Evaluation and Treatment of Lumbar Facet Cysts

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.

Evaluation and Treatment of Lumbar Spine Extradural Cysts: A Narrative Review

The main objective was to describe the different types and characteristics of lumbar spine extradural cysts and their optimal treatment options with a focus on endoscopic technique. We searched Pubmed, EMBASE, Medline, and Google Scholar for articles published between 1967 and 2020 using the keywords "Spinal Cyst," "Extradural Cyst," and "Lumbar Cyst." The various anatomical and histological types of the extradural cysts with their presentations, etiologies, imaging, and optimal treatment with a focus on endoscopic techniques were reviewed from the articles. Lumbar spinal cysts are relatively rare pathologies that might cause radicular symptoms similar to lumbar disc herniation. Spinal extradural cysts are classified either histologically based on the cyst lining tissues (synovial cysts or non-synovial, ganglion cysts) or anatomically based on the structure of origin (epidural cysts, ligamentum flavum cysts, discal cysts, post-discectomy pseudocysts, posterior longitudinal ligament cysts, facet cysts). Surgical excision is the recommended treatment of symptomatic cysts with endoscopic techniques being a viable option. Extradural lumbar cysts can be identified based on their histological structure or depending on their structure of origin. Regardless of their classification, they could all give similar clinical findings, and the optimal treatment would be surgical excision with endoscopic technique being a viable option with a satisfactory outcome.

Facet joint disorders: from diagnosis to treatment

One of the most common sources of spinal pain syndromes is the facet joints. Cervical, thoracic, and lumbar facet joint pain syndromes comprise 55%, 42%, and 31% of chronic spinal pain syndromes, respectively. Common facet joint disorders are degenerative disorders, such as osteoarthritis, hypertrophied superior articular process, and facet joint cysts; septic arthritis; systemic and metabolic disorders, such as ankylosing spondylitis or gout; and traumatic dislocations. The facet pain syndrome from osteoarthritis is suspected from a patient's history (referred pain pattern) and physical examination (tenderness). Other facet joint disorders may cause radicular pain if mass effect from a facet joint cyst, hypertrophied superior articular process, or tumors compress the dorsal root ganglion. However, a high degree of morphological change does not always provoke pain. The superiority of innervating nerve block or direct joint injection for diagnosis and treatment is still a controversy. Treatment includes facet joint injection in facet joint osteoarthritis or whiplash injury provoking referred pain or decompression in mass effect in cases of hypertrophied superior articular process or facet joint cyst eliciting radicular pain. In addition, septic arthritis is treated using a proper antibiotic, based on infected tissue or blood culture. This review describes the diagnosis and treatment of common facet joint disorders.

The effect of integrative Korean medicine treatment on symptomatic lumbar facet joint cysts: A case series

OBJECTIVE

The optimal treatment for facet joint cysts (FJCs) has remained controversial. Despite a higher success rate than the conservative option, surgical treatments may pose risks of postoperative complications and comorbidities may make the surgical approach difficult. Thus, this study reports four cases of pain amelioration and resorption of FJCs through noninvasive integrative Korean Medicine treatment.

METHODS

For intervention, four patients with symptomatic FJCs underwent integrative Korean medicine treatment with acupuncture, herbal medicine, pharmacopuncture, and Chuna manual therapy; after completion of the series of treatment sessions, patients were re-examined with magnetic resonance imaging (MRI).

RESULTS

Pain disappeared within 2 months for all four patients; the amelioration of pain was sustained for more than 6 months. Furthermore, the disappearance of FJCs was confirmed by MRI after a certain period from the time of pain disappearance.

CONCLUSIONS

This study reported the effectiveness of non-invasive, integrative Korean medicine treatment for patients with FJCs; this method shows promise as a conservative treatment option for patients with FJCs.

Percutaneous uniportal full-endoscopic surgery for treating symptomatic lumbar facet joint cysts under local anesthesia combined with monitored anesthesia care: a preliminary report of eight cases with at least 1 year follow-up

Background

Lumbar facet joint cysts (FJCs) are a relatively rare clinical pathology that can result in radiculopathy or neurogenic claudication. Various treatments such as percutaneous aspiration and surgery have been reported to have good clinical outcomes. However, few clinical studies have aimed to treat symptomatic lumbar FJCs by using uniportal full-endoscopic (UFE) surgery. This study aimed to investigate the preliminary clinical outcomes of UFE surgery for the treatment of lumbar FJCs under local anesthesia combined with monitored anesthesia care (MAC).

