Epidural hematoma secondary to a rupture of a synovial cyst

Outcomes After Decompression Only Versus Decompression and Fusion for Lumbar Facet Cysts: A Systematic Review and Meta-Analysis

BACKGROUND AND OBJECTIVES

Lumbar facet cysts (LFCs) are considered the result of facet degeneration and segmental instability. Their surgical management has been controversial. Decompression only (DO) is less invasive, but it does not address the underlying degeneration/spondylolisthesis. Decompression and fusion (DF) is more invasive with higher perioperative morbidity. Comparative studies are scant in current literature. The objective of this study was to identify all such studies and synthesize outcomes including recurrence and reoperation rates. Secondary outcomes included back pain resolution, radiculopathy resolution, and length of stay.

METHODS

In this PROSPERO-registered Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review, the MEDLINE, Embase, and Cochrane databases were searched to identify comparative studies of DO vs DF patients with LFCs. A meta-analysis with random effects model was performed, and heterogeneity was assessed with the I2 statistic. Visual representation of results was performed with forest plots.

RESULTS

Nine comparative studies encompassing 3393 patients (DO: 1940, DF: 1453) were included. Spondylolisthesis rates were statistically significantly lower in the DO group (DO 24.3%; DF 65.8%; OR 0.04; CI 0.01-0.31; P < .01). The DO group had statistically significantly higher odds of cyst recurrence (DO 6.3%; DF 0%; OR 5.74; CI 1.51-21.72; P = .01) and lower odds of back pain resolution at follow-up (DO 56.6%; DF 74.5%; OR 0.43; CI 0.2-0.91; P = .03) compared with the DF group. Reoperation rates (DO 7.2%; DF 5.9%; OR 1.37; CI 0.72-2.6; P = .3) and odds for resolution of radiculopathy (DO 77.3%; DF 87.2%; OR 0.6; CI 0.3-1.21; P = .2) were comparable between the 2 groups. Length of stay was statistically significantly shorter in the DO group (mean difference -1.5; CI -2.38 to -0.63; P < .001).

CONCLUSION

Decompression with concomitant fusion was associated with lower odds of cyst recurrence and higher odds of back pain resolution but slightly longer hospital stay. Reoperation rates and radiculopathy resolution were comparable between the two groups.

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

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

Spinal synovial cysts. A case series and current treatment options

Synovial cysts constitute an uncommon degenerative lesion of the spine. They are usually asymptomatic but they may also cause symptoms of variable severity. The authors present three cases of such cysts, two in the lumbar region of a 55-year-old female and a 66 year old female and one in the cervical region of a 56-year-old male patient. All patients presented with radiculopathy. Magnetic Resonance Images revealed a cystic lesion at the L4/5 level in the first case, at L5/S1 level in the second case and at the C7/T1 junction level in the third case. Treatment has been microsurgical resection of all cysts with no post-operative complications and an excellent outcome. A discussion of current management options for this unusual disease is presented and a decision making flow chart is proposed.

Histopathological findings of hemorrhagic ganglion cyst causing acute radicular pain: a case report

Although juxtafacet cysts of the lumbar spine are being reported with increasing frequency, hemorrhage from a ganglion cyst is rare, and the pathophysiologic mechanism of the hemorrhage from the cyst is still unclear. A 75-year-old male presented with sudden radicular leg pain caused by hemorrhage from the ganglion cyst. Computed tomography revealed bony erosion of vertebral body and multiple punched-out lesions on facets. Magnetic resonance imaging showed the neural structure was compressed by a sharply delineating mass. Capsule and old hematoma with elastic consistency that extended to the epidural space were removed through a paramedian transforaminal approach, which led to the resolution of the patient's symptoms. Histopathologically, chronic inflammation with neovascularization and myxoid degeneration were present in the capsule. Alcian blue staining demonstrated the mixture of mucin and hematoma. The probable pathogenesis of hemorrhage from the cyst was discussed from the unique histopathological findings of surgical specimen.

Full-endoscopic interlaminar removal of chronic lumbar epidural hematoma after spinal manipulation

Background:

Spinal manipulation is widely used for low back pain treatments. Complications associated with spinal manipulation are seen. Lumbar epidural hematoma (EDH) is one of the complications reported in the literature. If lumbar chronic EDH symptoms are present, which are similar to those of a herniated nucleus pulposus, surgery may be considered if medical treatment fails. Percutaneous endoscopic discectomy utilizing an interlaminar approach can be successfully applied to those with herniated nucleus pulposus. We use the same technique to remove the lumbar chronic EDH, which is the first documented report in the related literature.

