Spontaneous hemorrhage in an upper lumbar synovial cyst causing subacute cauda equina syndrome

Epidural bleeding secondary to a synovial cyst rupture: a case report and review of literature

Hemorrhage into a juxtafacet cyst is rare and cyst rupture with hemorrhagic extension into the epidural space is even less commonly seen. We describe the case of a patient with a hemorrhagic synovial cyst with rupture associated to abundant bleeding in the epidural space. A 61-year-old man had a 5-month history of worsening low back pain radiating into the right leg with associated weakness and numbness. A magnetic resonance imaging scan showed the presence of a mild anterior spondylolisthesis of L5 on S1 with increased synovial fluid into both facet joints. A suspected synovial cyst of the right facet joint at level L5-S1, with signal characteristics consistent with hemorrhage was seen. Caudally, epidural blood was evident from S1 to S2 that involved spinal canal and right S1 and S2 foramens. These findings were confirmed at surgery.

Can acute radiculopathy be caused by upper lumbar hemorrhagic synovial cyst spinal compression in the elderly?

Introduction and importance

Acute radiculopathy caused by upper lumbar synovial cysts is rare. They generally present with a slow development of symptoms resulting from spinal canal involvement. Intracyst hemorrhagic synovial cysts are extremely uncommon and can manifest as radicular pain, radiculopathy or even cauda equina compression syndrome.

Case presentation

A 71-year-old woman with acute back and radicular leg pain presented with worsening symptoms after receiving 1 week of therapy to the left lower limb without trauma. Magnetic resonance imaging (MRI) showed a hemorrhagic synovial intracyst at L2-L3 on the front of the left inter-facet joint which was identified as the cause of the acute back pain and radiculopathy which required surgical removal. Post-surgery, the patient followed the rehabilitation program instructions and attended all scheduled follow-up visits. The patient was asymptomatic at the one-year follow-up.

Clinical discussion

Synovial cysts are commonly associated with degenerative changes that occur with aging, although the specific cause is unknown. Surgical removal of an upper lumbar synovial cyst gives better results than non-surgical treatments if the symptoms persist or recurrent.

Conclusion

For recurrent symptomatic upper lumbar spine synovial cysts (L2−L3), surgery is usually the best option. Surgical removal of an upper lumbar synovial cyst can result in full relief of acute symptoms and reduction of neurologic deficits.

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Intracyst hemorrhagic synovial cysts in the upper lumbar spine are extremely uncommon.

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Synovial cysts can manifest as radicular pain, radiculopathy or even cauda equina compression syndrome.

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Surgical removal of upper lumbar synovial cysts gives better results than non-surgical treatments.

Complete Resolution of a Large Hemorrhagic Lumbar Synovial Cyst Following Spinal Fusion Alone

The authors reported complete regression of a large hemorrhagic lumbar synovial cyst following posterior spinal fusion without direct cystic resection. A 64-year-old woman suffered from sudden onset of the left buttock pain radiating to the left leg after waking up in the morning following the previous history of a minor accident 2 months ago. Magnetic resonance imaging (MRI) of the lumbosacral spine showed a large extradural round mass originating from the left facet joint at the level of L3–L4. The mass was hyperintense on T1-weighted images and hypointense on T2-weighted images, probably compatible with hemorrhagic joint-related cyst. Surgical treatment was chosen for her because of persistent left radicular pain with no responding to medications. The patient underwent decompressive laminectomy, subtotal facetectomy, instrumented fusion, and only tissue biopsy due to severe adherence of the mass and dura. Histopathological examination was consistent with a hemorrhagic synovial cyst. The radicular pain completely disappeared after the surgery. Follow-up MRI of the lumbosacral spine obtained 6 months after the surgery demonstrated complete resolution of the hemorrhagic cyst. Complete resolution of hemorrhagic synovial cyst seems to correlate with subtotal facetectomy, probably resulting in leakage of cyst content and subsequent resorption of the cyst wall. In addition, hematoma within the synovial cyst may resolve spontaneously over time.

Facet joint cyst haematoma: a rare cause of cauda equina syndrome

Facet joint cysts are a feature of lumbar spondylosis and are an uncommon cause of radiculopathy. Facet joint cyst haematoma is a very rare entity and has previously been reported as a subacute cause of leg pain, back pain, sensory deficit and lower limb weakness. We present the unique case of facet joint cyst haematoma presenting as cauda equina syndrome. An 81 year old lady presented with a 7 day history of back pain and left foot drop, a 1 day history of perineal numbness and urinary retention with absent rectal tone, perianal anaesthesia and left leg hypoaesthesia. Emergency MRI scan demonstrated spinal canal stenosis as the aetiology of her cauda equina syndrome. She was taken to theatre for emergency lumbar decompression. At operation a facet joint haematoma compressing the cauda equina was found and extirpated with complete resolution of symptoms. In this case, the aetiology of cauda equina compression was not demonstrated effectively on pre-operative MRI scanning.

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.

A ganglion cyst derived from a synovial cyst: A case report

The synovial and ganglion cysts originating from the facet joint have been named under the name of the Juxtafacet cyst by the several researchers. They put forward that the synovial cyst originated from the synovial joint. But, they failed to clarify the pathophysiology of the formation of the ganglion cyst. In this case report, we reported a 67-year-old male patient was referred to the emergency from another center with the complaint of a left leg pain and weakness in the left foot and patient was treated with microchirurgical technique. His patological examination was evaluated a ganglion cyst. We have discussed and explained the pathophysiology of the formation of a ganglion cyst derivered from a synovial cyst. And separately, we have presented the spinal cysts by grouping them under a new classification called a cystic formation of the soft tissue attachments of the mobile spine as well as dividing them into sub-groups.

Can lumbar hemorrhagic synovial cyst cause acute radicular compression? Case report

Lumbar synovial cysts are an uncommon cause of back pain and radiculopathy, usually manifesting with gradual onset of symptoms, secondary to involvement of the spinal canal. Rarely, intracyst hemorrhage occurs, and may acutely present as radicular - or even spinal cord - compression syndrome. Synovial cysts are generally associated with degenerative facets, although the pathogenesis has not been entirely established. We report a case of bleeding complication in a synovial cyst at L2-L3, adjacent to the right interfacet joint, causing acute pain and radiculopathy in a patient on anticoagulation therapy who required surgical resection.

Haemorrhagic lumbar juxtafacet cyst with ligamentum flavum involvement

Juxtafacet cysts are an uncommon cause of radiculopathy. They occur most frequently in the lumbar region, and their distribution across the spine correlates with mobility. Haemorrhagic complications are rare and may occur in the absence of any provocation, although there is some association with anticoagulation and trauma. We present a case of acute radiculopathy due to an L5/S1 juxtafacet cyst with unprovoked haemorrhage which was found to extend into ligamentum flavum. The patient underwent uncomplicated microscope assisted decompression with excellent results. The demographics, presentation, aetiology, and management of juxtafacet cysts are discussed.