft tissue injury, less blood loss, shorter hospitalization, and faster recovery, should make this an attractive alternative to traditional open surgery. Continuing efforts in the minimally invasive field can be expected to yield new and potentially less invasive as well as possibly more efficacious treatment options in the future.