Posttraumatic lumbar epidural true synovial cyst. Case report

Hemorrhagic synovial cyst: An unexpected cause of acute cervical spinal cord compression. Case report

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Chronic inflammation of the synovial cyst induces neovascularization of its wall leading to a possible intra-cystic bleeding.

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The different signal modulations on MRI are due to the variable consistency and density of the cystic fluid.

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Synovial cyst hemorrhage produces a sudden increase in the size of the lesion with compression of the spinal cord and nerve roots.

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Surgery is the appropriate treatment in case of synovial cyst with spinal cord compression.

Introduction

Cervical synovial cysts are uncommon. They are most often responsible for a chronic clinical picture. Rarely, intracystic hemorrhage occurs, and may acutely present as radicular – or even spinal cord compression syndrome leading to irreversible neurological impairment.

Case

We reported a case of bleeding synovial cyst located in the cervico-thoracic spine causing spastic paraparesis in a 68-year-old male patient. MRI revealed narrowing of perimedullary subarachnoid space by a well circumscribed, extra-axial, homogeneous mass located posterolaterally to the right of the spinal cord at the level C7-T1. The cyst was removed thoroughly by laminectomy. Pathological findings were consistent with the diagnosis of hemorrhagic synovial cyst. The patient had an excellent recovery.

Discussion

Synovial cysts of the spine are rare and usually asymptomatic. It is extremely rare for intracystic bleeding to occur and be responsible for an abrupt presentation. Diagnosis of spinal synovial cyst relies on MRI but may not be evident as it depends on consistency and density of the cystic fluid.

Surgery remains the best therapeutic alternative, especially in the case of neurological impairment.

Conclusion

Surgery should be considered for any cervical synovial cyst. This is motivated by the risk, although rare, of bleeding and the resulting irreversible neurological damage that may occur.

Lumbar ganglion cyst: Nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review

AIM

To analyze different terms used in literature to identify lumbar extradural cysts and propose a common scientific terminology; to elaborate a new morphological classification of this pathology, useful for clinical and surgical purposes; and to describe the best surgical approach to remove these cysts, in order to avoid iatrogenic instability or treat the pre-existing one.

METHODS

We retrospectively reviewed 34 patients with symptomatic lumbar ganglion cysts treated with spinal canal decompression with or without spinal fixation. Microsurgical approach was the main procedure and spinal instrumentation was required only in case of evident pre-operative segmental instability.

RESULTS

The complete cystectomy with histological examination was performed in all cases. All patients presented an improvement of clinical conditions, evaluated by Visual Analogic Scale and Japanese Orthopaedic Association scoring.

CONCLUSION

Spinal ganglion cysts are generally found in the lumbar spine. The treatment of choice is the microsurgical cystectomy, which generally does not require stabilization. The need for fusion must be carefully evaluated: Pre-operative spondylolisthesis or a wide joint resection, during the operation, are the main indications for spinal instrumentation. We propose the terms “ganglion cyst” to finally identify this spinal pathology and for the first time its morphological classification, clinically useful for all specialists.

Case Report: Intraneural Intracanalicular Ganglion Cyst of the Hypoglossal Nerve Treated by Extradural Transcondylar Approach

We report a case of an intraneural ganglion cyst of the hypoglossal canal. The patient presented with unilateral hypoglossal nerve palsy, and magnetic resonance imaging showed a small lesion in the hypoglossal canal with no contrast enhancement and high signal on T2-weighted imaging. The lesion was assumed to be a cystic schwannoma of the hypoglossal nerve. Stereotactic irradiation was considered, but in accordance with the patient's wishes, surgical exploration was performed. This revealed that, rather than a schwannoma, the patient had an intraneural ganglion cyst, retrospectively contraindicating irradiation as an option. This case illustrates a very rare location of an intraneural ganglion cyst in the hypoglossal nerve. To our knowledge there are no previous reports of an intraneural ganglion cyst confined to the hypoglossal canal.

Minimally invasive resection of lumbar synovial cysts from a contralateral approach

Synovial cysts of the lumbar spine result from degeneration of the facet capsule and often mimic symptoms commonly seen with herniated intervertebral discs. In symptomatic patients, the prevalence of synovial cysts may be as high as 10%. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for lumbar synovial cyst resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption. The authors report 2 cases of a minimally invasive synovial cyst resection via a contralateral laminotomy. In both cases, complete resection of the cyst was achieved while sparing the facet joint.

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.

Using precisely controlled bidirectional orthopedic forces to assess flexibility in adolescent idiopathic scoliosis: comparisons between push-traction film, supine side bending, suspension, and fulcrum bending film

STUDY DESIGN

A prospective study.

OBJECTIVE

To validate the effectiveness of push-traction film (PTF) in assessment of curve flexibility in adolescent idiopathic scoliosis.