Methods

Eight patients (five males and three females) with symptomatic lumbar FJCs who underwent UFE surgery under local and MAC anesthesia were enrolled in this study between January 2018 and April 2022. The clinical characteristics, radiological features, operative information, visual analog scale (VAS) score, Oswestry disability index (ODI), and overall outcome rating based on the modified MacNab criteria were retrospectively analyzed.

Results

Of the eight patients, four underwent a transforaminal approach and four underwent an interlaminar approach. Postoperatively, the mean VAS score for leg pain decreased from 6.1 before surgery to 0.6 after surgery, and the ODI decreased from 74.5% to 14.7%. All patients were followed up for more than 1 year, and the good-to-excellent rate based on the modified MacNab criteria remained 100% at the last follow-up. No complications occurred during the follow-up period.

Conclusion

Lumbar FJCs can cause severe radiating leg pain and/or neurogenic claudication due to the dural sac compression and nerve roots. As an alternative treatment, UFE decompression under local and MAC anesthesia may provide effective clinical outcomes for symptomatic lumbar FJCs.

Awake transforaminal endoscopic lumbar facet cyst resection: technical note and case series

OBJECTIVE

The aim of this study was to describe a minimally invasive transforaminal surgical technique for treating awake patients presenting with lumbar radiculopathy and compressive facet cysts.

METHODS

Awake transforaminal endoscopic decompression surgery was performed in 645 patients over a 6-year period from 2014 to 2020. Transforaminal endoscopic decompression surgery utilizing a high-speed endoscopic drill was performed in 25 patients who had lumbar facet cysts. All surgeries were performed as outpatient procedures in awake patients. Nine of the 25 patients had previously undergone laminectomies at the treated level. A retrospective chart review of patient-reported outcome measures is presented.

RESULTS

At the 2-year follow-up, the mean (± standard deviation) preoperative visual analog scale leg score and Oswestry Disability Index improved from 7.6 ± 1.3 to 2.3 ± 1.4 and 39.7% ± 8.1% to 13.0% ± 7.4%, respectively. There were no complications, readmissions, or recurrence of symptoms during the 2-year follow-up period.

CONCLUSIONS

A minimally invasive awake procedure is presented for the treatment of lumbar facet cysts in patients with lumbar radiculopathy. Approximately one-third of the treated patients (9 of 25) had postlaminectomy facet cysts.

Minimally Invasive Surgical Decompression without Fusion for the Treatment of Lumbar Synovial Cysts: Feasibility and Long-Term Outcomes

BACKGROUND

Lumbar synovial cysts (LSCs) can cause painful radiculopathy and sensory and/or motor deficits. Historically, first-line surgical treatment has been decompression with fusion. Recently, minimally invasive laminectomy without fusion has shown equal or superior results to traditional decompression and fusion methods.

OBJECTIVE

This study investigates the long-term efficacy of minimally invasive laminectomy without fusion in the treatment of LSC as it relates to the rate of subsequent fusion surgery.

METHODS

A retrospective review was performed over a 10-year period of patients undergoing minimally invasive laminectomy for symptomatic LSCs. The primary end point was the rate of revision surgery requiring fusion.

RESULTS

Eighty-five patients with symptomatic LSCs underwent minimally invasive laminectomy alone January 2010-August 2020 at our institution. The most common location was L4-5 (72%). Preoperative imaging identified spondylolisthesis (grade 1) in 43 patients (57%), none of which was unstable on available dynamic radiographs. Average procedure duration was 93 minutes, with 78% of patients discharged home on the same day of surgery. Over 46 months of mean follow-up, 17 patients (20%) required 19 revision operations. Of those operations, 16 were spinal fusions (17.6%). Median time to fusion surgery was 36 months. There were no identifiable risk factors on multivariate regression analysis that predicted the need for fusion.

CONCLUSIONS

Minimally invasive laminectomy is an effective first-line treatment for symptomatic LSCs and avoids the need for fusion in most treated patients. Of our patients, 18% required a fusion over 46 months, suggesting that further studies are required to guide patient selection.

