Retrospective study of 77 patients harbouring lumbar synovial cysts: functional and neurological outcome

Lumbar spinal ganglion cyst: A systematic review with case illustration

PURPOSE

Ganglion cysts are benign soft tissue lesions found in joints, most commonly wrists. The incidence for juxtafacet cysts, the condition under which spinal ganglion cysts are categorized, is between 0.06% and 5.8%. Spinal ganglion cysts often arise in the most mobile segment of the lumbar spine, L4-L5. Patients commonly present with pain, radiculopathy, and weakness. Conservative management is used, but surgical resection is the most common treatment modality. We aim to review the literature and present a rare case of an L2-L3 situated spinal ganglion cyst, treated with maximal safe resection.

METHODS

A systematic review of literature was conducted in accordance with PRISMA guidelines. PubMed, Web of Science, and Cochrane databases were queried using Boolean operators and search terms, "spinal ganglion cyst, lumbar ganglion cyst, and lumbar juxtafacet cyst". Presentation, surgical management, and postoperative course of a 29-year-old male with an L2-L3 spinal ganglion cyst are also described.

RESULTS

The search yielded 824 articles; 23 met inclusion criteria. These papers consisted of 27 spinal ganglion cyst cases with disaggregated patient data. 63.0% of patients were male, and 53.4 years (range: 23-86) was the average age at presentation. Mean symptom duration was 1.9 years (range: 3 days-12 years). 70.4% of patients reported complete symptom resolution. 14.8% of cases noted neural foramen involvement.

CONCLUSIONS

Spinal ganglion cysts are benign lesions typically presenting with radiculopathy. Maximal safe resection is an effective treatment modality with low complication rates. Future studies are needed to understand if neural foramen involvement leads to increased symptom severity.

Creation and validation of a predictive model for lumbar synovial cyst recurrence following decompression without fusion

OBJECTIVE

Lumbar synovial cysts (LSCs) represent a relatively rare clinical pathology that may result in radiculopathy or neurogenic claudication. Because of the potential for recurrence of these cysts, some authors advocate for segmental fusion, as opposed to decompression alone, as a way to eliminate the risk for recurrence. The objective of this study was to create a predictive score for synovial cyst recurrence following decompression without fusion.

METHODS

A retrospective chart review was completed of all patients evaluated at a single center over 20 years who were found to have symptomatic LSCs requiring intervention. Only patients undergoing decompression without fusion were included in the analysis. Following this review, baseline characteristics were obtained as well as radiological information. A machine learning method (risk-calibrated supersparse linear integer model) was then used to create a risk stratification score to identify patients at high risk for symptomatic cyst recurrence requiring repeat surgical intervention. Following the creation of this model, a fivefold cross-validation was completed.

RESULTS

In total, 89 patients were identified who had complete radiological information. Of these 89 patients, 11 developed cyst recurrence requiring reoperation. The Lumbar Synovial Cyst Score was then created with an area under the curve of 0.83 and calibration error of 11.0%. Factors predictive of recurrence were found to include facet inclination angle > 45°, canal stenosis > 50%, T2 joint space hyperintensity, and presence of grade I spondylolisthesis. The probability of cyst recurrence ranged from < 5% for a score of 2 or less to > 88% for a score of 7.

CONCLUSIONS

The Lumbar Synovial Cyst Score model is a quick and accurate tool to assist in clinical decision-making in the treatment of LSCs.

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.

Bilateral Lumbar Facet Synovial Cysts as a Cause of Radiculopathy

Remarkable advancements in endoscopic spinal surgery have led to successful outcomes comparable to those of conventional open surgery with the benefits of less traumatization and postoperative spinal instability. Bilateral lumbar facet cysts are rarely found in the spinal canal. We report a rare case of L4–L5 bilateral lumbar facet cysts compressing the nerve root in a patient who presented with L5 radiculopathy. Endoscopic decompression and removal of the cysts without fusion were performed. Histopathology revealed synovial cysts. Postoperatively, the patient showed a total resolution of symptoms with sustained benefits at the final evaluation. No recurrence of pain and no further segmental instability were observed at the 1-year follow-up.

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.

Surgically managed symptomatic intraspinal lumbar facet synovial cyst outcome of surgical treatment with resection and instrumented posterolateral fusion, a case series

Background

There is controversy regarding the treatment of symptomatic synovial cysts, specifically, the need for a concomitant fusion when surgical resection of the synovial cysts is required. We present a retrospective review of a series of patients treated for symptomatic synovial cysts of the lumbar region during the last 20 years by a single surgeon, analyzing the current available literature.

Methods

Retrospective review. The same surgical technique was applied to all patients. Demographic, clinical, surgical data and synovial cyst recurrence rate were recorded. Postoperative results reported by patients were documented according to the McNab score.

Results

Sixty nine subjects, with mean follow-up of 7.4 years. 62% (43) were female, with a mean 57.8 years at the time of surgery. In 91.3% (63), the primary management was conservative for a minimum period of 3 months. All subjects underwent surgery due to the failure of conservative treatment. The segment most operated on was L4–L5 (63.77%). 91.3% (63) of the sample reported excellent and good and 6 subjects (8.6%) fair or poor results. There was no evidence of synovial cysts recurrence at the operated level.

