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Hemorrhagic lumbar synovial cyst: Case report and literature review

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Intraspinal synovial cysts are infrequent causes of back and radicular leg pain. Commonly associated with degenerative spinal disease, the majority of synovial cysts appear in the lumbar spine. Rarely, intracystic hemorrhage can occur through an unclear mechanism. Similarly rare, cysts may also become migratory. The pathogenesis of hemorrhagic synovial cysts remains uncertain and their potential for migration also remains unclear. A 36 year-old male presented to the clinic with 5 months of back pain and leg pain that began after a work-related injury. An initial MRI obtained by another surgeon 3 month prior demonstrated an epidural cystic mass with T1 hypointensity and T2 hyperintensity at L2-L3. With worsening pain, the patient came to our clinic for a second opinion. A second MRI demonstrated resolution of the L2-L3 epidural cystic mass and formation of a new epidural cystic mass at L3-L4 causing compression of the thecal sac. The patient subsequently underwent decompressive hemilaminectomy with cyst removal. We present a case of two lumbar synovial cysts, separated over time and a vertebral level and giving the appearance of a single, migratory cyst. This is the first case of an "occult migratory" synovial cyst with repeat MR imaging capturing spontaneous resolution of the initial cyst and formation of a hemorrhagic cyst one level below. We also present a summary of the 44 cases of hemorrhagic synovial cysts reported in the literature and propose a mechanism that may account for the hemorrhagic and migratory progression in some patients.
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481
CASE REPORT
Nagoya J. Med. Sci. 77. 481 ~ 492, 2015
Hemorrhagic lumbar synovial cyst: case report
and literature review
Gregory Cannarsa, BS; Shannon W. Clark, MD; Norah Chalouhi, MD;
Mario Zanaty, MD and Joshua Heller, MD
Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
ABSTRACT
Intraspinal synovial cysts are infrequent causes of back and radicular leg pain. Commonly associated
with degenerative spinal disease, the majority of synovial cysts appear in the lumbar spine. Rarely, intracys-
tic hemorrhage can occur through an unclear mechanism. Similarly rare, cysts may also become migratory.
The pathogenesis of hemorrhagic synovial cysts remains uncertain and their potential for migration also
remains unclear. A 36 year-old male presented to the clinic with 5 months of back pain and leg pain that
began after a work-related injury. An initial MRI obtained by another surgeon 3 month prior demonstrated
an epidural cystic mass with T1 hypointensity and T2 hyperintensity at L2-L3. With worsening pain, the
patient came to our clinic for a second opinion. A second MRI demonstrated resolution of the L2-L3
epidural cystic mass and formation of a new epidural cystic mass at L3-L4 causing compression of the
thecal sac. The patient subsequently underwent decompressive hemilaminectomy with cyst removal. We
present a case of two lumbar synovial cysts, separated over time and a vertebral level and giving the
appearance of a single, migratory cyst. This is the rst case of an “occult migratory” synovial cyst with
repeat MR imaging capturing spontaneous resolution of the initial cyst and formation of a hemorrhagic
cyst one level below. We also present a summary of the 44 cases of hemorrhagic synovial cysts reported
in the literature and propose a mechanism that may account for the hemorrhagic and migratory progression
in some patients.
Key Words: lumbar synovial cyst, hemorrhagic, juxtafacet cyst
BACKGROUND AND IMPORTANCE
Spinal synovial cysts, also known as juxtafacet cysts, are an infrequent cause of radicular leg
and back pain. The majority occur in the lumbar spine, especially the L4-L5 level, and are as-
sociated with facet joint osteoarthritis and spondylolisthesis1,2). Rarely, synovial cysts can become
hemorrhagic through an uncertain mechanism, though factors such as trauma and anticoagulation
may play a role3,4). Lumbar synovial cysts also may become migratory through an uncertain
mechanism5,6). We report on a patient who initially presented with a hemorrhagic lumbar cystic
mass originating at L2-3 level which was read as lumbar epidural mass vs. hemorrhage; however,
on repeated imaging obtained three months later, it had migrated to L3-4 level with further signs
of acute hemorrhage. Due to the apparently migrated lesion, epidural hematoma was the tentative
diagnosis but the nal surgical pathology demonstrated L3-4 lesion to be consistent with synovial
Received: November 6, 2014; accepted: February 2, 2015
Corresponding author: Shannon W. Clark, Department of Neurosurgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
Telephone: +1-813-527-4403, Fax: +1-215-503-9170, e-mail: Shannon.hann@jefferson.edu,
482
Gregory Cannarsa et al.