High Rate of Revision Surgery After Limited Decompression of Lumbar Facet Cysts

INTRODUCTION

The surgical treatment of lumbar facet cysts has long been debated. Some surgeons elect for limited decompression of such cysts while other surgeons elect for primary decompression and fusion over concerns for recurrence and instability. Previous studies have suggested the rate of revision surgery after facet cyst excision to be as low as 1%, whereas others have reported this rate to be markedly higher. In this study, we examined revision surgery rates and patient-reported outcomes and conducted a radiographic analysis to identify predictors of failure after limited decompression of lumbar facet cysts.

METHODS

A retrospective review of the electronic medical records of patients treated at our institution using the Current Procedural Terminology code 63267 before January 2018 was conducted. The primary outcome measure was revision surgery at the index level for recurrence or instability or a minimum 2-year follow-up without revision surgery. Secondary outcome measures include radiographic assessments of preoperative and postoperative spondylolisthesis and patient-reported outcome measures. Using preoperative MRI studies, an analysis of facet angles at the surgical level was conducted and the presence, location, and amount of facet fluid were calculated.

RESULTS

A total of 162 patients met inclusion criteria. Of these, 93 patients had a minimum 2-year follow-up. Of these, 19 had undergone a revision surgery at the index level for cyst recurrence or instability. The revision rate for this group was 20.4%. The median time to initial revision surgery was 2.2 years. The median time from index operation to last follow-up was 3.8 years. No differences were observed between the groups regarding the presence of preoperative spondylolisthesis, age, sex, body mass index, blood loss, or patient demographics. 60.2% of all procedures were done at the L4-5 level, but this level accounted for 73.7% of primary failures. A radiographic analysis showed facet angle >45° at L4-5 to be associated with risk of failure of primary decompression. The presence and absolute amount of fluid in the facets were not associated with risk of failure at the L4-5 level.

DISCUSSION

Our revision rate of 20.4% is higher than what is commonly reported in the literature. The radiographic analysis shows that at the L4-5 level, a facet angle of >45° is associated with failure of primary decompression.

Five-Year Outcomes After Decompression and Fusion Versus Decompression Alone in the Treatment of Lumbar Synovial Cysts

BACKGROUND

Spinal synovial cysts are acquired, fluid-filled lesions of the facet joint that most commonly occur in the lumbar spine. They are thought to arise from degenerative changes and to result from segmental instability. Although the treatment of these lesions has been studied, the long-term implications and effects of the different strategies for surgical intervention (i.e., decompression and fusion vs. decompression alone) have not yet been elucidated or established.

METHODS

Using an all-payer database with 53 million patient records (MARINER-53), patients with a diagnosis of lumbar synovial cysts were identified. Patients who had undergone lumbar fusion versus laminectomy were matched 1:1 using binomial and gaussian logistic regression models to evaluate the need for future lumbar surgery within 5 years after their index procedure.

RESULTS

No statistically significant differences were noted between the 5-year rates of subsequent intervention, additional laminectomy, or fusion among patients who had undergone index decompression and fusion (n = 51; 10.5%) versus decompression alone (n = 43; 8.8%; P = 0.39). Furthermore, no significant differences were found in the odds of intervention type after index decompression and fusion versus decompression alone (subsequent laminectomy: odds ratio, 0.59; 95% confidence interval, 0.32-1.09; subsequent fusion: odds ratio, 1.14; 95% confidence interval, 0.64-2.02).

CONCLUSIONS

Patient-specific factors and surgeon-patient-shared decision-making should be used when planning interventions for these lesions. However, synovial cysts might not require a fusion procedure for presumed instability. Further investigation is required, using randomized and prospective studies, to further evaluate the effective treatment of this entity.

Does complete regression of intraneural ganglion cysts occur without surgery?

PURPOSE

The dynamic nature of intraneural ganglion cysts, including spontaneous expansion and regression, has been described. However, whether these cysts can regress completely in the absence of surgical management has important therapeutic implications. Therefore, we aim to review the literature for cyst regression without surgical intervention.

METHODS

We reviewed our database of 970 intraneural ganglion cysts in the literature to search for evidence of complete regression based on strict radiologic confirmation, either spontaneously, or after percutaneous cyst aspiration or steroid injection.