Conclusion

In symptomatic synovial cysts, it seems that conservative treatment is only effective in a limited number of patients and in the short term. Thus, the recommendation of a surgical indication should proceed as soon as the conservative management fails to result in significant symptom relief. Based on our results, we recommend, together with the resection of the cyst, the instrumentation of the segment to avoid its recurrence and the management of axial pain.

Resection of Lumbar Spinal Facet Joint Cysts and Cerebrospinal Fluid Leakage: Incidence, Prognostic Parameters, and Outcome in a Single-center Series

STUDY DESIGN

Single-center series.

OBJECTIVE

Intraspinal facet joint cysts can lead to nerve root compression symptoms with severe discomfort and disability. Permanent improvement can be achieved by surgical resection of the cyst. However, cerebrospinal fluid (CSF) leakage is a common problem in resection of facet joint cyst.The aim of the study was to investigate the frequency of CSF leak after resection of a joint cyst and to determine predictive factors.

METHODS

A total of 176 consecutive patients underwent surgery for lumbar spinal facet joint cyst in our institution between 1997 and 2018. Patients with a CSF leak were compared with patients without a CSF leak (control group).

RESULTS

CSF leakage occurred in 14 patients (8.0%) In 2 of the cases (14.3%), the CSF leak was recognized only postoperatively, in 12 cases (85.7%), the CSF leak was detected intraoperatively. Despite intraoperative dura repair, 4 of these 12 patients (33.3%) presented with CSF leakage postoperatively. Altogether 6 patients had postoperative CSF leakage. Compared with patients without CSF leak, there were no differences in preoperative symptoms, surgical technique, complications, or postoperative findings. Adhesion of the cyst to the dura mater was present in all 14 patients with CSF leakage (100%), but only 61.7% of the control group ( P <0.005). All patients in the CSF leak group showed an improvement of their preoperative symptoms.

CONCLUSIONS

The rate of CSF leakage in resection of spinal facet joint cyst was 8% in the present study. The occurrence of a CSF leakage was independent of clinical factors, level, or side of the cyst, but significantly correlated to dural adhesion of the cyst.Since neither clinical recovery nor recurrence rates do depend on complete removal of the cyst, aggressive resection of dural adherend parts of the cyst wall should be avoided to prevent CSF leakage.

[Treatment of neuropathy of inferior gluteal and pudendal nerves following periarticular synovial cyst of the hip joint. A case report and literature review]

The authors report a patient with neuropathy of inferior gluteal and pudendal nerves following periarticular synovial cyst of the hip joint. Effectiveness of treatment was analyzed. ENMG and MRI of pelvic soft tissues and hip joint were applied to confirm neuropathy of inferior gluteal and genital nerves. Periarticular synovial cyst of the hip joint followed by compression and ischemia of inferior gluteal and pudendal nerves was detected. In pre- and postoperative period, intensity of pain syndrome was assessed using visual-analogue scale. Neuropathic pain and quality of life were evaluated using the Leeds scale (LANSS) and NeuroQoL questionnaire, respectively. The patient underwent microsurgical neurolysis and decompression of inferior gluteal and pudendal nerves and resection of periarticular synovial cyst of the hip joint. Complete regression of pain syndrome and improvement in quality of life were observed after surgery. Compression of neurovascular structures with periarticular hip cysts followed by clinical and neurological disorders is an indication for microsurgical neurolysis and resection of cyst.

Outcomes and complications following minimally invasive excision of synovial cysts of the lumbar spine: A systematic review and meta-analysis

OBJECTIVE

Lumbar synovial cysts (LSC) are one of the manifestations of spinal degenerative cascade. Spinal stenosis or presence of instability in these patients can lead to various symptoms and surgery is indicated following failure of non-operative management for symptomatic synovial cysts. Surgery when performed consists of either decompression with resection of cyst with our without fusion. The efficacy and complications of minimally invasive techniques using tubular retractors (microscopic or endoscopic) in comparison to traditional open techniques remain to be studied.

METHODS

A comprehensive search of different databases was performed to retrieve studies describing the use of minimal invasive techniques using tubular retractors (both microscopic and endoscopic) in patients with LSC. Meta-analysis with subgroup analysis and metaregression was done.

RESULTS

Twenty articles were selected for the systematic review and meta-analysis with total of 388 patients. Eighty-six percent of patients (95% Confidence Interval (CI): 80-90%) had favorable outcome as per Macnab's criteria (excellent and good outcome) with the pooled standard mean difference between preoperative and postoperative Oswestry Disability Index (ODI) being -4.44 (95% CI -8.78 to -0.10, p-value=0.0474, I² 82%). The pooled percentage change in visual analogue scale (VAS) after surgery was 76.5% (95% CI 66.9-84%, I² 82%). The pooled proportion of incidental durotomies, cyst recurrence and patients requiring operation being 8% (95% CI 5-11%, I² 0%), 4% (95% CI 2-7%, I² 0%,) and 5% (95% CI 3-9%) respectively. Studies were homogeneous with an I² value of 0%. Subgroup analysis revealed no significant difference in the outcome rates or complication rates between the microscopic and endoscopic subgroups.