cyst with hemorrhage. Migration of a hemorrhagic lumbar synovial cyst demonstrated by repeated
MR imaging has not been reported previously. We discuss the presenting symptoms, surgical
management, and putative migratory etiology of hemorrhagic synovial cysts. We also conducted
comprehensive literature review which found 44 published cases of lumbar hemorrhagic synovial
cysts, and summarized the management strategy of this rare pathology.
CLINICAL PRESENTATION
A 36 year-old male with no past medical history presented with low back pain and bilateral
leg pain and numbness that began ve months earlier after a work related injury. His initial
MRI lumbar spine demonstrated a cystic hemorrhagic epidural mass with T1 hypointensity and
T2 hyperintensity on the L2-L3 level with considerable thecal sac and nerve root compression
(Fig. 1). The lesion originated near the left L2-3 facet joint and extended under the lamina of
L2 and L3 centrally.
After three months of progressive worsening of his pain and conservative management recom-
mended by another surgeon, the patient came for a second opinion at our clinic due to newly
developed worsening right leg weakness. The second MRI lumbar spine, performed three months
after the initial, demonstrated complete resolution of the L2-3 hemorrhagic cystic mass but with
a new hemorrhagic epidural mass formed at L3-4 causing compression of the thecal sac and
L3 nerve root on the right side (Fig. 2). Additionally, the patient was noted to have bilateral
spondylolysis at the L4 with pars defect along with bilateral facet hypertrophy at L3-L4. At this
time, his right iliopsoas and quadriceps were 4/5 in motor strength.
The patient was offered surgical treatment and subsequently underwent right L3-L4 hemilami-
nectomy and medial facetectomy under a microscope. After opening the ligamentum avum at L3,
bloody uid egressed out of the epidural space. Thickened tissue associated with the L2-3 facet
joint was resected. Intraoperative pathology was consistent with brinous tissue as well as blood
suggestive of synovial cyst. The post-operative lumbar MRI demonstrated complete decompression
of thecal sac after resection of the synovial cyst originating at L2-3 right facet (Fig. 4). With
the possibility of malignancy, the L4 pars defect was not repaired during the procedure. After
Fig. 1 Initial lumbar spine sagittal magnetic resonance images performed 3 months prior to presentation. The
T2-weighted image shows a hyperintense cystic mass at the L2-L3 dorsal epidural space.
483
Hemorrhagic lumbar synovial cyst
conrming no malignancy on nal pathology, the patient was taken back to operative room one
week later for L4 pars repair with bilateral L4 transpedicular screws and sublaminar hooks. Right
iliac crest bone graft was harvested for bone grafting of pars defects (Fig. 5)
Final pathological ndings were broadipose tissue with reactive changes including focal
hemosiderin deposition, along with fragments of tissue with spindle cells consistent with ligament
and synovial tissue. Figure 3 shows the H&E stein of the resection hemorrhagic synovial cyst.
At 3 weeks follow-up, the patient’s leg pain and weakness had resolved with mild low-back
pain at the site of the incision.
Fig. 2 Second lumbar spine magnetic resonance imaging three months after the initial imaging. T2-weighted
sequence shows a heterogeneous hyperintense cystic mass at the L3-L4 dorsal epidural space and the
initial cystic mass at L2-3 level has resolved.
Fig. 3 Histological appearance of the hemorrhagic synovial cyst showing synovial cell lining, broconnective
tissue, neoangiogenesis, and hemosiderin microdeposits (H&E stain, ×200).
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Gregory Cannarsa et al.