RESULTS

We did not find any examples of complete regression without surgical treatment that met inclusion criteria. Spontaneous regression was reported in four cases; however, only two cases had follow-up imaging, both of which demonstrated residual cysts. Nineteen cases of percutaneous intervention were found in the literature, 13 of which reported clinical improvement following aspiration/steroid injection; however, only seven cases had available imaging. Only two cases reported complete resolution of cyst on MR imaging at follow-up, but reinterpretation found residual intraneural cyst in both cases.

CONCLUSION

We believe that pathology (structural abnormalities and/or increased joint fluid) always exists at the joint origin of intraneural ganglion cysts which persist even with regression of the cyst. The persistence of a capsular abnormality or defect can lead to recurrence of the cyst in the future, and while imaging may show dramatic decreases in cyst size, truly focused assessment of images will show a tiny focus of persistent intraneural cyst at the joint origin. Thus, expectant management or percutaneous intervention may lead to regression, but not complete resolution, of intraneural ganglion cysts.

Pearls and Pitfalls of Oblique Lateral Interbody Fusion: A Comprehensive Narrative Review

Lumbar degenerative disease is a common problem in an aging society. Oblique lateral interbody fusion (OLIF) is a minimally invasive surgical (MIS) technique that utilizes a retroperitoneal antepsoas corridor to treat lumbar degenerative disease. OLIF has theoretical advantages over other lumbar fusion techniques, such as a lower risk of lumbar plexus injury than direct lateral interbody fusion (DLIF). Previous studies have reported favorable clinical and radiological outcomes of OLIF in various lumbar degenerative diseases. The use of OLIF is increasing, and evidence on OLIF is growing in the literature. The indications for OLIF are also expanding with the help of recent technical developments, including stereotactic navigation systems and robotics. In this review, we present current evidence on OLIF for the treatment of lumbar degenerative disease, focusing on the expansion of surgical indications and recent advancements in the OLIF procedure.

The Fate of Lumbar Facet Cyst After Indirect Decompression Using Oblique Lateral Interbody Fusion in Degenerative Spondylolisthesis

Favorable clinical outcomes have been reported for oblique lateral interbody fusion (OLIF) for various lumbar degenerative diseases. However, there is only limited evidence on the safety and effectiveness of OLIF in degenerative spondylolisthesis with lumbar facet cyst (LFC), and OLIF is often regarded as a relative contraindication for these patients. The authors prospectively enrolled patients who underwent a single-level OLIF for degenerative spondylolisthesis with LFC to evaluate the morphological changes of LFC and their clinical significance following OLIF. Twenty patients with a mean age of 69.6 years (range, 65-86 years) were enrolled. At 1 week postoperative, 5 (25%) patients had a residual cyst, whereas 15 (75%) patients had completely resolved cysts on magnetic resonance imaging (MRI). No patient had a residual cyst on the 1-year postoperative MRI. Patients with cyst resolution (n=15) on the 1-week postoperative MRI had a larger slip percentage difference on the preoperative dynamic radiograph when compared with patients with no cyst resolution (n=5) (4.7%±2.8% vs 1.3%±0.3%, P=.002). The group with cyst resolution also showed a greater expansion of facet fluid width following OLIF, although this was not statistically significant (1.2±0.7 mm vs 0.7±0.5 mm, P=.098). For both groups, all preoperative clinical scores showed a significant improvement at 1 year after OLIF, but there was no significant difference between the groups at all time points. Preliminary 1-year follow-up results from this prospective series suggest that OLIF can be a useful option for fusion surgery in LFC patients with apparent segmental instability. [Orthopedics. 2021;44(5):306-312.].

Mid thoracic intra-spinal facet cyst with lumbar canal stenosis: a rare 'double crush'

INTRODUCTION

Intraspinal synovial cysts occurrence causing spinal canal occlusion are mostly seen in mobile segments of the spine (lumbar and cervical). An appearance of the cyst in thoracic spine is a relatively rare occurrence. We present an interesting case of 'double crush' caused by Lumbar canal stenosis with a mid-dorsal Facet cyst.