CONCLUSION

Minimally invasive techniques for the resection of LSC is a safe and effective alternative to traditional surgical approaches with no difference between the microscopic and endoscopic approaches.

Spinal ganglion cyst presenting with radiculopathy: diagnostic challenges and differential

INTRODUCTION

Ganglion cysts are benign soft tissue lesions, usually arising from periarticular connective tissue. These are very rarely reported in the spine, but when seen can cause radiculopathy or myelopathy.

CASE PRESENTATION

A 68-year-old female patient presented with worsening radiculopathy and right foot drop and imaging noted a right L5-S1 foraminal mass. The lesion was gross totally resected. Histological analysis revealed myxoid degeneration and inflammation, without a synovial lining, consistent with ganglion cyst.

DISCUSSION

While uncommon, intra-foraminal ganglion cysts can be distinguished from synovial cysts through imaging and histology and are typically amenable to surgical resection. Greater knowledge and insight about differentiating ganglion versus synovial cyst may prevent resection of facet joints and prevent a fusion procedure.

Comparison of Decompression versus Decompression and Fusion for Lumbar Synovial Cysts and Predictive Factors for Cyst Recurrence

BACKGROUND

The management of lumbar synovial cysts (LSC) has been a controversial topic for many years. Whereas many authors label LSC as markers of instability and thus necessitating fusion, others suggest that decompression alone without fusion is a viable initial treatment option. Our objective was to clarify outcomes in patients undergoing decompression alone and decompression with fusion for symptomatic LSC and identify factors for cyst recurrence.

METHODS

A retrospective case series was performed of all patients undergoing initial treatment for LSC at a single institution ranging from January 1999 to February 2020. Surgical treatment included either decompression with cystectomy or decompression with cystectomy and a fusion procedure. Preoperative symptoms were collected and included radicular pain, motor deficits, sensory deficits, or bowel/bladder changes. Radiographic data were calculated individually and confirmed with radiology reports. Categorical variables were assessed using χ² analysis and continuous variables were assessed with the 2-sample t test.

RESULTS

In total, 161 patients were identified as presenting with symptomatic LSC. Of these, 104 patients underwent decompression alone versus 57 who underwent decompression and fusion. In the decompression group 11 patients required reoperation at the level of the cyst compared with none in those undergoing fusion as their initial procedure (10.5% vs. 0%, P = 0.012). On subgroup analysis of those undergoing decompression as their initial procedure, patients with cyst recurrence demonstrated a statistically significant greater coronal facet inclination angle compared with those without cyst recurrence (52.4° vs. 40.6°, P = 0.02).

CONCLUSIONS

Decompression alone is a reasonable choice for the initial management of LSC, although it does carry a significant risk of same-level reoperation due to cyst recurrence and spondylolisthesis. Preoperative coronal facet inclination angle may be a useful measurement in predicting cyst recurrence following decompression.

Fluoroscopy-Guided Transfacet Lumbar Epidural Steroid Injection for Symptomatic Synovial Cyst Treatment: A Case Report

We report the case of a patient with a right-sided L4 synovial cyst, which had been causing significant pain, who had a successful transfacet epidural steroid injection to rupture the cyst. Using fluoroscopy, the needle was advanced through the right L4 facet joint and the cyst was ruptured using saline. The needle was then advanced into the epidural space and a transfacet epidural steroid injection was done. The patient's symptoms resolved. Repeat magnetic resonance imaging (MRI) done 2 years later showed no recurrence of the cyst. We discuss the role of transfacet epidural steroid injection in synovial cysts treatment.

Management of Postoperative Facet Cysts: A Report of 3 Cases

CASE

The exact underlying etiology behind synovial facet cysts remains unclear, and optimal surgical management continues to be a challenge. The authors present a series of 3 patients who underwent primary lumbar decompression and developed postoperative facet cysts within 6 months of index surgery requiring operative intervention. No patients had radiographic evidence of instability. Average follow-up after revision surgery was 14 months.

CONCLUSION

We report on the 3 cases with the phenomenon of postoperative facet cysts and present a complication that falls within the spectrum of lumbar decompression surgery with several successful treatment options.

The Variability of Lumbar Facet Joint Synovial Cyst Recurrence Requiring Revision Surgery After Decompression-only and Decompression/Fusion

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

The objective of this study was to evaluate lumbar spine synovial cyst recurrence rates of decompression-alone versus decompression/fusion procedures.

BACKGROUND

Improvements in imaging modalities allow for increased diagnosis and surgical treatment of symptomatic spinal juxtafacet synovial cysts. Conservative management may be used as a first-line management strategy, however rarely provides durable, effective relief of symptoms. Surgical treatment of spinal synovial cysts ranges from decompression and cyst excision to decompression with fusion procedures. Decompression procedures alone have a higher risk of recurrence of spinal synovial cysts.

METHODS

We retrospectively reviewed 87 patients undergoing surgical treatment of lumbar spinal juxtafacet synovial cysts as a single institution over 20 years. Surgical treatment consisted of either decompression versus decompression/fusion procedures. Preoperative symptoms included back pain, radiculopathy, motor deficits, or sensory deficits. The incidence of recurrence of spinal synovial cysts at the same-site or differing sites was compared between 2 categories of surgical treatment. Revision surgical procedure rates were also evaluated.

