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

Bilateral Synovial Cysts as a Rare Cause of Myelopathy in a 38-year-old Woman

Synovial cysts are rare, and they occur even more rarely bilaterally or in the cervical spine. A 38-year-old previously healthy female presented with acute onset of numbness and tingling down her arms and weakness in her legs, which progressed steadily over 2-3 weeks to include significant gait disturbance. She denied bowel or bladder symptoms, saddle anesthesia, night sweats, weight loss, fever, or chills. MRI spine revealed a C7-T1 extradural mass consistent with bilateral synovial cysts emanating from bilateral neuroforamina resulting in critical spinal cord compression with T2 signal change in the cord. There was questionable patch enhancement after gadolinium contrast. The patient underwent C7-T1 laminectomies and partial bilateral medial facetectomies with excision of the cysts. Intraoperative cultures unexpectedly grew Staphylococcus aureus, suggesting superinfection of cysts. The patient recovered neurologic function postoperatively and was discharged on a 6-week course of IV antibiotics. We report and discuss the clinical presentation, pathogenesis, and neuroradiological findings in an adult case of bilateral synovial cysts at the C-T-spine junction. Immediate resection at symptom onset is indicated due to the good clinical outcome following resection and the real risk of paralysis if cysts are not excised in a timely fashion.

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.

Juxtafacet cyst infection

PURPOSE

In the realm of spinal surgery, infections have multiple etiologies and sites of origin. In this case series, we describe a juxtafacet cyst spinal infection that can often be missed or attributed to common symptomology of benign processes despite florid infection.

METHODS

In rare instances, the juxtafacet cyst may become infected and require direct intervention. This case report attempts to describe the prodrome leading to such a diagnosis and two different ways to manage an infected facet cyst.

RESULTS

Management of spinal infections varies due to the multiplicity of causes and location of infections. The juxtafacet cyst infection should remain a part of the differential diagnosis for low back pain as their presentation often mimics more common presenting complaints.

CONCLUSIONS

In our two patient presentations, both were diabetics and had remote histories of cancer that necessitated chemotherapy or radiation therapy. They also seemingly had de novo onset of infected juxtafacet cyst. The variety of causes and presentations of spinal infections should heighten the astute surgeon to be suspicious of these entities and thus intervene early with appropriate management.

Management of lumbar spine juxtafacet cysts

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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