Evidence that atypical juxtafacet cysts are joint derived

Clinical Management and Treatment Guidelines for Intraforaminal Lumbar Synovial Cyst Presentation: Report of Two Cases

We report two cases of unusually located foraminal lumbar synovial cysts: a 46-year-old female and a 59-year-old male, both of whom experienced pain and/or associated numbness. One patient underwent decompressive laminectomy and cyst resection, while the other required concomitant interbody fusion. All patients reported symptom resolution with no recurrence of the cysts. The foraminal location for lumbar synovial cysts is relatively uncommon and lacks conclusive treatment guidelines. Notably, the necessity for arthrodesis in addition to decompression remains controversial. However, these cases suggest that surgical resection of these cysts can be successful.

[Long-term postoperative outcomes in patients with lumbosacral spine synovial cysts]

Searching of literature data revealed only a few reports devoted to long-term postoperative outcomes in patients with lumbosacral spine synovial cysts. These results are ambiguous and largely contradictory.

OBJECTIVE

To analyze the long-term postoperative outcomes in patients with lumbosacral spine synovial cysts.

MATERIAL AND METHODS

A retrospective observational cohort study was performed between January 2015 ando September 2022. The study included patients who underwent surgical treatment for lumbosacral spine synovial cysts with clinical and neurological manifestations. There were 94 medical records of respondents (36 (38.3%) men and 58 (61.7%) women aged 18-82 years). Mean postoperative follow-up period was 24.6±7.5 months.

RESULTS

Patients underwent various surgical interventions for synovial cysts. VAS scores of pain syndrome after 3, 6, 9, 12 and 24 postoperative months revealed significant pain relief in the lower back and extremities (p<0.01). In long-term follow-up period, we observed significantly lower disability (Oswestry Disability Index) (p<0.001). Adverse postoperative events occurred in 9 (9.6%) cases.

CONCLUSION

Interlaminectomy with cyst wall resection and preservation or partial resection (no more than 1/3) of facet joint without segmental fusion is an effective and preferable surgical method with minimal incidence of adverse clinical events.

Visualisation of facet joint recesses of the cadaveric spine: a micro-CT and sheet plastination study

Objectives

The size and shape of a joint cavity are the key determinates for the mobility of the joint. The anatomy and configuration of the facet joint (FJ) recesses at different levels of the spine remain unclear and controversial. The aim of this study was to identify the configuration of the FJ recesses in the cervical, thoracic and lumbar spine using a combination of micro-CT and sheet plastination techniques.

Methods

Of 19 cadavers (9 males, 10 females, age range of 54–89 years), the FJ cavities of 3 spines were injected with contrast filling and scanned with micro-CT, and 16 plastinated spines were prepared as the series of sagittal (9 sets), transverse (5 sets) or coronal (2 sets) sections with a thickness of 2.5 mm and examined under a stereoscopic microscope.

Results

This study characterised the FJ spaces and recesses of the spine and found that (1) the configuration and extent of the FJ recesses varied along the spine. The optimal needle approach to the FJ cavity was via an anterolateral or posterolateral recess at the cervical level, along the tip of the inferior articular process at the thoracic level and via the posteromedial recess at the lumbar level. (2) The FJ cavity did not communicate with the retrodural space.

Conclusion

The anatomical features of the FJ recesses at different levels of the spine confirm no direct communication between the FJ cavity and retrodural space.

Reliability of standing weight-bearing (0.25T) MR imaging findings and positional changes in the lumbar spine

OBJECTIVE

To test the reliability and absolute agreement of common degenerative findings in standing positional magnetic resonance imaging (pMRI).

METHODS AND MATERIALS

Low back pain patients with and without sciatica were consecutively enrolled to undergo a supine and standing pMRI. Three readers independently evaluated the standing pMRI for herniation, spinal stenosis, spondylolisthesis, HIZ lesions and facet joint effusion. The evaluation included a semi-quantitative grading of spinal stenosis, foraminal stenosis and spinal nerve root compression. The standing pMRI images were evaluated with full access to supine MRI. In case lower grades or the degenerative findings were not present in the supine images, this was reported separately as position-dependent changes. A subsample of 20 pMRI examinations was reevaluated after two months. The reproducibility was assessed by inter- and intra-reader reliability (kappa statistic) and absolute agreement between readers.

RESULTS

Fifty-six patients were included in this study. There was fair-to-substantial inter-reader reliability (κ 0.47 to 0.82) and high absolute agreement (72.3% to 99.1%) for the pMRI findings. The intra-reader assessment showed similar reliability and agreement (κ 0.36 to 0.85; absolute agreement: 62.5% to 98.8%). Positional changes between the supine and standing position showed a fair-to-moderate inter- and intra-reader reliability (κ 0.25 to 0.52; absolute agreement: 97.0% to 99.1).

CONCLUSION

Evaluation of the lumbar spine for degenerative findings by standing pMRI has acceptable reproducibility; however, positional changes from the supine to the standing position as an independent outcome should be interpreted with caution because of lower reliability, which calls for further standardisation.