RESULTS

A total of 55 (63%) patients were treated with an index decompression-only procedure for the lumbar spinal synovial cyst compared with 32 (37%) patients treated with an index decompression and fusion procedure. Fifty-eight (68%) of the lumbar spinal cysts occurred at the L4-L5 level. There were 10 (11.5%) spinal synovial cyst recurrences in the decompression-only group, and 0 recurrences in the decompression/fusion group. Revision decompression procedures were performed in 4 of the 10 (4.6%) recurrences, and 6 of 10 (6.9%) recurrences had subsequent decompression and fusion surgery. The mean time to recurrence was 23.9±17.3 months. The mean length of follow-up was 65.1±48.6 months. Both recurrence and nonrecurrence cohorts had significant symptomatic improvement using Odom criteria.

CONCLUSIONS

Decompression and cyst excision was the more common surgical treatment of lumbar spinal synovial cysts compared with decompression/fusion procedure in our study. The rate of synovial cyst recurrence and revision surgery in patients undergoing index decompression was relatively low and comparable to current literature. Symptomatic improvement of patients undergoing decompression versus decompression/fusion was similar in our study. Although the fusion may be required for the extent of pathology or coexisting instability, decompression and excision of spinal synovial cysts provide durable, effective treatment with a known, appropriate risk of recurrence and subsequent revision surgery.

A rare clinical case of surgical treatment of a periarticular cyst of the facet joint of the lumbar spine

Background. Periarticular cysts of the facet joint, due to their rare occurrence, often slip away from the attention of clinicians. However their formation and progression may cause compression of vascular-neural structures with subsequent manifestations of severe neurological disorders. Description of the clinical case. We present a rare clinical case of surgical treatment of a periarticular cyst of the facet joint. A comprehensive examination of the patient S. revealed: Dorsopathy with degenerative spinal canal stenosis at LV-SI level; spondyloarthrosis; periarticular facet cyst at LV-SI level on the left; radiculopathy LV on the left, in the acute stage; pronounced pain and musculo-tonic syndrome. Complaints of the patient: constant pain in the lumbar spine, extending to the left lower extremity and aggravating when walking at a distance of 50-100 meters; feeling numb when walking on the plantar surface of the left foot. When examining the local status, a forced posture with a bowed head and torso forward was noted; smooth lumbar lordosis and antalgic right-sided scoliosis; tension of paravertebral muscles. Neurological examination revealed LVradiculopathy on the left with moderate paresis of the extensor muscles of the left foot and ipsilateral Lasègue's positive test. MRI examination revealed spinal canal stenosis, facet joint cyst at the level of LV-SI with dimensions of 14×8×8.5 mm. An operative intervention was performed: reconstructive decompressive-stabilizing spinal surgery with a single block removing the articular facet with a periarticular cyst at the left LV-SI level with subsequent posterior transpedicular fixation of the vertebral motor segment. Two months after the operation, complete medical and social rehabilitation of the patient was achieved. No complaints. Conclusion. In case of compression of a periarticular cyst of vascular-neural structures with severe neurological disorders, surgical treatment with the cyst removal is recommended.

Stable Spondylolisthesis: Should Management Change Based on Presence of Facet Cysts?

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.

PERIARTICULAR CYSTS OF FACET JOINTS: ETIOPATHOGENESIS, DIAGNOSIS, METHODS OF SURGICAL TREATMENT. A CLINICAL EXAMPLE

Background. Periarticular cysts (PC) of facet joints is a rare pathology in neurosurgical practice. The concept of PC is applicable for all cysts that are located either pararticularly in the region of facet joints, or start from them.

Material and methods. A systematic search was performed in medical databases: Medline, RINC, EMedicine, UMKB, Pubmed on the relevant topic in Russian and English. The search query includes  words: arcuate joint, periarticular cyst, clinic, diagnosis, surgical  treatment. One of the significant factors of PC development is the  instability of the vertebralmotor segment of both degenerative and post-traumatic character.

Results. The result of the literature review was the writing of a clinical lecture, the current state of the issue of etiopathogenesis, diagnosis and management of patients with  periarticular cysts of facet joints was studied. The article gives a  clinical example of surgical treatment of a patient with a periarticular cyst at the level of LIV-LV on the right.

Conclusion. Periarticular cysts of facet joints are one of the factors of compression of cauda equina roots, with surgical treatment being  a radical and effective way of treatment. A detailed study of this  pathology is a promising direction in spinal neurosurgery. Further  research is required on comparative analysis of clinical and  instrumental efficacy of various methods of surgical treatment of periarticular cysts of facet joints.

