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Lumbar Synovial Cysts: A review of diagnosis, surgical management, and outcome assessment

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Synovial cysts of the lumbar spine contribute significantly to narrowing of the spinal canal and lateral thecal sac and nerve root compression. Cysts form as a result of arthrotic disruption of the facet joint, leading to degenerative spondylolisthesis in up to 40% of patients. Clinical findings and neurodiagnostic confirmation prompt surgical intervention consisting of varying decompressions with or without primary fusion. Most patients present in their mid-60s, with a male-to-female ratio varying from 2:1 to 1:1. Preoperative symptoms include low back pain, radiculopathy, and neurogenic claudication. Motor and sensory signs usually reflect the anatomic location of the synovial cyst and the level of resultant maximal lumbar stenosis. In descending order of frequency, they are typically found at the L4-L5, L5-S1, L3-L4, and L2-L3 levels. Lumbar synovial cyst surgery includes unilateral or bilateral laminotomies, hemilaminectomies, or laminectomies alone or in combination with in situ or instrumented fusion. Those patients undergoing decompression alone may postoperatively develop progression or the new appearance of olisthy, while those primarily fused rarely show further increase or a new onset of slip. Outcome measures spanning 1- to 2-year postoperative intervals frequently included surgeon-based rather than the current patient-based analysis, the lat-ter including the Medical Outcomes Trust Short Form-36.
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REVIEW ARTICLE
Lumbar Synovial Cysts
A Review of Diagnosis, Surgical Management, and Outcome Assessment
Nancy E. Epstein, MD
Abstract Synovial cysts of the lumbar spine contribute significantly
to narrowing of the spinal canal and lateral thecal sac and nerve root
compression. Cysts form as a result of arthrotic disruption of the facet
joint, leading to degenerative spondylolisthesis in up to 40% of pa-
tients. Clinical findings and neurodiagnostic confirmation prompt
surgical intervention consisting of varying decompressions with or
without primary fusion. Most patients present in their mid-60s, with a
male-to-female ratio varying from 2:1 to 1:1. Preoperative symptoms
include low back pain, radiculopathy, and neurogenic claudication.
Motor and sensory signs usually reflect the anatomic location of the
synovial cyst and the level of resultant maximal lumbar stenosis. In
descending order of frequency, they are typically found at the L4–L5,
L5–S1, L3–L4, and L2–L3 levels. Lumbar synovial cyst surgery in-
cludes unilateral or bilateral laminotomies, hemilaminectomies, or
laminectomies alone or in combination with in situ or instrumented
fusion. Those patients undergoing decompression alone may postop-
eratively develop progression or the new appearance of olisthy, while
those primarily fused rarely show further increase or a new onset of
slip. Outcome measures spanning 1- to 2-year postoperative intervals
frequently included surgeon-based rather than the current patient-
based analysis, the lat-ter including the Medical Outcomes Trust
Short Form-36.
Key Words: lumbar synovial cysts, diagnosis, outcomes
(J Spinal Disord Tech 2004;17:321–325)
T
he clinical, neurodiagnostic, surgical management, and
outcome assessment of 440 lumbar synovial cysts reported
in 15 published series are critically reviewed (Table 1).
Synovial cysts are typically found in the lumbar spine,
posterolateral to the thecal sac, where they contribute to central
and/or lateral recess stenosis with nerve root compression.
1–6
Defined by both magnetic resonance (MR) and computed to-
mography (CT) studies, lumbar synovial cysts typically arise
from arthrotic overlying facet joints, which may contribute to
attendant degenerative spondylolisthesis. Synovial cysts are
often accompanied by significant spondylostenosis requiring
laminectomy rather than laminotomy or hemilaminectomy for
adequate decompression. In certain instances, the presence of
olisthy or instability necessitates simultaneous fusion. The ma-
jority of outcome studies use a surgeon-based scale, with very
few series based upon patient-based analysis like the Medical
Outcomes Trust Short Form-36.
7
FREQUENCY
Of 1800 lumbar CT and MR studies performed over an
18-month interval, Eyster and Scott
8
reported 11 (0.6%) in-
stances of synovial cysts involving the lumbar spine. Of 440
cases of synovial cysts reported in 15 series, the smallest study
consisted of a single case report,
9
while the largest series pre-
sented by Lyons et al
10
included 194 cases followed over an
average 6-month follow-up interval. The actual numbers of pa-
tients in these studies reported in ascending order therefore
varied from 1 to 194 (see Table 1).
1–6,8–16
Synovial cysts occur more frequently in the lumbar
spine than in the cervical or thoracic regions. In the study of
Howington et al,
3
29 (94%) lumbar synovial cysts were found
along with 1 (2%) thoracic and 1 (2%) cervicothoracic cyst.
Similarly, Friedberg et al
2
encountered 23 (85%) lumbar sy-
novial cysts, but only 1 (5%) cervical and 2 (10%) thoracic
cysts.