SUMMARY OF BACKGROUND DATA

There is no agreement among surgeons about the most advantageous method in flexibility evaluation of scoliosis. As all methods available provide the orthopedic force from one direction and use a single torque, it is difficult for them to achieve the postoperative correction; also they could not meet the needs for different types of curves.

METHODS

Precisely controlled bidirectional (push and traction) orthopedic forces were applied for curve flexibility evaluation in 31 consecutive adolescent idiopathic scoliosis patients. The correction rate (CR) of postoperation, supine side-bending, suspension, and fulcrum bending radiographs were compared with PTF in instrumented main thoracic (MT) and thoracolumbar/lumbar curves. Correlation and linear regression analyses were also been done to find the best predictor among the four methods.

RESULTS

In MT group, CR of PTF was significantly higher than that of side bending (P = 0.010) and suspension (P = 0.000) but not significantly different from that of fulcrum bending (P = 0.335). In TL/L group, CR of PTF was significantly higher than that of suspension (P = 0.000), but not significantly different from that of side bending (P = 0.681) and fulcrum bending (P = 0.382). There was no significant difference between CR of PTF and postoperation in both MT (P = 0.122) and TL/L (P = 0.068) groups. Correlation and linear regression analyses showed that PTF provided the highest correlation of the four methods, with the postoperative angle in both MT (r = 0.957) and MT/L group (r = 0.779).

CONCLUSION

To our knowledge, this was the first report about using precisely controlled bidirectional correction forces for curve flexibility evaluation. Although it did not achieve the best CR among the four methods studied, correlation and regression analyses confirmed that PTF was a more stable and accurate method to predict flexibility. We believe that further exploration of a more rational push-traction force ratio would help to obtain a better flexibility.

Subaxial cervical synovial cysts: report of 35 histologically confirmed surgically treated cases and review of the literature

STUDY DESIGN

Retrospective study

OBJECTIVE

The authors' aim of the present study is to report their experience with subaxial cervical synovial cysts hoping to provide further insight into these lesions including the presenting symptoms, possible mechanisms of cyst development associated with cervical level, surgical treatments and clinical outcomes.

SUMMARY OF BACKGROUND DATA

Synovial cysts are relatively common in the lumbar spine and very uncommonly identified in the subaxial cervical spine. Several case reports and a few small series have been reported in the literature over the past four decades.

METHODS

The authors retrospectively reviewed the cases of 35 patients who underwent surgical treatment for histologically confirmed symptomatic subaxial cervical synovial cysts between 1993 and 2009. The presenting symptoms, age, sex, cervical level, operation, complications and outcomes were analyzed in this cohort. Preoperative and postoperative neurologic assessments were done by staff neurologists independent of the operating surgeon. This study was approved by the Mayo Clinic institutional review board.

RESULTS

Thirty-five patients underwent surgical treatment for their synovial cysts and follow-up for at least 12 months postoperatively. The mean follow-up time was 49 months (range, 12-134). There were no deaths associated with the surgery. There was one postoperative infection in a patient undergoing a decompressive laminectomy and posterior instrumented fusion. Patient outcomes were assessed using the Modified Rankin Score for 12 patients was 0, 17 patients was 1, 4 patients was 2, and 2 patients was 3.

CONCLUSION

This series of 35 patients with subaxial cervical synovial cysts surgically treated over a period of 17 years illustrates the relative rarity of these lesions. Magnetic resonance imaging is currently the optimal radiographic study to identify these lesions. Surgical resection can be an effective treatment.

Bipartite atlas with os odontoideum and synovial cyst: case report and review literature

STUDY DESIGN

Case report and review of the literature.

OBJECTIVE

To present an os odontoideum with bipartite atlas and synovial cyst at the C1-C2 junction in a 13-year-old girl and to review the relevant background literature.

SUMMARY OF BACKGROUND DATA

Bipartite atlas associated with os odontoideum and synovial cyst at the C1-C2 junction is extremely rare.

METHODS

The patient's clinical presentation, evolution of physical findings, and sequential radiologic studies. Surgery of the bipartite atlas with os odontoideum and synovial cyst. Posterior fixation between occipital and C 2 without resection of the mass was performed.

RESULTS

The patient had significant improvement and spontaneous regression of the cyst was identified on the follow-up magnetic resonance imaging (MRI) taken 3 months after posterior fixation. To our knowledge, no case of a bipartite atlas with os odontoideum and synovial cyst with complete recovery of an accompanying quadriparesis after reduction has been previously reported in English medical literature.

CONCLUSION

We described a rare association of an anterior arch defect, posterior arch aplasia, os odontoideum, and synovial cyst at the C1-C2 junction. This case report supports surgical intervention of synovial cyst with craniovertebral instability using posterior fixation without resection of the cyst.

