Thoracic juxtafacet cyst (JFC): a cause of spinal myelopathy

Upper Thoracic Spine Synovial Cyst Resulting in Paraplegia Following Transient Hypotension

Development of synovial cysts in the rigid thoracic spine is rare. Additionally, synovial cysts with compression of nerve roots typically cause subacute or chronic radiculopathy. We present a patient who had a new diagnosis of upper thoracic (T1-2) synovial cyst that caused acute paraplegia while hospitalized for therapies and surgical planning. The patient is a 56-year-old male with a history of congestive heart failure secondary to alcoholic cardiomyopathy. He presented with a progressive bilateral lower extremity discoordination, urinary incontinence, and altered perineal sensation. His examination revealed intact strength to bedside assessment, intact rectal tone, but upgoing toes on Babinski testing. Given concern for myelopathy, MRI thoracic spine was obtained and demonstrated large T1-2 synovial cyst causing severe compression with associated T2 signal change within the spinal cord. He underwent expedited cardiac optimization that included resumption of outpatient antihypertensive medications and the addition of a single dose of intravenous diuretic. The patient had subsequent transient hypotension following significant diuresis and developed acute paraplegia in his bilateral lower extremities. Fluids and vasopressors were initiated, and he underwent emergent surgery for decompression and synovial cyst resection. The patient did very well and had normalization of his neurological exam within 24 hours. We present a case of acute paraplegia secondary to hypotension and spinal cord hypoperfusion in a patient with upper thoracic synovial cyst. This is rare pathology with an even more unique presentation. The authors recommend careful perioperative hemodynamic monitoring to help avoid acute worsening in this patient population.

Rapid Neurologic Deterioration due to an Enlarging Thoracic Spine Synovial Cyst: A Case Report

CASE

We present the case of a 69-year-old man arriving to our clinic after a previous outside hospital recommendation of L1-S1 fusion due to degenerative scoliosis. A thoracic spine synovial cyst was identified through magnetic resonance imaging. The patient had rapid progression of his neurologic deficit due to cyst enlargement. We elected to perform cyst decompression and instrumented fusion of the involved thoracic segment. The patient rapidly regained full neurologic function. After the one-year follow-up, he remained asymptomatic with no progression of thoracolumbar degeneration.

CONCLUSIONS

Thoracic spine synovial facet cysts are uncommonly encountered. Decompression alone or decompression and fusion are both viable treatment options depending on the surgeon's assessment of spine stability after decompression. This diagnosis should be considered in patients presenting with unilateral lower extremity upper motor neuron findings.

The Role of Imaging in the Management of Cystic Formations of the Mobile Spine (CYFMOS)

PURPOSE OF REVIEW

The purpose of this review is to give a better understanding of the pathogenesis of cystic formations of the mobile spine (CYFMOS) and the correlating imaging findings. This would help with medical decision-making, given the plethora of conservative, interventional, and surgical treatment options.

RECENT FINDINGS

There has been a general understanding that CYFMOS are associated with degenerative spine changes. More recent articles however have suggested that identifying detailed imaging characteristics can assist in determining outcomes when CYFMOS are treated with interventional percutaneous methods or surgical decompression with or without concomitant fusion. CYFMOS although uncommon are not a rare finding seen in the spine when there is a background of degenerative spine changes. These cystic lesions are generally symptomatic by exhibiting mass effect on adjacent structure. Most treatments are aimed at decompression by interventional percutaneous or surgical means. Various imaging characteristics of these CYFMOS described in this article including their signal intensity, presence of spinal instability, particular patterns of adjacent degenerative changes, and imaging changes following interventional treatments can help guide physicians when managing these cases.