AGE AND SEX
Patients with lumbar synovial cysts typically present in
their mid-60s. In the Trummer et al study,
14
the average age of
patients with synovial cysts involving the lumbar spine was 65
years, the mean age in the Lyons et al series
10
was 66 years,
with other studies presenting a range from 28 to 94 years.
4,10,13
Male-to-female ratios vary from nearly 2:1 (13 M/6 F) in Hsu
et al
4
to nearly 1:1 (100 M/94 F) in Lyon et al
10
and to the
approximate 1:2 ratio (4 M/9 F) in Onofrio and Mih.
13
PREOPERATIVE SYMPTOMS AND SIGNS
Lumbar synovial cyst symptoms include unilateral or bi-
lateral radiculopathy as reported in 55–97% of cases.
3,4,6,10
Received for publication March 16, 2003; accepted September 4, 2003.
From the Department of Neurological Surgery, Albert Einstein College of
Medicine, Bronx, and Winthrop University Hospital, Mineola, NY.
Supported by the Joseph A. Epstein Neurosurgical Education Foundation.
Reprints: Nancy E. Epstein, MD, Long Island Neurosurgical Associates, P.C.,
410 Lakeville Rd., Suite 204, New Hyde Park, NY 11042 (e-mail:
dch3@columbia.edu).
Copyright © 2004 by Lippincott Williams & Wilkins
J Spinal Disord Tech Volume 17, Number 4, August 2004 321
Neurogenic claudication was observed in 2544% of patients,
typically in those with underlying spinal stenosis.
3,6,10
Neuro-
logic deficits accompany synovial cysts in 18% of patients.
3,6
These specifically include motor deficits in 26.340% of pa-
tients,
4,10
sensory deficits in up to 45% of patients,
10
and reflex
abnormalities in 57% of patients.
10
Cauda equina syndromes
were observed in 13% of Lyons et als 194 cases.
10
NEURODIAGNOSTIC STUDIES
Preoperative dynamic x-rays revealed an increased inci-
dence of facet arthrosis with or without grade I spondylolisthe-
sis.
13
On 0.68% of lumbar MR and CT studies, synovial cysts
occurred in a juxta-articular, posterolateral, epidural location
within the lumbar spinal canal.
12,17
Hsu et al
4
observed that
significant facet joint degeneration was noted on 75% of x-ray
studies and MR examinations. Banning et al
16
noted facet joint
arthropathy in 90% of patients at the site of synovial cysts, with
12 (38%) of the 31 patients demonstrating accompanying de-
generative spondylolisthesis. Trummer et al
14
observed that 12
of 19 patients demonstrated hypermobile facet joints, while 6
(32%) showed spondylolisthesis. Lyons et al
10
fused 18
(9.2%) of 194 patients with lumbar synovial cysts for docu-
mented preoperative instability based on preoperative MR and
CT studies where cysts often extended into the yellow liga-
ment underlying degenerated facet joints. In the Howington et
al study of 29 cases,
3
each cyst was also accompanied by sig-
nificant arthropathy of the overlying facet joint.
MR SCANS OF SYNOVIAL CYSTS
On preoperative MR studies, synovial cysts are hypoin-
tense to isointense on T1-weighted images and are often ac-
companied by peripheral hypointensity reflecting microcalci-
fication and old hemorrhage into the capsule (Figs.
13).
11,18,19
On T2-weighted studies, the central portions of
synovial cysts are hyperintense, while on gadolinium-
enhanced studies, peripheral capsular enhancement is seen. CT
and myelo-CT examinations reveal hypodense to isodense
cystic centers with hyperdense rims reflecting calcification of
the capsule (Fig. 4).
MR VERSUS CT SCANS OF SYNOVIAL CYSTS
Salmon et al
15
determined that MR was more sensitive
than CT in documenting the presence of a synovial cyst and
that the diagnostic accuracy of the MR was 77% compared
with 56% for CT only and 42% for myelography alone. In the
Hsu et al series,
4
a 60% frequency of bilobed cysts both ventral
and dorsal to the spinal canal was demonstrated utilizing the
combination of facet arthrography, CT, and MR. Others re-
ported that cysts were often filled with air (nitro-
gen).
3,6,11,12,19
LEVELS OF SYNOVIAL CYSTS
Eighty-eight percent to 99% of all synovial cysts occur
in the lumbar spine, while cervical (14%) and thoracic (0
8%) lesions are only rarely encountered.
2,4,20
The majority of
synovial cysts are found at the L4L5 level, considered the
most mobile lumbar level, and are typically observed in de-
scending order at the L5S1, L3L4, and L2L3 lev-
TABLE 1. Lumbar Synovial Cysts Reported in the Literature
Series
No. of
Patients in Series
Marion and Kahanovitz
9
1
Yuh et al
11
5
Jackson et al
12
6
Yarde et al
6
8
Eyster and Scott
8
11
Onofrio and Mih
13
13
Hsu et al
4
19
Trummer et al
14
19
Artico et al
1
23
Friedberg et al
2
23
Salmon et al
15
28
Howington et al
3
29
Parlier-Cuau et al
5
30
Banning et al
16
31
Lyons et al
10
194
FIGURE 1. Transaxial T1-weighted MR scan showing a left-
sided synovial cyst at the L5S1 level resulting in significant
lateral thecal sac and nerve root compression.