Case report. Atlantoaxial synovial cyst causing isolated unilateral hypoglossal nerve paralysis

Cervical synovial cysts are rare entities that are, most of the time, asymptomatic. They can cause nerve root or spinal cord compression, especially when acute haemorrhage or a marked increase in size occurs. Isolated unilateral hypoglossal nerve paralysis caused by compression of its cisternal segment is also an extremely rare condition. We report the case of a 51-year-old woman who presented with dysarthria and tongue fasciculation. MRI revealed an atlantoaxial synovial cyst that extended cranially through the hypoglossal canal and compressed the fibres of the left XII nerve on its cisternal segment. To our knowledge, this is the first case report of XII nerve paralysis being caused by an atlantoaxial synovial cyst.

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

STUDY DESIGN

A clinicopathologic study of synovial cysts in the ligamentum flavum (LF) in patients with spinal stenosis.

OBJECTIVE

To investigate the pathogenesis of lumbar juxtafacet cysts.

SUMMARY OF BACKGROUND DATA

Contradictions in the terminology applied to lumbar juxtafacet cysts arise from the frequent sparsity of synovial lining cells, which has led to synovial cysts often being called "ganglion cysts" despite lacking confirmatory pathology.

METHODS

A total of 27 consecutive patients with radiologically confirmed stenosis underwent laminectomy. LF/facet joint (FJ) relationships were retained by en bloc excision of the LF and the medial inferior FJ. Controls were LF/FJ specimens from 47 cadaver lumbar spines.

RESULTS

The 27 patients yielded 51 LF/FJ specimens containing 28 synovial cysts, 12 of which were unilateral and 8 were bilateral. Fragments of articular cartilage and bone were embedded in the walls of 89% of cysts and in the walls of a bursa-like channel originating from the medial aspect of the FJ capsule and extending into the LF. Communication with the FJ via this channel was observed in 21 (75%) of the 28 synovial cysts. Extending up to 12 mm in length, the channel was present in nearly all control spines at the L4-L5 level but in only about half at the T12-L1 level.

CONCLUSION

Cysts having an extensive or meagre synovial cell lining are common in the LF of patients with symptomatic lateral or central stenosis. The cysts communicate with the FJ by a bursa-type channel within the LF. Advanced osteoarthritis of the FJ causes the liberation of fragments of cartilage and bone into the synovial fluid of the joint space. This enables some fragments to escape from the joint into the channel and become lodged within its wall where they provoke granulation tissue and scar formation. The tissue response to articular debris may block the synovial-lined channel to cause synovial cyst formation.

Surgical approach for synovial cyst of the atlantoaxial joint: a case report and review of the literature

STUDY DESIGN

Case report and review of the literature.

OBJECTIVE

We describe the first case of a synovial cyst arising from pseudarthrosis of a previous dens fracture. The literature is reviewed and etiological, diagnostic, and therapeutic options of atlantoaxial cysts are discussed.

SUMMARY OF BACKGROUND DATA

Symptomatic synovial cysts of the atlantoaxial joint are rare. To the authors' knowledge only 24 cases have been reported.A 60-year-old patient presented with bilateral hand numbness, quadrihyperreflexia, and gait deterioration. Magnetic resonance imaging of the cervical spine disclosed a cystic mass located at the transverse ligament of dens axis causing bulbomedullary compression.

METHODS

Surgery was performed via transoral image guided approach. The ventral atlas arch, dens, transverse ligament, tectorial membrane, and the compressing cyst were removed, followed by a C0-C3 fusion.

RESULTS

Two months postsurgery the patient recovered completely from the cervical myelopathy with transient remnant dysparesthesia of the finger tips.

CONCLUSION

Magnetic resonance imaging findings are not specific enough to establish a preoperative diagnosis. Radical resection via image-guided transoral route followed by posterior fusion allows complete resection of the cystic lesion and results in excellent long-term decompression.

Isolated unilateral hypoglossal nerve palsy secondary to an atlantooccipital joint juxtafacet synovial cyst

Juxtafacet cysts of the atlantooccipital joint that present with isolated hypoglossal nerve palsy are rare and may mimic more common pathological entities. The authors report on the third such case in the literature and discuss the differential diagnosis, imaging hallmarks, preoperative recognition, and surgical management of this lesion, and provide a review of the literature.

The authors discuss their experience with the treatment of a 67-year-old woman who presented with an isolated hypoglossal nerve palsy caused by a nonenhancing cystic septated lesion abutting the lateral medulla just medial to the left hypoglossal canal. The lesion was presumed to be a necrotic hypoglossal schwannoma or epidermoid tumor. Intradural surgical exploration failed to demonstrate an intradural lesion, but confirmed the presence of an extradural mass caudal to the hypoglossal nerve. Extradural exploration revealed a synovial cyst of the atlantooccipital joint, which was then resected. Postoperatively, the patient developed worsening dysphagia and hoarseness. Failure to recognize this rare entity preoperatively resulted in unnecessary intradural exploration and cranial nerve morbidity. In retrospect, the preoperative diagnosis of this lesion was suggested by lack of central enhancement, absence of dumbbell formation and the presence of erosive synovial changes. Regardless, the extreme rarity of this lesion at this location will always make its recognition challenging.