NeuroSpine Surgery Research Group (NSURG) Classification System for Grading Lumbar Synovial Cysts

To classify facet joint cysts (FJC) which will assist in identification of patient groups to best fit with a particular intervention. Sagittal T₂ -weighted magnetic resonance images (MRI) of these patients are used to measure cyst size, while axial T₂ -weighted MRI are used to determine the percentage of the vertebral canal occupied by the cyst. The degree of spondylolisthesis is also measured through standing X-rays or sagittal MRI. The proposed grading system is as follows. Grade I includes cysts that occupy less than 25% of the canal diameter that usually present with unilateral radiculopathy. Grade II includes cysts that occupy less than 50% of the canal diameter and may present with radiculopathy, with or without claudicant symptoms. Grade III cysts may present with radiculopathy and claudication with bilateral leg symptoms, along with facetogenic pain symptoms. Grades IV and V include potential instability as defined by greater than 15% spondylolisthesis in addition to either less than or greater than 50% canal stenosis. With higher grade cysts, presentation may include: facetogenic back pain, radiculopathy and claudicant pain in variable degrees of severity. The optimal classification system grades FJC from I to V on the basis of canal compression and degree of spondylolisthesis. Prospective studies are required to confirm the validity of this grading scale for long-term use.

Comparison of Decompression With and Without Fusion for Patients With Synovial Facet Cysts

STUDY DESIGN

This is a retrospective study.

OBJECTIVE

To compare (1) recurrence of radiculopathy and (2) back pain after decompression with and without fusion for patients with a symptomatic synovial cyst.

BACKGROUND

Previous work described favorable outcomes following cyst excision with and without fusion. Because of the association of facet cysts with spinal instability it is hypothesized that a decompression with fusion will lead to better outcomes. However, previous studies present contradicting results.

METHODS

We included 314 consecutive patients that underwent operative treatment for a facet cyst between 2003 and 2013 at 2 tertiary spine referral centers: 224 (71%) underwent decompression without fusion (35% spondylolisthesis), 90 (29%) underwent decompression with fusion (63% spondylolisthesis). Baseline data were compared between the groups. Bivariate log-rank analysis was used to compare outcomes between groups, followed by multivariable Cox regression analysis accounting for differences in baseline characteristics.

RESULTS

Patients undergoing decompression with fusion presented with a higher incidence of back pain (P=0.004) and spondylolisthesis (P<0.001), had more often bilateral decompressions (P<0.001), more facetectomies (P<0.001), and more levels of decompression (P=0.004) than those who underwent decompression alone. We found a difference in recurrence of radiculopathy (no fusion: 25% vs. fusion: 9.4%, P=0.029) in bivariate analysis. However, this difference did not hold when accounting for confounders (hazard ratio, 0.50, 95% confidence interval, 0.19-1.31, P=0.16). There was no difference in recurrence of back pain in bivariate (no fusion: 29% vs. fusion: 22%, P=0.51) and multivariable analysis (hazard ratio 0.51, 95% confidence interval, 0.23-1.14, P=0.10).

CONCLUSIONS

We found, with the numbers evaluated, no difference in recurrence of radiculopathy or back pain between patients undergoing decompression with or without fusion after accounting for confounders. The decision for fusion should be considered in light of the extent of decompression and the existence of other pathology.

LEVEL OF EVIDENCE

Level III-therapeutic study.

Surgical Treatment of Spinal Synovial Cysts in Elderly Patients: Symptoms, Treatment Course, and Outcome in Patients >75 Years of Age

BACKGROUND

With the aging of our society comes a rising number of elderly patients with progressive degeneration of the spine associated with synovial cysts. Surgical treatment may be particularly challenging in elderly patients because of comorbidities.

METHODS

Patients treated in our department between 1999 and 2014 for spinal synovial cysts were screened. The 28 patients ≥75 years old were classified as elderly and were compared with 96 patients 50-74 years old. No patient underwent fusion as part of cyst resection.

RESULTS

Despite a significantly higher frequency of muscle reflex changes in elderly patients at presentation, symptoms, cyst levels, rate of complications, and surgical method were not different between groups. Cyst adherence to the dura and subtotal resection were observed significantly more often in the elderly group (18% vs. 3%; P < 0.05). Outcome according to the Oswestry Disability Index was classified as no disability or minimal disability in 85% of the elderly group and in 82% of the control group. Recurrent cyst and delayed fusion rates were lower in the elderly group (4% and 4%) compared with the control group (7% and 8%).

CONCLUSIONS

The clinical course of elderly patients with surgical treatment of spinal synovial cysts did not differ compared with younger patients. Good or excellent results could be achieved and persisted for a long time in most cases. Fusion should be performed only in cases of severe instability. Nonaggressive cyst removal in cases of dural attachment enables low cerebrospinal fluid fistula rates without increasing cyst recurrence rates.

Percutaneous Translaminar Facet Cyst Rupture and Epidural Access-Description of a Novel Technique

Synovial cysts of the lumbar zygapophysial joints can be treated by percutaneous injection of corticosteroids, with distension and rupture of the cyst. Some cysts can be difficult to access, particularly when they lie deep in relation to the lamina. This technical report describes a fluoroscopy-guided technique for accessing sublaminar pathology. Crucial to the safety of the technique is visualization of the ventral margin of the lamina using a contralateral oblique view, and controlling and limiting the insertion of the needle such that only its tip passes the lamina.

Should We Label All Synovial Cysts as Unstable?

STUDY DESIGN

Retrospective study.

OBJECTIVE

To analyze the various anatomical parameters that influence segmental stability in patients suffering from lumbar intra spinal cysts (LISCs) and to determine the outcome of microscopic unilateral laminotomy and cystectomy.