DISCUSSION
The two possible etiologies of this patient’s presentation is either spontaneous hemorrhagic
epidural bleed that migrated caudally over three months or a hemorrhagic synovial cyst initially
originating at left L1-2 facet joint and extending to epidural space at L2-3 level that resolved
spontaneously and another different hemorrhagic synovial cyst formed at the level below upon
new injury to the lumbar spine three months later. Since synovial joints are conned to each facet
joints, it would be unlikely that the single synovial cyst actually migrated caudally. Furthermore,
the new MRI also showed intense STIR signal at L2-3 and L3-4 interspinous ligaments which
was not evident on the rst MRI suggesting another injury in between the MRIs. This makes
the development of two separate synovial cysts more likely than migration of epidural bleed,
especially considering intraoperative visualization of right sided synovial cyst and resection
pathology. Hemorrhagic conversion of the cyst content could be attributable to the fact that the
patient was taking large amounts of aspirin for his back pain during this period. Regarding the
apparent migration of the cyst, it’s likely that an occult phenomenon occurred where two separate
Fig. 4 Post-operative T2 MRI sequence demonstrating decompressed lumbar spinal canal with total resection
of the synovial cyst
Fig. 5 Post-operative lateral and AP view of lumbar radiograph after the pars repair at L4
485
Hemorrhagic lumbar synovial cyst
cysts formed in proximity with one resolving while the other worsened making it appear to be
the same lesion. Synovial cyst is a known pathology but symptomatic, hemorrhagic synovial
cysts are rare. Two large, symptomatic, hemorrhagic synovial cysts forming within three months
of each other with one completely resolving has not been reported.
Synovial or ganglion cysts usually present in the extremities and have been known to occur
with joint disease and hypermobility38,39). Once considered rare, spinal synovial cysts, which, as
noted, are mostly of lumbar origin, have been increasing in prevalence along with the increase in
use of CT and MRI for spinal disorders. Imaging in symptomatic and highly-active, asymptomatic
populations has shown the incidence to be in the range of 7.0–22.4%, with some patients having
multiple cysts40,41). Increasing prevalence on imaging suggests that the majority of these cysts
resolve or remain asymptomatic, and there are reports of spontaneous resolutions of these cysts 42).
However, synovial cysts may also undergo rapid enlargement through both hemorrhagic as well
as nonhemorrhagic mechanisms causing acute cauda equina syndrome18,43).
From our literature review, we found 44 previously published cases of hemorrhagic synovial
cysts, dened by intraoperative nding of blood in the cyst or the observation of blood or
hemosiderin on pathological analysis. Table 1 summarizes each case’s presentation, surgical
managements, and outcomes as well as patients’ satisfaction according to the Macnab criteria.
The average age at presentation was 63.4±3.2 (SEM) years, with 39/43 (91%) cases occurring
after age 50. There were 25 males (60%) and 17 females (40%) in the cases. The average age
of the females at presentation was 69.2±2.2 years compared to 59.6±3.1 years for males. Of
note, the four cases presenting before age 50 (ages 24, 29, 36, 42) were all male.
Table 1 Review of the Literature: Summary of 44 cases of Hemorrhagic Lumbar Synovial Cysts
Authors/
Year
Age/
Gender Level Symptom
Duration
Back
Pain
Leg
Pain Weakness Sensory
Change
Decreased
Reexes Other MRI*
(T1/T2)
Surgical
Treatment
– Lami-
nectomy
Follow-
up Outcome
Applied
Macnab
Score†
Brish
and
Payan,
19725)
51/M L4-L5 3 mo + + + + NR
Complete
resolu-
tion of
presenting
symptoms
Excellent
Pendleton
et al.,
198331)
50/F L3-L4 3 mo ->
2wks +++++ +1 mo Improved
symptoms Good
Kjerulf
et al.,
198619)
56/F L5-S1 5 mo + + + + 1 yr
Complete
resolu-
tion of
presenting
symptoms
Excellent
Franck
et al.,
198712)
62/F L4-L5 2 mo + + + NR
Complete
resolu-
tion of
presenting
symptoms
Excellent
Onofrio
and Mih,
198827)
64/F L4-L5 3 mo + + + + 3 mo Pain free Excellent
71/F L4-L5 3 mo + + + 3 mo
Mild
residual
foot pain
Good
Reust
et al.,
198835)
77/F L4-L5 1 mo + + + 1 y
Complete
resolu-
tion of
presenting
symptoms
Excellent
486
Gregory Cannarsa et al.