Multilevel bilateral calcified thoracic spinal synovial cysts

Synovial cysts of the thoracic spine are quite rare. Bilateral presentation is even less frequent, and to the authors' knowledge multilevel occurrence and consistent calcification have not been reported so far. The pathogenesis of these cysts is unknown and their histological features have not been studied. They may be overlooked as the cause of myelopathy. The authors report a series of 4 cases of bilateral, multilevel, consistently calcified thoracic synovial cysts. The details of clinical, radiological, and histological findings are presented, along with a review of the literature, and a hypothesis on the pathogenesis of these lesions is formulated based on results of the clinical and pathological studies performed in these patients.

Lumbar juxta-facet cyst after trauma

We report a post-traumatic lumbar facet cyst in which results of magnetic resonance imaging (MRI) performed at the time of injury were available. The patient was a 59-year-old man who presented with severe low back and right leg pain immediately after injury of his sacroiliac region in a traffic accident. MRI at the time of injury revealed high intensity signal change in the right facet joint at L4/5. Re-examination 5 months after the injury with MRI revealed a cyst, which was continuous with the facet joint. Surgical resection of the cyst yielded satisfactory results. We describe detailed MRI findings for this case and review the literature on traumatic juxta-facet cyst in the lumbar spine.

Chiropractic treatment of lumbar spine synovial cysts: a report of two cases

OBJECTIVE

To present the treatment of low back and radicular pain due to synovial cysts of the lumbar spine including chiropractic distraction manipulation and physiological therapeutic care.

CLINICAL FEATURES

Two patients (71-year-old man and 59-year-old woman) with magnetic resonance imaging (MRI)-diagnosed large synovial cysts at the L3 through L4 and L4 through L5 vertebral levels, respectively, had lower extremity pain, numbness, and tingling of the respective L4 and L5 dermatomes.

INTERVENTION AND OUTCOME

Chiropractic distraction manipulation was performed at the level of the synovial cyst. The manipulation was performed daily until 50% pain relief was attained, followed by diminished frequency of care. Physiotherapy included positive galvanism, iontophoresis, tetanizing electrical stimulation, stabilization exercises, and home cryotherapy. The male patient's pain was reduced by 50% in 14 days and 100% at 60 days. Range of motion of the thoracolumbar spine increased, walking distance increased from 1 to 2 blocks to 1 mile without pain, and repeat MRI showed reduced size of the cyst. The female patient, under the same treatment regimen, was pain free in 6 weeks.

CONCLUSION

Chiropractic distraction manipulation and physiological therapeutic care relieved 2 patients with low back and radicular pain attributed to MRI-confirmed synovial cysts of the lumbar spine. This treatment may be an initial conservative treatment option for synovial cysts with careful patient monitoring for progressive neurologic deficit which would necessitate surgery. Distraction manipulation may be a safe and effective conservative treatment of synovial cyst causing radicular pain; further data collection of clinical outcomes is warranted.

Synovial cysts of the lumbar spine: surgery-related results and outcome

OBJECT

The authors conducted a study to determine the surgery-related results and outcomes in patients with synovial cysts of the lumbar spine. They emphasize several specific characteristics useful in clinical management.

METHODS

Forty-six consecutive patients with 54 lumbar synovial cysts underwent surgery between 1990 and 2001. A retrospective analysis of the clinical presentation and follow-up data, radiological findings, and surgical techniques was performed. Clinical presentation was dominated by acute or subacute sciatic pain. No specific symptom allowed differentiation of synovial cyst from a lumbar disc herniation. Computerized tomography scanning aided in establishing the correct diagnosis in 19 of 30 cases and magnetic resonance (MR) imaging did so in all cases. Three of the 46 patients presented with bilateral lumbar synovial cysts. The L4-5 level was affected in 61%, and radiological signs of disc degeneration/spondylosis were observed in 54% of the patients. Immediate symptom relief without local recurrence was obtained by complete microsurgical excision in which bipolar coagulation was used to remove the synovial membrane and in which the interapophysial joint was preserved. During the 1st postoperative year, a newly formed symptomatic synovial cyst developed on the contralateral side or at a superior vertebral level in five patients. They underwent surgery; results were good and there was no recurrence.

CONCLUSIONS

The findings in this series suggest that synovial cysts can occur at multiple lumbar sites within a short period of time and could be predisposed to developing in certain individuals, predominantly in women older than 40 years of age. Postoperative follow up is recommended and MR imaging mandatory in cases of recurrent sciatica.