METHODS

All patients that were surgically managed for a LISC between 2007 and 2013 with more than 3 years of follow-up were reviewed. Those without associated instability were evaluated for segmental mobility, segmental angulation, facet inclination, stage of disc degeneration, and level of involvement on MRI and dynamic radiographs. Outcomes of unilateral laminotomy and cystectomy were evaluated using VAS (Visual Analogue Score), ODI (Oswestry Disability Index), and Macnabs criteria. Dynamic radiographs were performed in all cases pre- and postoperatively and at the last follow-up.

RESULTS

Thirty patients were operated for a LISC between 2007 and 2013. The levels involved were L4-5(23), L3-4(4) and L5-S1(3). The mean facet angle was 42.6 (± 6.1) degrees. The stage of disc degeneration was scattered haphazardly across all the cases (Gr 2[17]; Gr 3[1]; Gr 4[8]; Gr 5[4]). VAS and ODI scores improved significantly in all patients. Mean follow-up was 46.5 months (36-96 months). No patient developed postoperative instability at the last follow-up.

CONCLUSIONS

The coronal inclination of the facet joints, absence of radiological instability, and poor co-relation with stages of disc degeneration suggests the presence of adequate residual stability. In this study, stand-alone decompression for LISCs without instability had well sustained good/excellent outcomes. Fusion is recommended for LISCs with associated instability.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Synovial cysts of the spine: long-term follow-up after surgical treatment of 141 cases in a single-center series and comprehensive literature review of 2900 degenerative spinal cysts

OBJECTIVE Synovial cysts of the spine are rare lesions, predominantly arising in the lumbar region. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures in the spinal canal. Treatment strategies are still a matter of discussion. The authors performed a single-center survey and literature search focusing on long-term results after minimally invasive surgery. METHODS A total of 141 consecutive patients treated for synovial cysts of the lumbar spine between 1997 and 2014 in the authors' department were analyzed. Medical reports with regard to signs and symptoms, operative findings, complications, and short-term outcome were reviewed. Assessment of long-term outcome was performed with a standardized telephone questionnaire based on the Oswestry Disability Index (ODI). Furthermore, patients were questioned about persisting pain, symptoms, and further operative procedures, if any. Subjective satisfaction was classified as excellent, good, fair, or poor based on the Macnab classification. RESULTS The approach most often used for synovial cyst treatment was partial hemilaminectomy in 70%; hemilaminectomy was necessary in 27%. At short-term follow-up, the presence of severe and moderate leg pain had decreased from 93% to 5%. The presence of low-back pain decreased from 90% to 5%. Rates of motor and sensory deficits were reduced from 40% to 14% and from 45% to 6%, respectively. The follow-up rate was 58%, and the mean follow-up period was 9.3 years. Both leg pain and low-back pain were still absent in 78%. Outcome based on the Macnab classification was excellent in 80%, good in 14%, fair in 1%, and poor in 5%. According to the ODI, 78% of patients had no or only minimal disability, 16% had moderate disability, and 6% had severe disability at the time of follow-up. In this cohort, 7% needed surgery due to cyst recurrence, and 9% required a delayed stabilization procedure after the initial operation. CONCLUSIONS Surgical treatment with resection of the cyst provides favorable results in outcome. Excellent or good outcome persisting for a long-term follow-up period can be achieved in the vast majority of cases. Complication rates are low despite an increased risk of dural injury. With facet-sparing techniques, the stability of the segment can be preserved, and resection of spinal synovial cysts does not necessarily require segmental fusion.

Long-term outcomes of percutaneous lumbar facet synovial cyst rupture

OBJECTIVE

To evaluate the therapeutic value, safety, and long-term clinical outcomes of percutaneous lumbar facet synovial cyst (LFSC) rupture.

MATERIALS AND METHODS

Our study was institutional review board (IRB)-approved and Health Insurance Portability and Accountability Act (HIPAA)-compliant. The study group comprised 71 patients (44 women, mean age: 65 ± 17 years) who underwent CT- or fluoroscopy-guided percutaneous LFSC rupture. The technical success of LFSC rupture, the long-term clinical outcome, including repeat procedures or surgery, and imaging findings on MRI and CT were recorded.

RESULTS

Seventy-nine LFSC ruptures were performed in 71 patients. CT guidance was used in 57 cases and fluoroscopy guidance in 22 cases. LFSC rupture was technically successful in 58 out of 79 cases (73 %). Mean injection volume for cyst rupture was 3.6 ± 2.2 mL and a combination of steroid and anesthetic was injected in all cases. Over a mean follow-up time of 44 months, 12 % of patients underwent repeat cyst rupture, and 46 % eventually underwent surgery, whereas the majority of patients (55 %) experienced symptomatic relief and did not undergo surgery. There was no significant association between a successful outcome and age, sex, level, or size of LFSC (p > 0.1). LFSCs with T2 hypointensity were more likely to require surgery (p = 0.02). There was one complication, a bacterial skin infection that completely resolved following antibiotic therapy.

CONCLUSION

Percutaneous LFSC rupture is an effective and safe nonsurgical treatment option for LFSC. More than half of treated patients were able to avoid subsequent surgery. Therefore, percutaneous LFSC rupture should be considered before surgical intervention.