Epstein J Spinal Disord Tech Volume 17, Number 4, August 2004
322 © 2004 Lippincott Williams & Wilkins
els.
4,6,10,12,15,16
Salmon et al
15
noted that 18 of 28 cysts were at
L4L5,6atL5S1, and 4 at L3L4. Hsu et al
4
observed that
68.4% of cysts were found at L4L5 and 21.1% at L5S1, with
5.2% at L1L2 and 5.2% at L2L3. Banning et al
16
observed
that 51% of the cysts in their series were found at the L4L5
level, while Lyons et al
10
observed that 64% of cysts occurred
at the L4L5 level.
CONSERVATIVE MANAGEMENT OF
SYNOVIAL CYSTS
Parlier-Cuau et al
5
reported that one-third of patients
with lumbar synovial cysts respond favorably within 16
months to the injection of steroids into the facet joints. Addi-
tionally, three of four patients in the series of Hsu et al
4
with 19
total patients experienced short-term relief of symptoms fol-
lowing facet joint injection of steroids but later required sur-
gery.
SURGERY
The surgical management or extent of decompression is
mandated by the degree of co-existent spondylostenosis. Many
studies rely heavily on laminectomy to adequately decompress
or excise the synovial cyst and deal with the attendant steno-
sis.
1,2,4,6
To remove a unilateral synovial cyst in a stenotic spi-
nal canal, for example, at the L4L5 level, usually a partial
laminectomy of L3, full laminectomy of L4, and partial lami-
nectomy of L5 are required. Superiorly, ventrally, and forami-
nally, the exiting L4 nerve root and thecal sac must be differ-
FIGURE 3. A right-sided parasagittal T2-weighted MR scan
demonstrating significant posterolateral thecal sac compres-
sion at the L3L4 level. Also observe the grade I retrolisthesis
indicating the presence of instability.
FIGURE 2. T2-weighted left parasagittal unenhanced MR scan
demonstrating posterolateral L3L4 synovial cyst. Note the in-
homogeneity of the contents of the cyst, which markedly com-
presses the thecal sac.
FIGURE 4. Parasagittal three-dimensional CT study demon-
strating posterolateral synovial cyst at the L4L5 level.
J Spinal Disord Tech Volume 17, Number 4, August 2004 Lumbar Synovial Cysts
© 2004 Lippincott Williams & Wilkins 323
entiated from the synovial cyst, which often fills the lateral
gutter, extending toward the cephalad L3L4 interspace.
Working across the table under the operating microscope al-
lows for the initial decompression of the bony stenosis with a
rotating Kerrison rongeur. This is followed by removal of hy-
pertrophied and often ossified yellow ligament in the lateral,
foraminal, and often extreme lateral subarticular regions. Ipsi-
lateral dissection with identification of the superior nerve root
and thecal sac follows, allowing for resection of the synovial
cyst, often in a layered fashion. First, the cyst may be gutted
or decompressed, removing the often thick, viscous contents.
Second, it is ascertained whether or not a clean dural plane
exists ventrally between the capsule of the cyst and underlying
theca. If a plane is identified, the synovial cyst may be entirely
removed. However, if there is ossification or marked adhesion
of the ventral aspect of the cyst to the dura, decompression
alone without excision should suffice, while also avoiding or
risking a cerebrospinal fluid fistula.
OUTCOME MEASURES
Most series report average 6-month (134/194 patients,
10
30 patients
5
), 1-year (8 patients),
6
or 2-year (29 patients)
16
out-
comes following surgery for lumbar synovial cysts. Howing-
ton et al
3
reviewed a series of 29 lumbar cysts treated over a
period of 10 years: The minimum follow-up was only 1 year.
Lyons et al
10
studied 194 patients with lumbar synovial cysts
but with only an average 6-month postoperative follow-up in-
terval.
Laminectomy Alone
The majority of studies reported outcomes following
laminectomy utilizing varied surgeon-based measures
(Odoms criteria, MacNabs criteria, Prolos criteria): excel-
lent: no residual symptoms/signs; good: mild residual
symptoms/signs; fair: minimal to no improvement; and poor:
worse.