Rapid, symptomatic enlargement of a lumbar juxtafacet cyst: case report

STUDY DESIGN

A case is reported in which a 45-year-old man developed cauda equina syndrome caused by enlargement of an L4-L5 juxtafacet cyst diagnosed 4 months earlier.

OBJECTIVES

To highlight the short interval that can elapse between the discovery of a juxtafacet cyst and its remarkable progression.

SUMMARY OF BACKGROUND DATA

Although juxtafacet cysts are acquired lesions, how long they take to develop remains unclear. Hemorrhage is a well-known cause of rapid or even dramatic cyst enlargement. This is the first report providing magnetic resonance imaging evidence of rapid, remarkable enlargement of a nonhemorrhagic juxtafacet cyst.

METHODS

The patient underwent conservative treatment for an L4-L5 right juxtafacet cyst diagnosed by magnetic resonance imaging during evaluation of posttraumatic lower back pain. Four months later, the patient presented with severe pain radiating down the right lateral leg, urinary retention, and impaired dorsal flexion of the right foot. Repeat magnetic resonance imaging showed the cyst now markedly enlarged and occupying almost the entire width of the canal.

RESULTS

The cyst was removed, and the patient's symptoms abated. At 15 months after surgery, he is symptom-free.

CONCLUSIONS

Juxtafacet cyst may occasionally enlarge and cause severe symptoms within months.

Patient outcome after resection of lumbar juxtafacet cysts

STUDY DESIGN

Retrospective review of patients who underwent lumbar juxtafacet cyst resection with questionnaire follow-up.

OBJECTIVES

Determine the long-term outcome after resection of lumbar juxtafacet cysts.

SUMMARY OF BACKGROUND DATA

Juxtafacet cysts are uncommon causes of radicular pain and are often associated with significant spinal degenerative disease. Previous studies have not focused on the outcome of patients who have undergone resection.

METHODS

Charts of 29 patients who underwent lumbar juxtafacet resection were reviewed and an outcomes questionnaire was sent to each.

RESULTS

Thirty-three lumbar juxtafacet cysts were resected from 29 patients. Cysts, 31 (94%) from facets and 2 (6%) from the ligamentum flavum, most commonly arose at the L4-L5 level (51%). Twelve patients (41%) were found to have some degree of spondylolisthesis before surgery, while 26 patients (90%) had facet arthropathy. Two patients (7%) underwent concurrent resection and fusion. Recurrence occurred in 3%. Three patients (9%) had subsequent lumbar spine operations, including 2 fusions (6%). Incidental durotomy was the most common surgical complication occurring in 3 cases (9%). Twenty-four patients (83%) responded to follow-up questionnaire or phone interview. Mean length of follow-up was 24 months (4-64 months). Twenty patients (83%) reported improvement in pain, and 16 (67%) reported an improved level of function. All respondents reported some degree of improvement in their condition after surgery.

CONCLUSIONS

Juxtafacet cysts are an uncommon cause of radiculopathy. Surgical resection is the treatment of choice with low rates of complications, recurrences, and residual complaints.

Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience

OBJECT

The authors report a retrospective analysis of 194 patients surgically treated at their institutions for symptomatic lumbar synovial cysts from January 1974 to January 1996.

METHODS

Patient characteristics including age, sex, symptoms, signs, and preoperative neuroimaging studies were reviewed. Surgical procedures, complications, results, and pathological findings were correlated with preoperative assessment. One hundred ninety-four patients were surgically treated for symptomatic lumbar synovial cysts. Eighty percent were diagnosed and treated between 1987 and 1996. There were 100 men and 94 women with an average age of 66 years (range 28-94 years). The most common symptoms were painful radiculopathy (85%) and neurogenic single or multiroot claudication (44%). However, sensory loss (43%) and motor weakness (27%) were also presenting symptoms. Eleven percent of patients had undergone previous lumbar surgery prior to being referred to the Mayo Clinic. Preoperative neurological examination demonstrated motor weakness (40%), sensory loss (45%), reflex changes (57%), and variants of cauda equina syndrome (13%). In 19% of patients, normal neurological status was demonstrated. There was equal left/right-sided laterality, and eight patients presented with bilateral synovial cysts. The most commonly affected level was L4-5 (64%). All patients underwent laminectomy and resection of the cyst. Concomitant fusion was performed in 18 patients in whom clinical evidence of instability had been observed. However, subsequent fusion was required in only four patients who developed symptomatic spondylolisthesis. Surgery-related complications included cerebrospinal fluid leak (three patients), discitis (one patient), epidural hematoma (one patient), seroma (one patient), and deep vein thrombosis (one patient). One patient died 3 days after surgery of cardiac dysrhythmia. Follow-up data obtained for at least 6 months postoperatively were available in 147 patients. Of these, 134 (91%) reported good relief of their pain and 82% experienced improvement in their motor deficits.