CASE PRESENTATION

A 67-year-old woman presented with complaints of back pain with neurogenic claudication with significant loss of touch sensation and motor power of MRC grade 3/5 in lower extremities bilaterally. However, patient was hyperreflexic with Babinski sign positive. She was unable to perform tandem walking test and complained of instability. MRI of lumbar spine revealed lumbar canal stenosis. However, in view of the UMN signs, an MRI of the dorsal spine was done. It revealed an extradural, well-delineated lesion along the dorsal aspect of spine at T6-7 level. Thus the patient had a 'double crush' due to the FC along with lumbar canal stenosis.

CLINICAL FINDINGS CORRELATED WITH THE IMAGING

Two teams simultaneously operated the 2 pathologies and T6-7 laminectomy along with left sided TLIF at L4-5 level was performed. Presently she is asymptomatic for back pain, claudication distance has improved to 800 m.

CONCLUSION

Our case reiterates the importance of thorough clinical examination to avoid missing a diagnosis. Our case is the first in literature to report a 'double crush' due to a proximal dorsal FC and distal LCS. Both the pathologies were tackled in a single setting by two operating teams with a good functional outcome.

Preoperative facet joint arthropathy does not impact long-term clinical outcomes after lumbar-stability-preserving decompression and dynesys fixation

To evaluate the impact of the preoperative severity of facet joint arthropathy on long-term functional outcomes and spinopelvic parameters in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. In this retrospective study, 88 patients undergoing combined surgery at our hospital from 2008 to 2015 were included. The patients were divided into two groups, the less and more than mean degeneration groups, based on preoperative facet joint arthropathy of the index level(s). The clinical outcomes were the Visual Analogue Scale (VAS) score, the Oswestry Disability Index (ODI) score and spinopelvic parameters. The mean follow-up durations for the less and more than mean degeneration groups were 84.83 ± 27.58 and 92.83 ± 20.45 months, respectively. The combined surgery significantly improved VAS and ODI scores, and increased sacral slope (SS) regardless of preoperative arthropathy severity. In addition, facet joint arthropathy at adjacent levels continued to worsen after surgery in both arthropathy severity groups. Preoperative facet joint arthropathy did not influence most long-term clinical outcomes in patients undergoing lumbar-stability-preserving decompression and Dynesys fixation. This combined surgery may be suitable for patients with facet joint arthropathy regardless of disease severity.

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.

An Unusual Case of Radicular Pain Caused by Bilateral Lumbar Synovial Cyst: A Case Report and Review of the Literature

Introduction

Spinal synovial cysts (SSCs) constitute an uncommon degenerative lesion of the spine. They are usually asymptomatic but they may also cause symptoms of variable severity. SSCs are benign growths adjoining the facet joints that may induce low back pain, lumbar radiculopathy, and neurological deficit. There are different treatment options that range from conservative management to interventions like image-guided epidural steroid injection or direct cyst puncture and finally to open or endoscopic spinal canal decompression and spinal bone fusion with/without instrumentation. A discussion of current management options for this unusual disease is presented. Material and Methods. A 52-year-old female patient presented with low back pain and left leg pain. Plain radiography demonstrated instability at the L4-L5 level. Magnetic resonance images (MRIs) revealed a bilateral cystic lesion at the L4-L5 level with associated instability and degenerative disc disease at the level L5-S1. Initially, conservative treatment was performed by aspiration of the left cyst and infiltration with corticosteroids with improvement of the pain for 1 year. After this period, the radicular and the low back pain reoccurred.

Results

Following leg pain recurrence, a hybrid L4-S1 fusion was performed. After surgery, there was clinical improvement and six months later, the patient returned to daily activities. The radiological study after five-year follow-up shows adequate implant position, without signs of loosening, compatible with solid fusion.

Conclusion

After reviewing the literature, the optimal management for patients with symptomatic lumbar synovial cyst must be very individualized, which is essential to achieve a favorable outcome.

Transdural Approach to Resection of Intraspinal Extradural Ventral Cysts in the Lumbar Spine

BACKGROUND

Intraspinal extradural ventral cysts in the lumbar spine can cause back pain and neurological deficits of the lower extremities. For the resection of this type of space-occupying lesion, the transdural approach has not been reported in the literature.