24/M L4-L5 5 mo + + + 1 yr
Progres-
sive
improve-
ment
Good
Eyster
and
Scott,
198910)
60/M L4-L5 3 mo + + + NR
Complete
resolu-
tion of
presenting
symptoms
Excellent
Lemish
et al.,
198920)
78/F L5-S1 3 mo + + NR
Complete
resolu-
tion of
presenting
symptoms
Excellent
53/M L4-L5 21 d +
spinal
claudica-
tion
+ NR
Complete
resolu-
tion of
presenting
symptoms
Excellent
Rousseaux
et al.,
198936)
29/M L5-S1 7 mo + + NR NR NR
Jackson
et al.,
198916)
NR/NR L4-L5 NR + + Hi/Hi + NR
Improve-
ment in
pain and
relief of
radicu-
lopathy
Good
Summers
and
Quint,
199238)
60/M L2-L3 6 mo + + + hHi/hLo + NR NR NR
Tatter
and
Cosgrove,
199441)
59/M L3-L4 5 d + + + + Hi/hLo + 2 mo
Complete
resolu-
tion of
presenting
symptoms
Excellent
Yarde
et al.,
199547)
42/M L5-S1 12 mo + + NR + 4 mo Improved
symptoms Good
Howling
and
Kessel,
199715)
51/M L4-L5 21 d + + + + + hHi/hHi + NR
Complete
resolu-
tion of
presenting
symptoms
Excellent
Radatz
et al.,
199732)
65/M L4-L5 >1 mo + + + + Lo/Hi + 1 mo
Complete
resolu-
tion of
presenting
symptoms
Excellent
Henriet
and
Nobourgh,
199813)
56/F L4-L5 14 d + + + NR NR NR
Bandiera
et al.,
19993)
81/F L3-L4 4 mo +++
spinal
claudica-
tion
Hi/hHi + 1 yr
Complete
resolu-
tion of
presenting
symptoms
Excellent
Kaneko
and
Inoue,
200017)
55/M L3-L4 6 mo ->
3 d + + + + Hi/NR + 2.5 yr
Complete
resolu-
tion of
presenting
symptoms
Excellent
Wang
et al.,
200445)
76/F L4-L5 4 mo ->
few days + Hi/Lo + NR
Complete
resolution
of pain
Excellent
82/F L4-L5 3 mo ->
24 hr + + + Hi/Lo + NR
Complete
resolution
of pain
Excellent
487
Hemorrhagic lumbar synovial cyst
Eck and
Trian-
tafyllou,
20059)
77/M L3-L4 2 wk + + + NR/Hi + 1 yr
Complete
resolu-
tion of
presenting
symptoms
Excellent
Wait
et al.,
200544)
62/M L3-L4 6 mo ->
2 mo + + + Hi/NR + NR Full
recovery Excellent
69/M L3-L4 8 mo ->
2 wk +++++urinary
retention Hi/NR + 4 mo Full
recovery Excellent
Khan
et al.,
200518)
NR/NR NR NR NR
NR/NR NR NR NR
Ramieri
et al.,
200634)
71/F L5-S1 15 d + + + + hHi/NR + 1 yr
Complete
resolu-
tion of
presenting
symptoms
Excellent
75/F L3-L4 10 d + + + + + hHi/NR + 1 yr
Recovery
of
sensation,
reexes.
Partial
recovery
of
strength
Good
68/M L4-L5 14 d + + hHi/NR + 2 yr
No
radicular
pain,
continued
back pain
Good
Nour-
bakhsh
and
Garges,
200726)
67/M L4-L5 1.5 mo + + + + clonus Hi/hLo + 1 yr
Complete
resolu-
tion of
presenting
symptoms
Excellent
Arantes
et al.,
20082)
61/M L4-L5 2 mo ->
8 d + + + Hi/Lo + 6 mo
Complete
resolution
of neu-
rological
symptoms
Excellent
Miyatake
et al.,
200925)
86/M L1-L2 3 mo ->
1mo + Hi/Hi + NR
Complete
resolution
of neu-
rological
symptoms
Excellent
56/M L4-L5 1 mo ->
4 d + + cauda
equina Hi/Hi + NR
Complete
resolution
of neu-
rological
symptoms
Excellent
84/M L4-L5 2 mo ->
1 mo + + Hi/Hi + NR
Complete
resolution
of neu-
rological
symptoms
Excellent
57/M L5-S1 3 mo ->
2 mo + Hi/Hi + NR
Complete
resolution
of neu-
rological
symptoms
Excellent
Cicuendez
et al.,
20107)
72/F L3-L4 3 mo ->
1 wk + + + + Hi/h + ~4 wk Full
recovery Excellent
Utsu-
nomiya
et al.,
201143)
65/F L3-L4 2 mo ->
days + + + + hHi/Lo + 1 yr Complete
recovery Excellent
488
Gregory Cannarsa et al.