1,2,13,15,16
In the Artico et al study
1
of 23 cysts, laminec-
tomy resulted in total cyst excision in 18 patients and subtotal
removal in 5; 18 good/excellent results were reported, while 5
demonstrated no neurologic improvement. In the 23 patients
with synovial cysts of Friedberg et al,
2
all treated with lami-
nectomy, 15 demonstrated excellent and 7 good responses,
while 1 remained the same postoperatively. Of the eight pa-
tients treated with laminectomy in the series of Hsu et al,
4
three
showed excellent and four good responses, while one re-
mained the same postoperatively. Of the 13 patients of Onofrio
and Mih,
13
undergoing laminectomy for synovial cysts, all 13
exhibited good to excellent results. Two years following sur-
gery in the Banning et al series of 31 patients with synovial
cysts (29 undergoing laminectomy with 2 having laminectomy
accompanied by fusions),
16
20 patients exhibited
good/excellent responses, while 11 had fair outcomes. Of the
28 patients having synovial cysts excised via laminectomy in
the series of Salmon et al,
15
26 demonstrated good/excellent
outcomes with only 2 showing fair/poor results. Lyons et al
10
had 194 patients with lumbar synovial cysts: 176 had laminec-
tomy alone, while 18 had simultaneous fusions. Six months
postoperatively, good/excellent results were reported in 91%
of patients, while 9% demonstrated fair/poor outcomes. Of in-
terest, only four of the patients of Lyons et al developed post-
operative instability warranting a secondary fusion.
Laminectomy with Primary Fusion
Patients with lumbar synovial cysts accompanied by de-
generative spondylolisthesis may further benefit from simul-
taneous fusion. In the study of Fischgrund et al
21
of 67 patients
with lumbar stenosis and degenerative spondylolisthesis, lami-
nectomy was combined with randomly assigned noninstru-
mented or instrumented fusions at the segment of olisthy. Two
years postoperatively, patients undergoing the noninstru-
mented fusions demonstrated an 85% incidence of good to ex-
cellent outcomes despite a lower 45% incidence of radio-
graphically documented fusion. On the other hand, for those
having instrumented fusions, a lower 76% incidence of good to
excellent results was reported despite a higher 82% frequency
of x-ray-confirmed arthrodesis.
PATHOLOGY
In most adult postmortem studies, the synovium of the
lumbar facets typically extends beyond the articular surfaces
of the joint and into the yellow ligament.
22
Pathologically, the
synovium exhibits an epithelial lining that could be differenti-
ated from cystic degeneration of the yellow ligament.
23,24
COMPLICATIONS
Postoperative complications reported by Lyons et al
10
in
their series of 194 patients included cerebrospinal fluid fistula
(3 patients), postoperative instability warranting secondary fu-
sion (4/176 patients undergoing laminectomy), discitis (1 pa-
tient), epidural hematoma (1 patient), seroma (1 patient), phle-
bitis (1 patient), and death (1 patient from unrelated cardiac
disease). Banning et al
16
observed that of their 31 patients with
synovial cysts, recurrent cysts were observed in 3% of cases,
9% (3 patients) required subsequent surgery including two spi-
nal fusions (6%), while an additional 9% (3 patients) devel-
oped postoperative cerebrospinal fluid fistulas.
CONCLUSIONS
Patients with lumbar synovial cysts typically present in
their mid-60s with symptoms of radiculopathy and neurogenic
claudication. Both MR and CT studies, including myelo-CT
examination, document the location of the synovial cyst and
the presence of spondylostenosis. Also demonstrated are the
associated facet arthropathy and a unique incidence of spon-
dylolisthesis. The optimal surgical management may well in-
clude not only laminectomy but also simultaneous fusion
Epstein J Spinal Disord Tech Volume 17, Number 4, August 2004
324 © 2004 Lippincott Williams & Wilkins
where disruption of the facet and the joint capsule, particularly
in the presence of olisthy, renders their spines unstable.
ACKNOWLEDGMENTS
The author appreciates the editorial assistance of Dr. Jo-
seph A. Epstein and Ms. Sherry Grimm.
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J Spinal Disord Tech Volume 17, Number 4, August 2004 Lumbar Synovial Cysts
© 2004 Lippincott Williams & Wilkins 325
... These cysts originate from the facet joint capsule [1] . The incidence of such cysts is 0.65% to 10% among patients presenting with low back pain and in most of them it is in the L4-L5 region [2,3] . The usual presentation in patients is low back pain, radiculopathy and neurogenic claudication. ...
... There has been much debate regarding approach to treatment of LISCs. Many authors have concluded surgical intervention as the best treatment option [3] . But considering the potential complications of surgery, non-surgical options are being considered increasingly. ...
... Several authors have reported that LISCs are a rare finding among patients presenting with low back pain and signs of lumbar radiculopathy [2,3] . The diagnosis is confirmed by MRI and the incidence among such patients is 0.65% to 10% [2,3] . ...
... Both MR and CT studies are essential to preoperatively document the full extent of lumbar stenosis, hypertrophy/ossification of the yellow ligament (OYL), with/without degenerative spondylolisthesis (DS), and synovial Cysts (SC) [Tables 1 and 2; Figures 1-16]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] e smaller, more typical unilateral SC occupies not only the lateral recess where they compress the caudad nerve root, but extend significantly foraminally, far laterally, and often superiorly to the mid-pedicle level where they impinge on the ipsilateral cephalad nerve root. [2] Due to double nerve root compression (e.g. at the L4-L5 level, there is compression of the cephalad L4 and caudad L5 nerve roots), two-level lumbar laminectomies are often warranted to adequately/more safely excise SC. ...
