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

Clinical Manifestations and Diagnostic Considerations of C7-T1 Single-Level Myelopathy: A Case Series

Cervical myelopathy is caused by compression of the cervical spinal cord for any reason. Cervical myelopathy most commonly affects the C5-6 level. However, C7-T1 single-level myelopathy is rare, and neurological findings may be atypical, making diagnosis difficult. We report three cases and discuss their clinical manifestations. Unlike other levels of cervical myelopathy, C7-T1 single-level myelopathy may present with gait disturbance without neurological deficits in the upper extremities. In addition, all three of our cases had different levels of spinal cord compression and locations of sensory deficits; at the C7-T1 level, the spinal cord compression may not correspond to the site of the sensory deficit. These features may help clinicians in the diagnosing of myelopathy.

Full-endoscopy with intraoperative O-arm navigation for cervicothoracic gas-containing hemorrhagic synovial cyst: A case report

Background

Synovial cysts are benign fluid-filled sacs commonly found in the degenerative lumbar spine. Few studies have reported the detailed epidemiology and standardized therapy for this disease. Conservative treatment is recommended if synovial cysts are asymptomatic or show mild clinical symptoms. If percutaneous facet joint steroid injections are ineffective or neurologic symptoms are aggravated, the open decompression with additional fusion is the reasonable surgical strategy to remove the pain generator. Furthermore, the synovial cysts that occur at the cervicothoracic spine are infrequently, especially accompanied by hemorrhagic radiographic evidence. Therefore, we describe the efficacy and safety of the full-endoscopy surgical procedure assisted by intraoperative O-arm navigation guidance to manage C7/T1 spinal synovial cysts.

Case description

We describe a 71-year-old male patient diagnosed with cervicothoracic hemorrhagic synovial cysts. The pathologic site is located at the posterior side of the C7 vertebral body to the medial side of the C7-T1 left facet joint. Herein is described a step-by-step protocol for the full-endoscopic procedure via the posterior approach to remove the lesions under intraoperative O-arm navigation guidance.

Outcome

The patient was successfully treated via full-endoscopic removal of the synovial cysts guided by intraoperative O-arm navigation. Intraoperative bleeding of 30 mL occurred, and the operative time was 150 minutes. The patient's sensory strength improved, and no opioid medicine was required with no complications postoperatively. One-year follow-up magnetic resonance imaging (MRI) and computed tomography (CT) scans showed no synovial cyst recurrence.

Conclusions

Full-endoscopy assisted with intraoperative O-arm navigation guidance improves precision and safety in treating patients with synovial cysts of the cervicothoracic spine. The O-arm navigation system improves the efficiency and safety of intraoperative positioning at the cervicothoracic lesion and reduces radiation exposure to the surgeons. Meanwhile, this technique preserves the range of cervicothoracic motion and facilitates the patient return to normal life.

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

Background

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

Case Description

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

Conclusion

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

A Rare T2-T3 Synovial Facet Cyst Causing Progressive Myelopathy

Intraspinal extradural synovial cysts are a rare occurrence at the spinal cord level and thus a rare cause of myelopathy. Synovial cysts usually present in the more mobile lumbar and cervical parts of the spine; however, they may also arise in the thoracic spine. We present a case of a 59-year-old male with a left upper thoracic synovial cyst at T2-3 causing disabling, progressive myelopathy, and an incomplete spinal cord injury syndrome with inability to ambulate. An urgent decompressive laminectomy with bilateral facetectomies, cyst excision, and posterior fusion was performed. Subsequently, the patient recovered full function. Synovial cysts should be considered in the differential diagnosis of progressive thoracic myelopathy. This is only the sixth reported case of a synovial cyst of this kind occurring between the levels of T1 and T7. Urgent surgical decompression is the recommended treatment.

Upper Thoracic Spine Synovial Cyst Resulting in Paraplegia Following Transient Hypotension

Development of synovial cysts in the rigid thoracic spine is rare. Additionally, synovial cysts with compression of nerve roots typically cause subacute or chronic radiculopathy. We present a patient who had a new diagnosis of upper thoracic (T1-2) synovial cyst that caused acute paraplegia while hospitalized for therapies and surgical planning. The patient is a 56-year-old male with a history of congestive heart failure secondary to alcoholic cardiomyopathy. He presented with a progressive bilateral lower extremity discoordination, urinary incontinence, and altered perineal sensation. His examination revealed intact strength to bedside assessment, intact rectal tone, but upgoing toes on Babinski testing. Given concern for myelopathy, MRI thoracic spine was obtained and demonstrated large T1-2 synovial cyst causing severe compression with associated T2 signal change within the spinal cord. He underwent expedited cardiac optimization that included resumption of outpatient antihypertensive medications and the addition of a single dose of intravenous diuretic. The patient had subsequent transient hypotension following significant diuresis and developed acute paraplegia in his bilateral lower extremities. Fluids and vasopressors were initiated, and he underwent emergent surgery for decompression and synovial cyst resection. The patient did very well and had normalization of his neurological exam within 24 hours. We present a case of acute paraplegia secondary to hypotension and spinal cord hypoperfusion in a patient with upper thoracic synovial cyst. This is rare pathology with an even more unique presentation. The authors recommend careful perioperative hemodynamic monitoring to help avoid acute worsening in this patient population.

Scientific Contributions of the Mexican Association of Spine Surgeons (Asociación Mexicana de Cirujanos de Columna-AMCICO) to the Global Medical Literature: A 21-Year Systematic Review

BACKGROUND

Contributions from Latin America to the global literature are scarce; until 2011, spine surgeons had published 320 articles in indexed journals.