CONCLUSIONS

Lumbar synovial cysts are a more common cause of lumbar radicular pain than previously thought. Surgical removal of the cyst is a safe and effective treatment for symptomatic relief in patients with lumbar synovial cysts. A concomitant fusion procedure may be performed in select cases. In this study, only a few patients developed symptomatic spinal instability requiring a second operation.

Synovial cyst of the transverse ligament of the atlas in a patient with os odontoideum and atlantoaxial instability

STUDY DESIGN

A case report and review of the literature.

OBJECTIVE

To describe the diagnosis and successful treatment of a synovial cyst arising from the transverse ligament in a patient with os odontoideum and atlantoaxial instability.

SUMMARY OF BACKGROUND DATA

Synovial cysts arising from the transverse ligament of the atlas are extremely rare. Development of a synovial cyst is thought to be attributable to degenerative changes of the C1-C2 facet joints or to microtrauma. Direct excision of the cyst is the only treatment cited in previous reports.

METHODS

A synovial cyst arising from the transverse ligament of the atlas in a 45-year-old man with os odontoideum and atlantoaxial instability was treated surgically with posterior atlantoaxial fusion alone. The magnetic resonance images, surgical treatment, and related literature are reviewed.

RESULTS

Preoperative magnetic resonance images of the cervical spine showed a large cystic mass located ventral to the cord arising at the level of the transverse ligament of the atlas: the mass was of low signal intensity on T1-weighted images, was of high signal intensity on T2-weighted images, and was enhanced marginally with gadolinium-DTPA on T1-weighted images. Spontaneous regression of the cyst was identified on the follow-up magnetic resonance images taken 3 months after C1-C2 posterior wiring and fusion.

CONCLUSIONS

A patient with a synovial cyst arising at the C1-C2 junction ventrally at the level of the transverse ligament showed spontaneous regression of the lesion after C1-C2 posterior wiring and fusion.

Radicular pain caused by synovial cyst: an underdiagnosed entity in the elderly?

OBJECT

Synovial cyst is a recognized but infrequent cause of nerve root or spinal canal compression. The authors undertook a review of 839 decompressive spinal procedures performed over a 5-year period. They found seven cases in which the symptoms were caused by synovial cysts.

METHODS

Six of these cases were in a subgroup of 80 patients who were older than 60 years of age, which represents 7.5% of the total for this age group. More than 200 cases of this abnormality have been reported in the world literature, but the incidence, prevalence, and natural history remain unknown.

CONCLUSIONS

The authors propose that the incidence of synovial cysts may be more common than recognized in the elderly and suggest that preoperative diagnosis may help limit the extent of the surgical approach.

Intraspinal synovial cysts: 10-year experience at the Ochsner Clinic

OBJECT

Although synovial cysts commonly involve the joints of the extremities, they are also found in the spinal canal. When symptomatic, they produce signs and symptoms consistent with nerve root and spinal cord compression. In this report the authors review the clinical presentations, radiological studies, and operative findings in 28 patients with intraspinal synovial cysts treated surgically at the Ochsner Clinic between 1988 and 1998.

METHODS

The medical records and radiological studies obtained in 28 patients (31 intraspinal synovial cysts) were analyzed. Twenty-nine (94%) of the cysts were located in the lumbar, one in the thoracic (T8-9), and one in the cervicothoracic (C7-T1) spine. Sixteen (57%) of the 28 patients presented with radicular pain. The remaining patients presented either with neurogenic claudication (25%) or with radicular pain and an associated neurological deficit (18%). Each cyst was located adjacent to a facet joint in which there was evidence of degenerative disease.

CONCLUSIONS

Intraspinal synovial cysts are uncommon lesions most often found in the lumbar spine at the L4-5 level. They are invariably associated with facet degeneration and respond very well to surgical therapy.

Subaxial cervical synovial cyst presenting with myelopathy. Report of three cases

Synovial cysts occur infrequently in the spinal canal and are most often associated with degenerative facet joints. Despite the prevalence of degenerative spinal disease, symptomatic synovial cysts are extremely uncommon. There have been only two previously reported cases of subaxial degenerative synovial cysts of the cervical spine in patients who presented with a clinical picture of spinal cord compression. The authors report three additional patients treated for degenerative cervical synovial cysts who presented with myelopathy. In all three patients the cyst was successfully excised and a good clinical outcome achieved.