... [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15] e smaller, more typical unilateral SC occupies not only the lateral recess where they compress the caudad nerve root, but extend significantly foraminally, far laterally, and often superiorly to the mid-pedicle level where they impinge on the ipsilateral cephalad nerve root. [2] Due to double nerve root compression (e.g. at the L4-L5 level, there is compression of the cephalad L4 and caudad L5 nerve roots), two-level lumbar laminectomies are often warranted to adequately/more safely excise SC. Larger/massive SC may occupy the majority/ entire spinal canal, resulting in not only nerve root, but also severe cauda equina compression. ...
... Larger/massive SC may occupy the majority/ entire spinal canal, resulting in not only nerve root, but also severe cauda equina compression. [2] SC occurring alone or in combination with DS, may be managed without fusions in many patients, particularly older individuals with multiple significant comorbidities. However, for those with evidence of instability, noninstrumented vs. instrumented posterolateral fusions (PLF) vs. rarely, interbody fusions (e.g. ...
Article
Full-text available
Background Lumbar synovial cysts are often not sufficiently diagnosed prior to spine surgery. Utilizing both MR and CT studies is critical for recognizing the full extent/severity of these lesions. Methods In patients with chronic, acute, or subacute lumbar disease, obtaining both MR and CT studies is critical to correctly diagnose; disc disease, hypertrophy/ossification of the yellow ligament (OYL), stenosis, with/without degenerative spondylolisthesis, and/or synovial cysts (SC). Results MR T2 weighted images directly demonstrate hyperintensity within a SC. They initially cause lateral recess/caudad nerve root and/foraminal compromise, with larger extrusions causing significant lateral thecal sac, and far lateral/superior cephalad root compromise. CT 2 mm cuts often better demonstrate mid-vertebral level compression of cephalad nerve roots with/without SC calcification, along with the extent of mid-vertebral stenosis, hypertrophy/OYL, and DS. When CT studies directly document SC calcification, it alerts the surgeon to the increased potential risk of creating a cerebrospinal fluid fistula with full SC excision, and should prompt the adoption of alternative measures such as decompression/partial removal. Most critically, surgery for synovial cysts often warrants a 2-level laminectomy for fuller visualization of the cephalad and caudad nerve roots, and clearer differentiation of neural tissues from the large fibrotic SC capsule, to effect safer removal. Conclusions Preoperatively, establishing the full cephalad and cauda extent of lumbar synovial cysts with both MR and CT studies is critical. Anticipation and better visualization of the foraminal/far lateral and superior extent of these lesions often warrants more extensive multilevel laminectomies for thecal sac and both cephalad and caudad root decompression.
... However, when she underwent a L2-S1 laminectomy, the left L2-L3 lesion proved to be a massive synovial cyst [Figs. 1,2]. Postoperatively, the patient's symptoms immediately resolved, and she remained neurologically intact 6 months later. ...
... With degenerative spondylolisthesis, (DS), synovial cysts may occur in up to 40% of cases. [2] Most patients with synovial cysts are in their mid-60's, and the majority of these lesions occur at the following levels (descending order); L4-L5, L5-S1, L3-L4, and L2-L3. ...
... On rare occasion, lumbar synovial cysts may mimic herniated lumbar discs that have extruded dorsolaterally [Figs. 1,2]. Intraoperative confirmation of the correct level of the synovial cyst extrusion may help differentiate this from disc, and avoid additional unnecessary diskectomy. ...
Article
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Background The diagnosis of a lumbar herniated disc, stenosis, and other degenerative findings are typically established preoperatively with MR scans, supplemented with non-contrast CT studies. Here, a 77-year-old female, diagnosed as having L2-S1 stenosis and a large left-sided L2-L3 herniated disc was found at surgery to have a massive left-sided L2-L3 synovial cyst. Case Description A 77-year-old female was followed by pain management for 6-months with proximal left lower extremity weakness. The lumbar MR at that time was read as demonstrating a large left L2-L3 disc herniation with inferior migration to the L3 mid pedicle level, accompanied by L2-S1 lumbar stenosis. When she finally consulted neurosurgery, she exhibited severe left iliopsoas and quadriceps weakness (2/5), absent lower extremity reflexes, and profound decreased pin appreciation in the left L2-L3 distributions. The repeat MR and new CT studies confimred a large left L2-L3 disc accompanied by moderate/marked L2-S1 stenosis. However, at surgery, consisting of a laminectomy L2-S1, the supposed left L2-L3 disc proved to be a massive synovial cyst. Postoperatively, the patient regained normal function, and remained neurologically intact 6 months later. Conclusion In this 77 year-old female, the preoperative MR and CT scans were interpreted as showing a “typical” large left L2-L3 herniated disc. This proved at surgery to be a massive left L2-L3 synovial cyst. As demonstrated in this case, older patients with degenerative lumbar disease/stenosis, may have synovial cysts that mimic disc herniations both clinically and on preoperative diagnostic studies.