METHODS

This systematic review evaluates the scientific production of the Mexican Association of Spine Surgeons (Asociación Mexicana de Cirujanos de Columna-AMCICO) from its inception in 1998 to 2018 with the PRISMA statement using PubMed and Google Scholar search engines. The inclusion criteria were spine-related articles in indexed journals providing any (or no) level of evidence with ≥1 AMCICO member as an author. Journal metrics, article metrics, and author variables were analyzed using SPSS version 25.

RESULTS

Of the 444 surgeons historically belonging to AMCICO, only 126 members contributed a total of 441 articles between 1998 and 2018. An average of 21.00 annual publications with an annual scientific output per capita of 0.05 was found. The most frequent evidence level was III (211 articles, 48%), the highest level was I (12 articles, 3%). The main study objective was clinical research, with 308 articles (70%), and the main study foci was trauma, with 103 articles (23%). An average impact factor of 0.16 and 0.92 was obtained for publications in Spanish and English, respectively.

CONCLUSIONS

Scientific publications by AMCICO members are scarce, with a per capita annual index of 0.05 from a total of 441 articles in indexed journals. Second, the impact factor of these journals is low, with a mean value of 0.53. Further strategies should be implemented to increase the number and track the record of Mexican contributions to the scientific literature.

Surgical treatment of cervical subaxial intraspinal extradural cysts using a full-endoscopic uniportal posterior approach

PURPOSE

Symptomatic intraspinal extradural cysts of the cervical subaxial spine are rare, but usually require surgery. Conventional posterior decompression is the gold standard. However, there is increasing experience with endoscopic surgical techniques. The purpose of the study is to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the posterior approach in patients with symptomatic intraspinal extradural cysts of the cervical subaxial spine.

METHODS

Seven consecutive patients with a subaxial location of symptomatic intraspinal extradural cysts were decompressed in a full-endoscopic uniportal technique via the posterior approach between 2009 and 2015. Imaging and clinical data were collected in follow-up examinations for 18 months.

RESULTS

In all cases, the cyst was completely removed and adequate decompression was achieved using the full-endoscopic uniportal technique. One patient developed a dural leak that was sutured and covered intraoperatively. No other complications requiring treatment were observed. All patients had a good clinical outcome with stable regression of the radicular and central nerve pain or neurological deficits. The imaging follow-up showed sufficient decompression in all cases. No evidence was found of increasing instability during the follow-up period.

CONCLUSION

The full-endoscopic uniportal operation with a posterior approach allows the resection of the cyst and can minimize trauma and destabilization and has technical benefits and a low complication rate. It is an alternative surgical method that can offer advantages and is considered by the authors to be the surgical technique of choice for cervical subaxial intraspinal extradural cysts.

Sudden Onset of Paraparesis Caused by a Hemorrhagic Thoracic Synovial Cyst

BACKGROUND

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

CASE DESCRIPTION

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

CONCLUSIONS

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

Magnetic Resonance Imaging Features of Cervical Spine Intraspinal Extradural Synovial Cysts

Spinal synovial cysts are relatively uncommon and are most frequently found in the lumbar spine and rarely in the cervical spine. Intraspinal extradural cervical synovial cysts can occur and potentially cause cord/nerve root compression with symptoms of myelopathy/radiculopathy; however, most are asymptomatic and incidental findings. We conducted a literature review and present, to our knowledge, the largest imaging case series and describe the magnetic resonance imaging features of cervical synovial cysts.

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.

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.

A rare cause of root-compression: Subaxial cervical synovial cyst in association with congenital fusion

INTRODUCTION

Synovial cyst in the cervical spine is a very rare pathology that develops from the facet joint. When a synovial cyst emerges into the surrounding space, it can compress the nervous tissue and cause neurological symptoms. In the cervical area there is additionally the risk of spinal cord compression comparing to the more common presentation of synovial cysts in the lumbar spine.

PRESENTATION OF CASE

Here, a cervical synovial cysts from the left facet joint grew into the spinal canal and compressed the C8 nerve root which led to root compressing symptoms. Interestingly we found this synovial cyst with congenital fusion. We identified only nine similar cases in the literature. The cyst was removed surgically and the patient discharged without complications.

DISCUSSION

Numerous theories have been established to explain the pathogenesis of synovial cyst. Biomechanical alterations of the spine play a significant role in the development of synovial cyst. However, the etiology is still unclear.

CONCLUSION

Surgical treatment should be considered in cervical synovial cysts with neurologic deficit or with cord compression or when the conservative treatment is ineffective.

Recurrent atlantoaxial synovial cyst resection via a navigation-guided, endoscope-assisted posterior approach

Background:

Atlantoaxial cysts are rare, and only 46 histologically confirmed cases have been reported.

Case Description:

A 75-year-old male presented 2 years ago with headache, neck pain, loss of balance, and episodic dysphagia, for which he had undergone posterior cervical drainage of a left-sided atlantoaxial cyst. Although his original symptoms resolved, they recurred 2 years later and were correlated with an enhanced MR that showed a recurrent left C1-C2 synovial cyst causing marked cervical cord compression. It was successfully resected through a navigation-guided, endoscope-assisted posterior approach. The patient's symptoms/signs resolved completely, and he has remained symptom-free for over 30 months postoperatively, with no evidence of recurrence on MR or craniocervical instability.

Conclusions:

A patient who successfully underwent resection of a recurrent synovial cervical cyst using a navigation-guided, endoscope-assisted posterior approach has been reported here.

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

Object

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

Methods

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

Results

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

Conclusions

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