CASE DESCRIPTION

A 66-year-old man presented, suffering from progressive radiation pain of his bilateral lower extremities. Imaging examination revealed a cystic lesion in ventral side of lumbar spinal canal. We conducted the excision of the cyst with the transdural approach. The symptoms of the patient disappeared immediately after the operation and recurrence of the symptoms has not been observed in the 3-month follow-up.

CONCLUSIONS

This operation approach is safe and effective. Compared with the previous surgical approach reported in the literature, by this approach surgeons could achieve less injury, shorter operation time, and the same surgical outcomes in the short term. Therefore, we would like to present this approach to provide an alternative to deal with similar lesions.

New classification of facet joint synovial cysts

PURPOSE

Facet cysts develop due to degeneration of the zygapophyseal joints and can lead to radiculopathy and neurogenic claudication. Various surgical options are available for facet cyst excision. The aim was to facilitate surgical treatment of lumbar facet cysts based on a new classification.

METHODS

We retrospectively analyzed all patients of the last 10 years in whom a facet cyst was surgically removed (ipsilateral laminotomy, contralateral laminotomy, and segmental fusion). Several radiological parameters were analyzed and correlated with the patients' outcome (residual symptoms, perioperative complications, need for re-operation, need for secondary fusion, facet cyst recurrence).

RESULTS

One hundred eleven patients (55 women; median age 64 years) could be identified. Thirty-three (48%) of 69 cases, for which MRI data were available, were classified as medial facet cyst (compressing the spinal canal), 6 facet cysts were localized intraforaminal (9%) and 30 cases (43%) mediolateral (combination of both). The contralateral approach had the lowest rate for revision surgery (7.5%, p = .038) and the lowest prevalence of residual complaints (7.5%, p = .109). A spondylolisthesis and a higher/steeper angle of the facet joints were associated with poorer patient outcome.

CONCLUSIONS

Lateral facet joint cysts are best resected by a contralateral approach offering the best outcome while medial cysts are suitable for removal by an ipsilateral laminotomy. The approach of mediolateral cysts can be determined by the width of the lamina and the angle of the joint. Segmental fusion should be considered in cases with detected spondylolisthesis and/or steep facet joints.

OLIF Combined with Anterior Fixation for Lumbar Synovial Cysts with Instability

BACKGROUND

The optimal management of lumbar synovial cysts (LSCs) has always been controversial. Open or minimally invasive partial hemilaminotomy as a direct decompression approach has been widely studied, whereas to our knowledge, there has been no report of an indirect decompression method for LSC.

CASE DESCRIPTION

A 60-year-old male complained of chronic low back pain for 2 years. He reported that the pain had been getting worse and started radiating to the bilateral posterior thighs and right lateral calf for 6 months. An ovoid lesion with a hyperintense center attached to the medial side of the right facet joint at the L4-5 level, as well as L4-5 dynamic instability, were found with magnetic resonance imaging and lumbar x-ray examinations, respectively. L4-5 oblique lumbar interbody fusion combined with anterior fixation was performed. After surgery, the patient felt distinct pain relief and was discharged on the third day postoperatively. Three months later, lumbar magnetic resonance imaging and 3-dimensional computed tomography were performed again. The L4-5 disk height and foraminal height recovered from 7.1-12.3 mm and 14.8-18.5 mm, respectively. No evidence of a cyst was disclosed. The patient did not complain of any low back pain or radicular pain during the 12-month follow-up.

CONCLUSIONS

Indirect decompression surgery may be a new option for the management of LSC, especially in those with lumbar instability and that communicate with the facet joint. Further research with a larger and more comprehensive sample population is required.

Thoracic juxtafacet cyst (JFC): a cause of spinal myelopathy

Spinal cord compression due to synovial facet cyst in thoracolumbar spine is rare. Several etiologies of juxtafacet cysts (JFCs) in this location have been discussed, particularly overload of the arthritic facet joints. Due to the narrow caliber of the thoracic spine, JFC in this location can present with radicular pain or progressive myelopathy. We report an interesting case of a 67 year-old woman who presented with the signs and symptoms of thoracic myelopathy. A left-sided T11/12 JFC was identified on MRI and CT scans correlating with her myelopathy. She experienced a substantial improvement in her myelopathic symptoms after surgical excision of the JFC. The presentation, etiology, and therapeutic aspects of JFC are discussed in detail.