... Los quistes sinoviales (QS) espinales se originan a partir de la dilatación y potencial ruptura de la vaina sinovial de la articulación facetaria adyacente afectada comúnmente por un proceso degenerativo. [11,13] Si bien pueden presentarse en toda la columna vertebral, se ha reportado que aproximadamente el 96,2% afectan la región lumbar, [1,19] de los cuales el 70% lo hacen en el segmento L4-L5, el 2,6% se origina en la región cervical y un 1,2% restante en la columna torácica. [1,[6][7][8] Si el quiste crece dentro del canal espinal o neuroforámen, puede comprimir la raíz nerviosa pasante o saliente causando dolor, parestesia, debilidad, claudicación neurogénica de la marcha, lumbalgia y con menos frecuencia síndrome de cauda equina. ...
... [1,[6][7][8] Si el quiste crece dentro del canal espinal o neuroforámen, puede comprimir la raíz nerviosa pasante o saliente causando dolor, parestesia, debilidad, claudicación neurogénica de la marcha, lumbalgia y con menos frecuencia síndrome de cauda equina. [1,11] La resección quirúrgica de un quiste sinovial sintomático es considerado el tratamiento de elección debido a que descomprime directamente los elementos neurales comprometidos. El abordaje convencional se realiza a través una hemilaminectomía y una facetectomía del tercio medio ipsilateral. ...
... Los pacientes con QS sin espondilolistesis o con espondilolistesis G1 sin inestabilidad en la flexo-extensión son descomprimidos por un abordaje contralateral a nivel lumbar e ipsilateral en región cervical y torácica ser observados, mientras que para los sintomáticos se han descrito la utilización de analgésicos, fisioterapia, acupuntura, bloqueos farmacológicos, aspiración percutáne y resección quirúrgica con o sin fijación. [3,6,11,20] El tratamiento conservador así como la punción aspiración no han demostrado resultados efectivos a largo plazo, [10,20,22,29] por lo que la resección quirúrgica es considerada como el tratamiento de elección ante la persistencia de síntomas. La exéresis de la lesión a través de un abordaje convencional se realiza mediante una laminectomía bilateral o hemilaminectomía ipsilateral con una facetectomía del tercio medio o total asociada en algunos casos a fusión. ...
Article
Objective: To present the treatment algorithm, surgical technique, and results of a series of patients with spinal synovial cysts operated with minimally invasive techniques (MIS). Introduction: Spinal synovial cysts originate from the dilation and potential rupture of the synovial sheath of a facet joint. Surgical resection is considered the treatment of choice in symptomatic patients. The use of MIS techniques could reduce the disruption of the facet joint involved, reducing the risk of postoperative instability. Materials and methods: We retrospectively evaluated 21 patients with spinal synovial cysts operated by MIS approach and decompression. We analyzed the signs, symptoms, surgical time, hospital stay, evolution, and complications. The visual analog scale (VAS) was used to evaluate pain and the Weiner scale and the modified Macnab criteria to measure the patient's postoperative satisfaction. Results: A total of 21 patients were surgically treated with MIS technique; 76.2% (n = 16) did not require arthrodesis, the remaining 23.8% (n = 5) were fused. We performed 13 (61.9%) contralateral hemilaminectomies, 7 ipsilateral hemilaminectomies (33.3%), and 1 laminectomy in S1-S2. The average follow-up was 26 months; surgical time was 150.33 ± 63.31 min, with a hospital stay of 2.5 ± 1.78 days. The VAS decreased from 8.3 preoperatively to 2.3 postoperatively. Sixteen patients reported excellent results, four good and one regular in the scale of Macnab. 95.2% of patients perceived that the procedure was very/quite successful according to the Weiner scale. Conclusion: The minimally invasive approach is a safe and effective procedure for the complete resection of spinal synovial cysts. It provides excellent clinical-functional results by preserving muscles, ligaments, and joint facets.
... 3) These lesions are rare, and are mostly reported in Asia; their pathogenesis is still unknown. 4,5) Because of these features, there is no well-established treatment strategy, but the literature suggests that surgical treatment is the best option for discal cysts. 6) Various surgical therapeutic strategies have been suggested, but a standard surgical treatment method has not been established. ...
Article
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Discal cysts are a rare cause of low back pain and radiculopathy with unknown pathophysiologic mechanism. Associated symptoms are difficult to distinguish from those caused by extruded discs and other spinal canal lesions. Most discal cysts are treated surgically, but it is unclear whether the corresponding intervertebral disc should be excised along with cyst. We conducted a retrospective clinical review of 27 patients who underwent discal cyst excision at our institution between 2000 and 2017. The mean follow-up period was 63.6 months. We recorded symptoms, radiographs, operative findings, postoperative complications, and short- and long-term outcomes. Structured outcome assessment was based on Numeric Rating Scale (NRS) for pain intensity, Oswestry disability index, and Macnab classification. All patients underwent partial hemilaminectomy and microscopic cyst resection without discectomy. All patients had preoperative back or leg pain. Other preoperative clinical features included motor weakness, neurogenic intermittent claudication, and cauda equina syndrome. After surgery, NRS scores of back and leg pain decreased. The other symptoms also improved. During long-term follow-up, patients reported no restrictions on daily life activities, and were satisfied with our intervention. There were no cases of cyst recurrence. We conducted a review of the literature on lumbar discal cysts published before January, 2018. Including our cases, 126 patients were described. We compared two surgical modalities—cystectomy with and without discectomy—to elucidate both effectiveness and long-term complications. We found that microsurgical cystectomy without corresponding discectomy is an effective surgical treatment for lumbar discal cysts, and is associated with a low recurrence rate.