Methods:

We present a case with chronic lumbar EDH associated with spinal manipulation. Neurologic deficits were noted on physical examination. We arranged for a full-endoscopic interlaminar approach to remove the hematoma for the patient with the rigid endoscopy (Vertebris system; Richard Wolf, Knittlingen, Germany).

Results:

After surgery, the patient's radiculopathy immediately began to disappear. Magnetic resonance imaging (MRI) follow-up 10 days after the surgery revealed no residual hematoma. No complications were noted during the outpatient department follow up.

Conclusions:

Lumbar EDH is a possible complication of spinal manipulation. Patient experiencing rapidly progressive neurologic deficit require early surgical evacuation, while conservative treatment may only be applied to those with mild symptoms. A percutaneous full-endoscopic interlaminar approach may be a viable alternative for the treatment of those with chronic EDH with progressive neurologic deficits.

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

Lumbar spine synovial cysts are becoming more frequent, and they are generally associated with degenerative lumbar spinal disease. They are common in lower lumbar lesions but rare in upper lumbar lesions. Several cases of hemorrhage into lower lumbar juxtafacet cysts after trauma or anticoagulation therapy have been reported in the literature. This article describes a case of subacute cauda equina syndrome resulting from spontaneous hemorrhage into an upper lumbar synovial cyst. A 65-year-old man presented with a 3-month history of intermittent bilateral lumbar pain. One week before, he experienced a sudden exacerbation of lumbar pain and began falling frequently; he also reported weakness and tingling in his lower limbs. A hematic collection associated with a large juxtafacet cyst at L2-L3 was suspected on magnetic resonance imaging. He underwent surgical decompression, and the cyst was resected. Microscopic examination was consistent with the diagnosis of a synovial cyst. Two days postoperatively, he was walking independently. Although several descriptions exist of hemorrhagic lumbar juxtafacet cysts after trauma or anticoagulant therapy, to the authors' knowledge, this is the first documented case of hemorrhage in an upper lumbar synovial cyst with no previous traumatic event or medication use. Magnetic resonance imaging was essential in making the preoperative diagnosis. Surgical removal of the cyst was an effective treatment.

Non-popliteal synovial rupture

The ruptured popliteal synovial cyst is a common complication of chronic knee arthritis. In contrast, non-popliteal synovial rupture is less well recognized and may present a diagnostic dilemma. We report an 81-year-old woman who presented with chest wall pain and ecchymosis. Ultrasonography of the shoulder region readily diagnosed a dissecting parasynovial cyst. She developed the unusual complication of contralateral recurrence. Literature review revealed a small but important set of non-popliteal synovial ruptures in the regions of the shoulder, elbow, wrist, spine, hip, knee, and ankle. Local swelling, inflammation, ecchymosis, and nerve impingement may mimic other conditions. Awareness of the clinical presentations and a high index of suspicion are required to avoid diagnostic confusion. Management data are limited to case reports of arthrocentesis, injection, and very rarely, surgery.

Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a clinical outcome study

BACKGROUND CONTEXT

Lumbar zygapophyseal joint (Z-joint) synovial cysts can cause low back pain (LBP), spinal stenosis, and lower extremity radiculopathy. In the literature, there are several minimally invasive techniques described with mixed results. Typical recommended treatment is surgical resection of the cyst. Currently, there is little information available concerning the efficacy and outcome with treatment of Z-joint synovial cyst by percutaneous, fluoroscopic, contrast-enhanced distention, and rupture.

PURPOSE

To evaluate the therapeutic value and safety of Z-joint cyst rupture in symptomatic patients.

STUDY DESIGN/SETTING

Retrospective cohort study in an academic outpatient physiatric spine practice.

PATIENT SAMPLE

Thirty-two patients with moderate-to-severe LBP and leg pain (18 women and 14 men with an age range of 46-86 y; mean age, 66 y) with an average preprocedure symptom duration of 5 months. The patient's clinical symptoms correlated with magnetic resonance imaging studies documenting the presence of a synovial cyst at the corresponding level and side of symptoms. Patients had at least 6 months follow-up (range, 6-24).

OUTCOME MEASURES

Numerical Pain Rating Scale, Roland-Morris Disability Questionnaire, North American Spine Society four-point patient satisfaction survey, recurrence of synovial cyst requiring repeat rupture, and need for surgical intervention.