Evaluation and Treatment of Lumbar Facet Cysts

Lumbar facet cysts are a rare but increasingly common cause of symptomatic nerve root compression and can lead to radiculopathy, neurogenic claudication, and cauda equina syndrome. The cysts arise from the zygapophyseal joints of the lumbar spine and commonly demonstrate synovial herniation with mucinous degeneration of the facet joint capsule. Lumbar facet cysts are most common at the L4-L5 level and often are associated with spondylosis and degenerative spondylolisthesis. Advanced imaging studies have increased diagnosis of the cysts; however, optimal treatment of the cysts remains controversial. First-line treatment is nonsurgical management consisting of oral NSAIDs, physical therapy, bracing, epidural steroid injections, and/or cyst aspiration. Given the high rate of recurrence and the relatively low satisfaction with nonsurgical management, surgical options, including hemilaminectomy or laminotomy to excise the cyst and decompress the neural elements, are typically performed. Recent studies suggest that segmental fusion of the involved levels may decrease the risks of cyst recurrence and radiculopathy.

[Spinal sinovial cysts: Surgical treatment and clinical outcomes in a series of 18 cases]

OBJECT

A series of 18 patients with symptomatic synovial cysts was analysed from May 2009 to November 2013. Different approaches were performed for their removal.

MATERIAL AND METHODS

The study included 18 patients, 8 men and 10 women, aged between 50 and 77 years. An analysis was made of the variables including age, gender, symptoms, imaging studies, histopathology, surgery, follow-up, complications, and clinical outcome.

RESULTS

An articular synovial cyst was diagnosed in 17 cases, and a ganglion in one cases. The most common symptom was back pain with radiculopathy (94%). Motor deficits occurred in 4 cases (22%), and 1 case (5%) presented with urinary incontinence. The most common level was L4- L5 (67%), with one atypical case observed in the D12 -L1 location. Hemi-laminectomy was performed in 14 cases, with 9 of them having an interspinous spacer (ISP) device inserted. A laminectomy with a fusion procedure was performed in 3 patients and 1 patient had a bilateral decompression using a unilateral approach. The patients were followed-up for between 6 months to 2 years.

CONCLUSIONS

Synovial cysts are a cause of radiculopathy/neurogenic claudication. Spinal cysts are commonly found at the L4-L5 level. MRI is the tool of choice for diagnosis. The most common symptom was back pain with radiculopathy. Synovial cysts resistant to conservative therapy should be treated surgically. In our series, surgical resection of symptomatic juxtafacet cysts showed a good clinical outcome, but the optimal approach for patients with juxtafacet cysts remains unclear.

Surgical management of Juxtafacet cysts in the lumbar spine

INTRODUCTION

Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic juxta facet cysts in the Neurosurgical Department of our hospital and review of the literature.

METHODS

Data from seven patients (age range 58-68 years, mean age 63 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concominant local pathology, treatment and results of treatment were recorded. After surgery there was no case of a recurrent cyst during the follow-up period. The mean follow-up period of patients at the time of this study was 4 years.

RESULTS

All patients had back pain, while five also experienced unilateral radicular leg pain and two had bilateral leg pain. Four patients had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation.

CONCLUSION

Surgery is a safe and effective treatment for lumbar juxtafacet cysts.

The Relationship Between Osteoarthritis of the Lumbar Facet Joints and Lumbosacropelvic Morphology

STUDY DESIGN

Cross-sectional study.

OBJECTIVE

To investigate the relation between lumbosacropelvic morphology and the presence and degree of facet joint degeneration.

SUMMARY OF BACKGROUND DATA

Osteoarthritis of the facet joints is one of the most common degenerative changes in the spine. It is considered to be formed secondary to repetitive stress or trauma and spinal deformity with secondary overload. The cause(s) of facet joints osteoarthritis, however, have not been clearly identified.

METHODS

Abdominal computed tomography (CT) images of 723 patients which were taken between the years 2010 and 2014 were evaluated retrospectively. Patients with prior lumbar spinal surgery, serious congenital anomalies on CT, incomplete or complete lumbosacral transition, severe scoliosis, were excluded from the study. To eliminate the age- and sex-related differences in spinopelvic morphology, a study group was formed of the remaining subjects by including patients from a specific age group (30-35 yr) and same sex (females). For each patient the presence and grade of facet joint degeneration was investigated. In addition, pelvic incidence (PI), sacral slope and the angles of L1-L5 lumbar lordosis, sacral table, L5 vertebra posterior, and sacral kyphosis were measured for each patient.

RESULTS

Sacral slope, sacral kyphosis, and L1-L5 lumbar lordosis angle were significantly higher in patients with osteoarthritic compared with normal subjects (P = 0.015, P = 0.018, P = 0.016). L5 vertebra posterior and sacral table angle were found to be significantly lower in patients with osteoarthritic than in normal subjects (P = 0.019, P = 0.007). The degree of facet joint degeneration was noticed to increase parallel to the decrease in the sacral table angle and L5 vertebra posterior angle, and to the increase in the L1-L5 lumbar lordosis, PI, and sacral slope.