Article
Lumbar spine synovial cysts develop from degenerated zygapophyseal joints. Symptomatic patients present with radicular pain and weakness or neurogenic claudication.1 In the absence of significant concomitant degenerative spondylolisthesis, symptomatic patients can be managed with a laminectomy and microsurgical resection of the cyst, without the need for instrumented fusion.2,3 In this video, we present the microsurgical resection of a left-sided L4-5 synovial cyst in a 68-yr-old man with radicular pain refractory to conservative management. The radiographical features, relevant surgical anatomy, and salient operative steps are reviewed, and strategies for preventing cyst recurrence are emphasized. There were no complications, the postoperative course was unremarkable, and the patient was discharged on postoperative day 1 with significant improvement in his presenting symptoms. No identifying information is present, and patient consent was obtained for the procedure and for publishing the material included in this video.
Article
This chapter reviews nonoperative management of patients with radiographic evidence of degenerative spondylolisthesis. Degenerative spondylolisthesis is associated with multiple pain generators causing low back and leg pain. Biopsychosocial comorbidities should be recognized and treated appropriately. Physical therapy may be effective and should be the first line of treatment. Spinal injections can assist in confirming and treating the source of low back and leg pain. Spinal cord stimulation may provide relief in properly selected patients. The management of degenerative spondylolisthesis requires a comprehensive team approach to assess and treat all possible pain generators and underlying biopsychosocial factors.
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Background Intraspinal lumbar vertebral joint cysts are an unusual cause of nerve root compression symptoms and do not differ clinically from the symptoms of a herniated disc. Pathogenesis The cysts originate from the small vertebral joints and, depending on their size, compress the nerval structures. The affected vertebral joints typically show activated arthritic circumstances, which are associated with degenerative spondylolisthesis in about 50% of cases. In the majority of cases, MRT and CT can be used for diagnostic purposes. The exact etiology has not been fully clarified; various factors such as activated arthritis of the vertebral joints appear to be the major cause. Treatment Treatment options include conservative, semi-invasive and surgical therapy. Conservative and semi-invasive treatment methods lead to temporary improvement. The result of surgical treatment, however, is excellent in a complete resection of synovial cysts. In In rare cases, an initial fusion is necessary in rare cases.
Article
Study design: This is a retrospective cohort review. Objective: To determine whether a correlation exists between facet cysts and lumbar instability. Summary of background data: Lumbar facet cysts are common degenerative entities observed in patients with low-grade spondylolisthesis at a rate of 10%-50%. Surgical management with partial facetectomy with or without fusion remains controversial. Methods: Review of 86 patients with lumbar degenerative spondylolisthesis is performed. Preoperative magnetic resonance imagings were reviewed for the presence of lumbar facet cysts and Facet Fluid Indices (FFI)-calculated as the ratio of facet fluid width to facet width. Instability was defined as a difference of >3 mm in vertebral displacement between flexion and extension radiographs. T tests and the Pearson correlation analyses were used to determine statistical significance. Results: In total, 26 patients had unstable and 60 had stable spondylolisthesis. Facet cysts were present at an overall prevalence of 30.1%-in 10/26 patients in the unstable group and in 18/60 patients in the stable group (P>0.05). The average FFIs for the unstable and stable groups were 0.13 and 0.09, respectively (P>0.05). FFI in patients with facet cysts was significantly higher than those without (P<0.05). In addition, the group with facet cysts had a significantly higher proportion of patients with FF effusions >3 mm. Conclusions: Lack of correlation with instability hints that the presence of facet cysts may not indicate instability in lumbar degenerative spondylolisthesis. Therefore, presence of facet cysts in static magnetic resonance imaging revealing spondylolisthesis should not preclude the physician from performing dynamic films to evaluate for instability. Significantly higher FFI in patients with facet cysts reaffirms the degenerative pathophysiology involved in their formation. Although this is not an outcomes study, it does spark interest into whether patients with stable spondylolisthesis and concurrent facet cysts are suitable for partial facetectomy alone with fusion.
Article
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.
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Six cases of cyst of the ligamentum flavum with compression of a lumbar nerve root are reported. All patients exhibited recurrent back pain and sciatica. Investigation included computed tomography, myelography, or both. The correct diagnosis was reached before operation in only half the patients. High-resolution computed tomography performed in the four last patients outlined the cystic lesion with its low-density center. Surgical excision was performed in all patients. Microscopic examination showed a dense fibrous cyst arising from the ligamentum flavum. The lumen contained myxoid or necrotic material, but no epithelial lining. Cysts of the ligamentum flavum must be considered in the differential diagnosis of causes of sciatica. A firm radiological diagnosis may, at present, still require myelography combined with high-resolution computed tomography. Differentiation from synovial or ganglion cysts of the spine is discussed.