METHODS

Patients with symptomatic lumbar Z-joint synovial cyst were identified and their charts were reviewed. Patients included in the study either had symptomatic lumbar LBP or LBP with associated lower extremity radiculopathy. All patients in the study had magnetic resonance imaging's documenting Z-joint synovial cyst that corresponded with the patients' clinical symptoms. All patients received fluoroscopically guided, contrast-enhanced, percutaneous facet cyst distention and rupture followed by an intra-articular facet joint injection of 1 cc kenalog and 1 cc of 1% lidocaine. Seventeen of the patients also received a transforaminal epidural steroid injection just before facet cyst rupture. Telephone follow-up was conducted on all patients.

RESULTS

Excellent long-term (average follow-up 1 y; range, 6-24 mo) pain relief was achieved in 23 (72%) of 32 patients undergoing facet cyst rupture. Twelve patients (37.5%) had synovial cyst recurrence and 11 chose to undergo repeat rupture, which resulted in 5 patients (45%) obtaining complete relief of symptoms and 6 patients (55%) requiring surgical intervention for cyst removal. Fisher exact test demonstrated that all patients who did not have a cyst recurrence were a success and obtained complete relief of symptoms (p<.0002). Patients who underwent a repeat rupture had a 50% chance of a successful outcome. There was no statistical significance between a successful outcome and level of facet cyst rupture, the presence of spondylolisthesis, sex, age, or having a transforaminal epidural steroid injection at the time of the procedure. Wilcoxon signed-rank test demonstrated that the difference in Numerical Pain Rating Scale and Roland-Morris Disability Questionnaire scores before and after the procedure was statistically significant (p<.0001). No complications were reported.

CONCLUSIONS

Fluoroscopic percutaneous Z-joint cyst rupture appears to be a safe and effective minimally invasive treatment option. This procedure should be considered before surgical intervention.

Metastatic carcinoma related long segment thoracic spinal epidural hematoma: a case report

STUDY DESIGN

Case report.

OBJECTIVE

To report a long segment epidural hematoma with thoracic cord compression caused by a metastatic carcinoma.

SUMMARY OF BACKGROUND DATA

To our knowledge, there have been no previous reports of spontaneous spinal epidural hematoma caused by metastatic carcinoma.

METHODS

A 60-year-old woman with back pain and progressive leg weakness suddenly developed complete paraplegia and anesthesia below T8. A thoracic spine MRI showed an epidural hematoma and metastatic tumor. We describe the clinical course, radiographic imaging, operative findings, and treatment results.

RESULTS

Despite immediate surgery, the patient failed to have any significant improvement in her neurologic symptoms. A previously unsuspected primary lung tumor was diagnosed. She died 6 months after spine surgery.

CONCLUSION

Spinal epidural hematoma can occur in association with metastatic tumors in that area.

Synovial cyst of the thoracic spine: case report

Spinal cord compressing syndrome due to synovial cyst (SC) of the thoracic spine is a rare clinic condition. We report a case of SC located in the thoracic spine causing spastic paraparesis in a 14 year-old female patient. The SC was removed thoroughly by laminectomy. The patient had an excellent recovery. The etiological and therapeutic aspects are discussed.

Traumatic intraspinal extradural ganglion cyst in a teenager: Case report and review of the literature

Spinal extradural cyst is a rare cause of spinal cord or nerve root compression. We present a case which is unique due to both the young age of the patient and its distinctly acute haemorrhagic presentation. In what is normally considered a degenerative disease in older patients this has implications for the possibility of a traumatic aetiology in children. The literature on the classification of extradural cysts is reviewed.

Case reports: a rare cause of radicular complaints: ligamentum flavum hematoma

Hematomas in the lumbar ligamentum flavum are rare and may generate signs and symptoms of lumbar nerve root compression or neurogenic claudication similar to the far more common degenerative diseases. The pathogenesis of these hematomas is unclear. Ruptured irregular vessels of the degenerated and hypertrophic ligamentum flavum were assumed. We diagnosed three patients with a flavum hematoma intraoperatively leading to radicular complaints and spinal claudication. One occurred as a complication of local infiltration therapy, and the other two patients reported minor trauma as the releasing factor. Using spinal magnetic resonance imaging, a preoperative diagnosis is possible but the differentiation to synovial cysts is difficult. Surgical resection of the ligamentum flavum, including the hematoma, provided adequate treatment in these patients.