Paraparesis caused by a bilateral cervical synovial cyst

We describe a 64-year-old man who suffered from rapidly progressive paraparesis. At operation the cervical cord of the patient was found to be displaced anteriorly due to compression caused by an epidural synovial cyst. The cyst was located bilaterally on the dorsolateral aspect of both CVII facet joints. The rapid development of paraparesis in this patient can, thus, be explained by the enlargement of the cyst on both sides of the spinal cord. After microsurgical removal of the cystic tumor, the recovery of the patient was good. Cervical epidural cysts are extremely rare, and only anecdotal cases have been reported in the literature. Among all previously described patients the present case is unique due to the bilateral location of the cyst.

Synovial cysts: clinical and neuroradiological aspects

Lumbar and intraneural synovial cysts are uncommon lesions, although their incidence has increased since the introduction of MRI. The authors describe the results of a study comprising 23 patients with synovial cyst (5 lumbar, 19 intraneural). Neuroradiological investigations included CT scan and MRI; however, it was not always possible to diagnose the nature of the lesion. In 18 cases the lesion was removed totally including its capsule; in the other 5 cases it was removed subtotally. Seven of the 23 patients presented a total remission of symptoms/signs, 11 improved and 5 remained unchanged. The importance of treating synovial cysts as radically as possible is discussed together with their most significant clinical and neuroradiological aspects.

Atlantoaxial degenerative articular cysts

Cysts associated with spinal joints are not a common cause of neurological symptoms. The authors report a series of five patients with cysts of the atlantodental articulation and review five additional cases from the literature. The patients ranged from 60 to 85 years of age and included three men and seven women. No patient had evidence of rheumatoid arthritis or previous trauma. The cysts caused ventral cervicomedullary compression, did not enhance on magnetic resonance imaging, and were not associated with widening of the anterior atlantodental interval or osseous degeneration of the dens. All patients improved postsurgery. Fusion was required if a transoral procedure was performed. Patients undergoing posterior decompressions were clinically and radiographically stable after operation.

Ganglion cyst of the odontoid process. Case report and review of the literature

STUDY DESIGN

This case report illustrates that although it is rare, a ganglion cyst can occur intraosseously in the odontoid process.

OBJECTIVES

The tissue diagnosis was established by surgical resection of the cyst membrane and evacuation of the cyst content. The patient tolerated the procedure well, and the hospital course was uneventful.

SUMMARY OF BACKGROUND DATA

Synovial cyst of the spine is uncommon and is usually found in the lumbar region. Its occurrence in the cervical spine is rare, and no cases in the odontoid process, to the authors' knowledge, have been reported.

METHODS

This patient was evaluated initially for neck pain, which led to radiographic studies depicting the lesion. It raised the suspicion of metastatic neoplastic process, although the search for primary source proved to be negative. A biopsy was indicated.

RESULTS

Surgical findings consisted of mucoid material field cavity lined by a thin membrane. The cyst was excised, and pathologic evaluation confirmed the diagnosis of synovial cyst.

CONCLUSION

The correct radiographic diagnosis of this patient was not made because of lack of experience with such lesions in this location. The authors hope that this case report helps raise the awareness of clinicians in considering this diagnosis when facing similar radiographic presentation.

Experience with symptomatic spinal epidural cysts

Epidural cysts, either synovial or ganglion, are an unusual cause of epidural compressive syndromes. We report a series of 26 patients with cysts, including 1 cervical, 2 thoracic, and 23 lumbar. Complaints at the time of admission and findings were similar to those associated with other epidural lesions at the same locations. The surgical technique is similar to that for other spinal lesions, with a wide exposure to enable a clear view of the cyst and surrounding structures, and is governed by imaging studies. Patients with cervical and thoracic lumbar cysts were free of symptoms and signs postoperatively. Of the 23 patients with lumbar cysts, 15 were free of symptoms after an operation, 7 had symptomatic improvement but had some pain and neurological findings, and 1 patient had no improvement. Computed tomography and magnetic resonance imaging permit accurate preoperative evaluation.

Synovial cyst of dens causing spinal cord compression. Case report

We report a rare case of synovial cyst of the dens (odontoid process) in a 61 year old women with no previous history of trauma. She had progressive symptoms of 1 year's duration due to spinal cord compression. Magnetic resonance imaging of cervical spine revealed a large mass posterior to the dens which was compressing the spinal cord near the cervicomedullary junction. This lesion was at first considered radiologically to represent an exuberant pannus formation or a meningioma of the foramen magnum, but subsequent surgical intervention and pathological examination revealed that it was a synovial cyst. Similar cases reported in the literature are reviewed and discussed.

Compression of thoracic nerve root by a facet joint synovial cyst: case report

Synovial cysts are not an uncommon feature in the mobile spinal segments. The lack of reports at the thoracic level has stimulated us to present this patient with compression of the 10th dorsal root.