The most commonly involved vertebral levels were L4-L5 (46.5%) followed by L3-L4
(27.9%), L5-S1 (14.0%), and L2-L3 (7.0%). There has been one reported case at S1-S2 and
one reported case at L1-L2 (Fig. 6). Previous literature reviews have shown the majority (64%)
of non-hemorrhagic lumbar synovial cysts to be located at L4-L52).
The most common presenting symptoms and physical ndings were leg pain (88%), back pain
(70%), sensory changes including numbness, tingling, paresthesia (60%) and weakness (51%)
(Fig. 7). Absent reexes were reported in 18% of cases, while incontinence or other urinary
changes were rare with only two reported cases.
Among cases with recorded MRI findings, most cysts (93%, 26/28) were found to be
hyperintense or heterogeneously hyperintense on T1-weighted imaging. In 6 cases, contrast
enhancement on the peripheral rim of the cyst, the capsule, was noted on T1-weighted imaging.
With T2-weighting, there is a mixed picture; among 23 cases, 30.4% were hypointense, 34.7%
were heterogeneous and 34.7% were hyperintense. On MR imaging, non-hemorrhagic synovial
cysts are typically T1-hypointense and T2-hyperintense, but the signal varies depending on fac-
tors including protein content, blood products, and timing of hemorrhage within the cyst2). T2
imaging of cysts is known to have varying signal intensity, and previous reports have similarly
surmised previous old hemorrhages, elevated protein content, and calcication can all be causes
of this varying signal44).
Surgical decompression via laminectomy and cyst excision is the current standard and was the
treatment of choice in majority of the cases reviewed. Depending on cyst size, medial facetectomy
was also performed. Posterior fusion and stabilization was performed in only 3 cases. Of the
40 cases with documented postoperative outcomes, a majority of patients (75%) had complete
resolution of symptoms. Improved symptoms were noted in the remaining 25% of cases. There
were no recorded cases of fair or poor outcomes. For patients with recurrent cyst formation,
persistent back pain or leg pain symptoms due to concurrent pathology such as spondylolysis
or pars defect as in our patient, additional lumbar fusion or pars repair for stabilization are
often carried out to stabilize the spine. Pars repair offers benet of not losing the segmental
Xu et al.,
201146) 68/M L3-L4 4 mo ->
1 wk + + + + Hi/Lo + 8 mo
Resolution
of major-
ity of
radicular
symptoms
Good
Tofuka
et al.,
201142)
84/M L4-L5 >2 mo +++
urinary
distur-
bance
Hi/h + 1 wk
Symptoms
improved,
Pt could
walk
without
support
at 1 wk
post-op
Good
Park
et al.,
201230)
72/F L2-L3 acute + + Hi/Lo + 1 mo Full
recovery Excellent
Machino
et al.,
201222)
65/M L2-L3 3 mo ->
1 wk + + +
mild
inconti-
nence of
bowel and
bladder
Hi/Lo + 1 mo Full
recovery Excellent
Hoover
and
Pirris,
201414)
68/F S1-S2 3 wk + + + Lo/Hi + NR
Signicant
improve-
ment in
leg pain
Good
NR = Not recorded by authors
*h = heterogeneous, Hi = hyperintense, Lo = hypointense
†According to Macnab score23)
489
Hemorrhagic lumbar synovial cyst
motion at the involved level thereby exposing patients to less chance of developing adjacent
level disease in the future. We believe this was a good option for this particular young patient
who has extremely physically challenging career. Percutaneous rupture of intact lumbar synovial
cysts is also an option, but has not been used or recommended in hemorrhagic cases with the
risk of causing epidural bleed45).