CONCLUSION

A close relation exists between the presence and degree of degeneration in the facet joint and lumbosacral pelvic morphology. Prevalence and degree of the degeneration in facet joint increases as the angle of sacral slope, L1-L5 lumbar lordosis, and PI increases or the angle of sacral table and L5 vertebra posterior decreases.

LEVEL OF EVIDENCE

4.

Lumbar intraforaminal synovial cyst in young adulthood: case report and review of the literature

Study Design Case report. Objective Lumbar juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Most patients with lumbar cysts are in their sixth decade of life and have significant facet joint and disk degeneration. Lumbar synovial cysts (LSCs) are extremely rare in adolescence and young adulthood, and to our knowledge, only two pediatric cases of LSC have been reported in the literature. We aim to prove the existence of LSC in adolescent patients as a real entity that causes low back and radicular complaints and to discuss the possibility of traumatic injury as a pathogenic cause of LSC formation in adolescence. A case of an 18-year old patient with LSC is presented. We report the clinical presentation, management, outcome, and review of the literature, focusing on issues that remain debatable. Methods The case is presented together with its clinical course, the diagnostic techniques, the surgical findings, histologic results, and the treatment outcome. Results After surgical treatment, the patient's complaints were alleviated and almost no complaints were registered during the next 6 months' follow-up. Conclusions LSCs are extremely rare in adolescence, but they could be considered in the differential diagnosis in adolescent patients with low back pain and radiculopathy. Surgical removal of LSC could be considered as a treatment option to provide immediate and safe symptomatic relief.

Giant, completely calcified lumbar juxtafacet cyst: report of an unusual case

Study Design Case report. Objective To report the case of one patient who developed a giant, completely calcified, juxtafacet cyst. Methods A 57-year-old woman presented with a 2-year history of progressively worsening lower back pain, left leg pain, weakness, and paresthesias. Imaging showed a giant, completely calcified mass arising from the left L5-S1 facet joint, with coexisting grade I L5 on S1 anterolisthesis. The patient was treated with laminectomy, excision of the mass, and L5-S1 fixation and fusion. Results The patient had an uncomplicated postoperative course and had complete resolution of her symptoms as of 1-year follow-up. Conclusions When presented with a solid-appearing, calcified mass arising from the facet joint, a completely calcified juxtafacet cyst should be considered as part of the differential diagnosis.

Operation of Lumbar Zygoapophyseal Joint Cysts Using a Full-Endoscopic Interlaminar and Transforaminal Approach

In appropriate situations, extensive decompression with laminectomy often continues to be described as the method of choice for operations involving lumbar zygoapophyseal joint (z-joint) cysts. Tissue-sparing procedures are nevertheless becoming more common. Endoscopic techniques have become the standard procedures in many areas because of the advantages they offer in terms of surgical technique and in rehabilitation. One key aspect in spinal surgery was the development of instruments for sufficient bone resection carried out under continuous visual control. This enabled endoscopes to be used when operating on z-joint cysts. The objective of this prospective study was to examine the technical possibilities for the full-endoscopic interlaminar and transforaminal technique in lumbar z-joint cysts. A total of 74 patients were followed up for 2 years. The results show that 85% of the patients no longer have any leg pain or that the pain had been almost completely eliminated, and 11 % experience occasional pain. The complication rate was low. The full-endoscopic techniques brought advantages in the following areas: operation, complications, traumatization, and rehabilitation. The recorded results show that full-endoscopic resection of a z-joint cyst using an interlaminar and transforaminal approach provides an adequate and safe supplement, and is an alternative to conventional procedures when the indication criteria are fulfilled. It also offers the advantages of a minimally invasive intervention.

Minimally invasive resection of lumbar synovial cysts from a contralateral approach

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

Surgical excision of a Juxtafacet cyst in the lumbar spine: A report of thirteen cases with long-term follow up

CONTEXT

Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. Surgical treatment is indicated when there is failure of conservative measures. Primary spinal fusion at the time of surgical excision of the cyst is a matter of controversy. Few reports have described long-term follow-up for surgical treatment of spinal cysts.

AIM

The purpose of this study is to assess the long-term outcome of the surgical excision of a Juxtafacet cyst without spinal fusion.

STUDY DESIGN

This is a retrospective case series study, level IV evidence.

MATERIALS AND METHODS

This is a retrospective case series study on 13 patients with Juxtafacet cysts, who were treated with surgical excision of the cysts without spinal fusion. A questionnaire scoring system was used for evaluation of the surgical outcome.

RESULTS

The study was conducted on 13 patients, seven females (54%) and six males (46%), their age ranging from 38 to 69 years, with a mean age of 52 (±9.93 STD) years. The mean duration of the symptoms was 10.5 (±6.22 STD) months. All patients got benefit from surgery, with six excellent (46%), six good (46%), and one fair outcome (8%), with no surgery-related complications. The mean follow-up period of the patients at the time of this study was 4.2 years (±1.43 STD).

CONCLUSION

Long-term follow-up for surgical excision of symptomatic Juxtafacet cysts without spinal fusion revealed excellent to good results in 92% of the patients, with a satisfaction rate of 80% (±8.41 STD).