Haemorrhage into juxta-facet cysts causing bilateral foot drop

Acute Bilateral Foot Drop as Presenting Symptom of Hemorrhagic Synovial Cyst of Lumbar Spine

BACKGROUND

Acute bilateral foot drop is a rare clinical presentation.

CASE DESCRIPTION

A 77-year-old male presented with acute bilateral weakness of the foot and ankle dorsiflexion. Magnetic resonance imaging of the lumbar spine revealed ligamentum flavum hypertrophy, as well as a mass lesion that appeared hyperintense on T1-weighted images and hypointense on T2-weighted images. Emergent decompressive laminectomy and hemorrhagic synovial cyst excision were performed. Histopathologic examination of the tissue revealed a synovial cyst with hemorrhage.

CONCLUSION

Here, we describe a unique case of a hemorrhagic synovial cyst with a presenting symptom of acute bilateral foot drop.

Intraspinal Lumbar Juxtaarticular Cyst Treatment Through CT-Guided Percutaneus Induced Rupture Results in a Favorable Patient Outcome

Juxta-articular cysts are synovial cysts originating from the facet joints or the flava ligaments. If they grow intra-spinally they can compress nervous structures and cause a variety of symptoms. Micro-neurosurgery is usually the treatment of choice. Alternatively to surgical treatment the cyst can be approached and treated with a CT guided percutaneous injection inducing rupture. After fulfilling strict selection criteria twenty patients (25% of all treated lumbar synovial cyst patients), were treated minimally invasive by this method from 2010-2016. The facet joint was punctured under CT guidance and a mixture of a local anesthetic and contrast liquid was injected until the cyst was blasted. The mean follow-up period was 1.1 years (range 2 weeks - 5 years).

Fifteen of twenty procedures were successful and cyst rupture was confirmed by CT-scans. Twelve of these fifteen patients experienced a significant improvement of their symptoms and needed no further intervention or surgical procedure up until now, three patients showed no clinical improvement and were treated surgically within one week after cyst rupture. In five patients it was technically not possible to rupture the cyst. These patients were treated microsurgically by cyst resection and dynamic stabilization or fusion procedures. The percutaneus rupture of juxtaarticular cysts has fewer risks and is cost effective compared to microsurgical resection. It may be an alternative to surgical treatment for a selected group of patients. However there are some limitations to the procedure though, such as difficult patient selection, unpredictable outcome or technical problems due to highly degenerated facet joints.