Non-hemorrhagic synovial cysts are thought to be related to degenerative spinal changes and
segmental instability, with retrospective studies supporting these hypotheses1,9). MRI prevalence
studies have also shown cysts to have signicant associations with facet arthropathy, facet
joint osteoarthritis, and spondylolisthesis40). The pathogenesis of hemorrhagic cysts is less well
understood. While trauma and anticoagulation therapy have been implicated as factors, they have
Fig. 7 Spinal levels affected by hemorrhagic synovial cysts. Data collected from 43 cases published in the
literature.
Fig. 6 Incidence of the most common symptoms and physical ndings associated with hemorrhagic synovial
cysts. Data collected from 43 cases published in the literature.
490
Gregory Cannarsa et al.
not been associated in a majority of cases3). The literature review of 44 cases found that cyst
hemorrhage more often occurs in men and at an earlier age, lending support to a micro-trauma
hypothesis if occupation and lifestyle is considered. In our case, a 36 year-old male police ofcer
with bilateral spondylolysis at the L4 level, it is likely that degenerative changes in his lumbar
spine along with daily microtrauma caused by his occupation led to his initial synovial cyst and
eventual hemorrhagic transformation.
Regarding our patient’s apparent migratory cyst, previous reports of migratory synovial cysts
have shown migration to the erector spinae as well as between spinous processes5,6). In our case,
cyst migration is likely an occult phenomenon because the synovial cyst is apparently occurring
at two distinct levels. Our hypothesis is that the patient had initial trauma that induced rst
hemorrhagic synovial cyst at L1-2 level on left extending to L2-3 epidural level which resolved
and had another trauma on work duty that induced completely different hemorrhagic synovial
cyst at the level below at L3-4 on right. This is both consistent with the MRI nding of new
posterior ligamentous injury as well as the patient developing new symptoms of worsened right
leg pain and right quadriceps weakness during the intervening three months.
Unlike in our case, true synovial cyst migration around a facet, under the epidural space, or
into the erector spinae muscle, is likely to involve mechanical as well as chemical mechanisms.
An inammatory process in or near the cyst may cause an increase in the proteolytic enzymatic
activity of the cystic uid. Synovial uid contains metalloproteases, hyaluronidase, and other
enzymes capable of digesting through tissue, giving it the capability to create new pathways
through which it propagates via gravity and pressure-related mechanisms46). This migration of
inammatory, enzymatic cystic uid may be involved with the spontaneous hemorrhage observed
as vascular structures exposed are vulnerable to digestion. Previous reports have hypothesized
that anti-inammatories such as NSAIDs may play a role in regression of synovial cysts47). This
certainly could be the case for our patient’s spontaneous resolution of the cyst at L2-3 as he was
primarily taking NSAIDs to cope with his low back pain. The role of migration in hemorrhagic
transformation remains unclear. With increasing use of MRI, it is likely more cases with repeated
imaging will capture previously unseen migration.
CONCLUSION
Lumbar synovial cysts are an increasingly common nding on MR imaging in both symptom-
atic and asymptomatic populations. Trauma may play a role in their formation and a higher index
of suspicion may be warranted in males with active occupations. While the majority of synovial
cysts can be observed, acute worsening or change in symptoms may herald either a hemorrhagic
transformation or migration to a different level. Patients should be counseled regarding these rare
possibilities. As our case demonstrates, repeated MRI imaging is worthwhile. Surgical decompres-
sion with cyst excision remains the treatment of choice. In patients with associated pars defect
or spondylolisthesis, lumbar decompression with resection of cysts may not be enough to reduce
back pain symptoms warranting concurrent fusion or pars repair for better symptomatic relief.
CONFLICTS OF INTEREST
All authors have no nancial support or relationships that may pose a conict of interest to
disclose for this work.
491
Hemorrhagic lumbar synovial cyst
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... Hemorrhage into the cavity of synovial cyst may result in cyst enlargement leading to neural compression and acute worsening of the symptoms. [20] Based on the literature review of 44 published cases of lumbar hemorrhagic synovial cysts by Cannarsa et al., [21] they found that hemorrhagic cysts more often occurred in men and at an earlier age. Hemorrhagic synovial cyst can occur in the cervical and thoracic region, resulting in myelopathy. ...
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