Intraspinal juxta-facet cysts: a case of bilateral ganglion cysts

Juxta-facet cysts are relatively uncommon intraspinal lesions, causing radiculopathy, neurogenic claudication or myelopathy. To the best of our knowledge, only 4 cases of bilateral synovial or ganglioncysts were described. We report the 5th case of bilateral ganglioncysts of the lumbar spine. Generally, juxta-facet cysts should be differentiated from other intraspinal lesions, such as herniated discs, meningiomas and neurinomas. Correct preoperative diagnosis is necessary for adequate treatment, namely the (microscopic) resection of the cyst. After adequate treatment, complete recovery may be expected.

Preoperative diagnosis of an extradural cyst arising from a spinal facet joint: case report

A case of a lumbar spinal extradural cyst is reported. An accurate preoperative diagnosis was made using magnetic resonance imaging. Characteristic findings on magnetic resonance imaging obviate the need for any additional radiological studies. The clinical features, radiological findings, and pathogenesis of these lesions are discussed.

Spinal synovial cyst: case report using magnetic resonance imaging

The case of a 65-year-old woman who developed a spinal synovial cyst at the L4-5 disk space is reported. Her clinical signs and symptoms are presented. A comparison among her preoperative myelogram, computed tomography scan, and magnetic resonance imaging showed magnetic resonance imaging to be more accurate in detailing both the intraoperative and pathological findings.

Degenerative spondylolisthesis, synovial cyst of the zygapophyseal joints, and sciatic syndrome: report of two cases and review of the literature

Two cases of sciatica secondary to nerve root compression by a "synovial cyst" of a zygapophyseal joint are described. In light of these 2 cases and on reviewing the literature, it appears that zygapophyseal joint osteoarthritis with degenerative (or articular) spondylolisthesis can be a predisposing factor to the formation of such synovial expansions and, consequently, the cause of nerve root compression. The coexistence of a lumbar degenerative spondylolisthesis with a radicular syndrome should therefore encourage early investigation by computed tomography scan, so that conservative treatment would not be unnecessarily prolonged.

Synovial cysts of the lumbar spine: CT evaluation

Seven cases of surgically proven intraspinal synovial cysts are reported. Computed tomographic (CT) scans demonstrated a series of low-density masses adjacent to the facet joints; in three cases, a dense rim indicated a calcified wall on the cyst; in one, the wall was partially calcified; and in three the mass appeared to be filled with gas. In all of these cases, there was severe degenerative facet disease at the same level as the synovial cyst. In six patients, the cysts were unilateral, while one was bilateral; seven cysts were located at the level of L4-L5, and one at L3-L4. We conclude from this study that the intraspinal synovial cyst can be identified reliably by the CT scan.

Bilateral symptomatic intraspinal T12-L1 synovial cysts

A 72-year-old man presented with several months of increasing lumbar pain, sciatica, lower extremity weakness, numbness in his buttocks and posterior thighs, burning sensations in his scrotum, and urinary incontinence. Myelogram-computed tomography scan demonstrated a high grade incomplete block at the T12-L1 level due to bilateral synovial cysts and simultaneously a high grade partial block at L4-L5 due to spinal stenosis. Laminectomy of the T-12 vertebra and partial laminectomy of the L-1 vertebra with excision of both synovial cysts and laminectomies of the L-4 and L-5 vertebrae with foraminotomies resulted in a reversal of the patient's symptomatology.

A posttraumatic lumbar spinal synovial cyst. Case report

A patient with posttraumatic lumbar radicular paresthesias is presented. The preoperative diagnosis of an epidural synovial cyst was considered. At surgery, an epidural synovial microcystic mass was found emanating from a distracted L4-5 facet joint and dissecting into the layers of the ligamentum flavum. A brief review of the condition is presented.

Intraspinal synovial cyst: diagnosis by CT. Follow-up and spontaneous remission

We report a case of intraspinal synovial cyst with sciatic pain diagnosed by CT, that showed spontaneous resolution and clinical improvement with medical treatment and comment on another two cases of this unusual entity discovered among over 1500 spinal CT explorations.

Lumbar nerve root compression by synovial cysts of the ligamentum flavum. Report of four cases

Synovial cysts of the ligamentum flavum, measuring 1 cm in diameter, caused compression of the lumbar nerve roots in four patients. The authors discuss the association of these cysts with advanced focal spondylosis, and speculate on their etiology.

Synovial cyst (ganglion) of the lumbar spine simulating extradural mass

Four additional cases of synovial cyst (ganglion) arising from the facet joint between L4 and L5 are reported. Only five such cases have been reported in the past. For the first time impressive and characteristic myelographic findings are described, which make a preoperative diagnosis possible in these cases.

Synovial cyst of spinal facet. Case report

✓The authors report a case in which a true synovial cyst was found attached to a cervical facet joint. The differential diagnosis involving herniated cervical disc as well as other types of extradural cyst is discussed. The anatomically oriented term “juxta-facet cyst” is proposed to include both ganglion and synovial cysts seen in this area.