Article
Five intraspinal synovial cysts in four patients were evaluated with noncontrast magnetic resonance imaging and magnetic resonance imaging with the contrast agent gadolinium diethylenetriaminepentaacetic acid. Useful findings included demonstration of both solid and cystic components, early enhancement of the solid component and cyst periphery, delayed enhancement of the cyst, persistent enhancement of the solid component and cyst capsule, enhancement of the apophyseal joint, and recognition of a possible connection between the cyst and apophyseal joint. Although computed tomographic findings of synovial cysts are quite characteristic for the diagnosis in most cases, contrast magnetic resonance imaging may provide additional information for a more definitive diagnosis.
Article
The joint spaces and synovium of the lumbar facet joints extend beyond the articular surfaces of the joint in the majority of adults. The authors correlated magnetic resonance (MR) imaging, computed tomographic (CT), and axial cryomicrotome sections of 66 facet joints in nine cadavers. Extensions of the synovium and joint space along the superior and inferior articular processes, under the ligamentum flavum, and into the ligamentum flavum could be recognized with use of MR and, less successfully, CT. The injection of a paramagnetic contrast medium into the facet joint facilitated visualization of the capsule on MR images. On the ventral aspect of the lumbar facet joint, MR images showed regions of high signal intensity where the joint space extended into the ligamentum flavum or between the ligamentum flavum and lamina. On the dorsal aspect of the joint, MR demonstrated prominence of the fibrous joint capsule where the joint space extended under it along the inferior articular process or along the superior articular process. The variable appearance of the ventral and dorsal aspects of the lumbar facet joint on CT and MR images is due to extension of the synovium and joint space.
Article
Juxtaarticular intraspinal synovial cysts are unusual lesions of the spine associated with facet arthropathy. These lesions can cause radicular symptoms and may masquerade clinically as other, more common entities. Synovial cysts have been detected at myelography and have been well characterized at computed tomography as posterolateral epidural masses, typically at L4-5. Six synovial cysts of the lumbar spine were demonstrated on magnetic resonance (MR) images. The signal-intensity patterns of these lesions are variable. MR imaging can be used to document the presence of hemorrhage within the cyst, which may relate to the exacerbation of symptoms. Air-filled synovial cysts may be difficult to detect and distinguish from facet arthropathy.
Article
Over the past 18 months we have encountered 11 cases of symptomatic lumbar synovial cysts. This experience occurred during a period during which some 1,800 lumbar computed tomographic scans were done. The apparent increased incidence of these lesions is most likely due to the increased diagnostic ability made possible by the advent of high-resolution computed tomography and magnetic resonance imaging. This is a report and discussion of our 11 cases with a review of the literature. There is nothing distinctive in the physical findings or in the histories of our patients, but we have found, as have others, that high-resolution computed tomographic scanning and magnetic resonance imaging significantly enhance the diagnosis of such lesions.
Article
A series of 13 patients with synovial or ganglion cysts of the spinal facet joints causing nerve root compression is reported. These cysts were found in both the cervical and the lumbar spine, and the anatomical location of each cyst corresponded to the patient's signs and symptoms. In no case was there evidence of intervertebral disc abnormality found at operation. The patients ranged from 49 to 77 years of age and included 4 men and 9 women. Radiographic evidence of facet degenerative change and degenerative spondylolisthesis was frequently but not invariably noted. The extradural defects defined with positive contrast myelography or postmyelography computed tomographic scanning were usually posterior or posterolateral to the common dural sac and were misinterpreted as extruded discs in the majority of cases. Treatment consisted of laminectomy and surgical excision of cysts. All patients reported improvement or resolution of their presenting symptoms.
Article
The presentation of a patient with acute low back pain and distal radiation to the lower extremities is often attributed to a herniated nucleus pulposus (NHP). The purpose of this report is to illustrate how an intraspinal lumbar synovial cyst can have a similar presentation. A 52-year-old man presented with low back pain with left lower extremity weakness and distal radiation. An electrodiagnostic evaluation was consistent with lumbar-sacral radiculopathy. Computed tomography and magnetic resonance imaging showed a synovial cyst of the L4-5 facet joint. The patient underwent a L4-L5 laminotomy, synovial cyst excision, and decompression of the L5 nerve root. There were no postoperative complications. The patient had residual left lower extremity numbness but gradually regained the strength of his left lower extremity. Intraspinal synovial cyst can mimic the clinical pattern of NHP. An intraspinal lumbar synovial cyst can present with symptoms of nerve root compression. Given the presentation of lumbar-sacral radicular symptoms such as radiating pain, muscle weakness, and numbness, surgical excision of the lumbar synovial cyst remains the definitive treatment of choice.