Midline Ligamentum Flavum Cyst of Lumbar Spine

BACKGROUND

Ligamentum flavum cysts are thought to develop due to facet joint hypermobility; however, the etiology of these lesions is not completely elucidated. These cysts may lead to compressive pathologies of the spine requiring surgical intervention.

CASE REPORT

We report the case of a 63-year-old male with chronic back pain and progressive neurogenic claudication for 6 months. He was found to have a ligamentum flavum cyst situated along the dorsal midline of the lumbar spinal canal contributing to spinal stenosis. The patient underwent a decompressive L4 laminectomy and en bloc excision of the ligamentum flavum cyst with complete resolution of his symptoms postoperatively.

CONCLUSIONS

We suggest that chronic mechanical stress leads to degeneration of the ligamentum flavum and contributes directly to cyst formation.

Intraneural ganglion cysts: a systematic review and reinterpretation of the world's literature

OBJECTIVE The etiology of intraneural ganglion cysts has been controversial. In recent years, substantial evidence has been presented to support the articular (synovial) theory for their pathogenesis. The authors sought to 1) perform a systematic review of the world's literature on intraneural cysts, and 2) reinterpret available published MR images in articles by other authors to identify unrecognized joint connections. METHODS In Part 1, all cases were analyzed for demographic data, duration of symptoms, the presence of a history of trauma, whether electromyography or nerve conduction studies were performed, the type of imaging, surgical treatment, presence of a joint connection, intraneural cyst recurrence, and postoperative imaging. Two univariate analyses were completed: 1) to compare the proportion of intraneural ganglion cyst publications per decade and 2) to assess the number of recurrences from 1914 to 2003 compared with the years 2004-2015. Three multivariate regression models were used to identify risk factors for intraneural cyst recurrence. In Part 2, the authors analyzed all available published MR images and obtained MR images from selected cases in which joint connections were not identified by the original authors, specifically looking for unrecognized joint connections. Two univariate analyses were done: 1) to determine a possible association between the identification of a joint connection and obtaining an MRI and 2) to assess the number of joint connections reported from 1914 to 2003 compared with 2004 to 2015. RESULTS In Part 1, 417 articles (645 patients) were selected for analysis. Joint connections were identified in 313 intraneural cysts (48%). Both intraneural ganglion cyst cases and cyst recurrences were more frequently reported since 2004 (statistically significant difference for both). There was a statistically significant association between cyst recurrence and percutaneous aspiration as well as failure to disconnect the articular branch or address the joint. In Part 2, the authors identified 43 examples of joint connections that initially went unrecognized: 27 based on their retrospective MR image reinterpretation of published cases and 16 of 16 cases from their sampling of original MR images from published cases. Overall, joint connections were more commonly found in patients who received an MRI examination and were more frequently reported during the years 2004 to 2015 (statistically significant difference for both). CONCLUSIONS This comprehensive review of the world's literature and the MR images further supports the articular (synovial) theory and provides baseline data for future investigators.

Minimally Invasive Approach For Extraforaminal Synovial Cyst L5-S1

Symptoms from synovial cysts are produced by neural compression in the spinal canal or the foramen. Few cases of extraforaminal synovial cyst have been published in the literature. This is a case report of a 65-year-old female who presented with a three-month history of sciatic pain and no relief with conservative treatment. MRI showed a left-sided extraforaminal synovial cyst at L5-S1 with compression of the L5 nerve root at the lateral portion of the foramen. Minimally invasive surgery for resection was performed using an extraforaminal tubular microscopic endoscopy-assisted approach. The patient improved clinically and remained symptom-free for the entire follow-up of 30 months.

Subaxial cervical juxtafacet cysts: single institution surgical experience and literature review

OBJECTIVES

Juxtafacet cysts (JFCs) of the subaxial cervical spine are rare causes of neurological deficits. Their imaging characteristics, relationship to segmental instability, and potential for inducing acute symptomatic deterioration have only been described in a few case reports and small case series. The objective of the current study was to review the surgical experience at our center and across the literature to better define these variables.

METHODS

A single-institution, multisurgeon series of 12 consecutive patients (mean age 63.4 years, range 52-83 years) harboring 14 JFCs treated across 9 years was retrospectively reviewed. Clinical history, neurological status, preoperative imaging, operative findings, pathology, and postoperative outcomes were obtained from medical records. The mean follow up was 9.2 ± 7.8 months. A literature review identified 35 studies with 89 previously reported cases of surgically treated subaxial cervical JFCs.

RESULTS

Consistent with previously reported cases, most JFCs in our series involved the C7/T1 level. Nine patients reported axial neck pain, 12 patients had radicular symptoms, four patients had myelopathy, and one patient experienced rapid neurological decline attributable to cystic hemorrhage. Cyst expansion without hemorrhage caused subacute deterioration in one patient. All patients experienced sensory and/or motor improvement following surgical decompression. Preoperative axial neck pain improved in eight of nine patients (89 %). Seven out of 12 patients (58 %) underwent fusion either at the time of decompression (six patients) or at a delayed timepoint within the follow-up period (one patient). Prior history of cervical instrumentation, hypermobility on dynamic imaging, and other risk factors for segmental instability were more common in our series than in previous reports.

CONCLUSIONS

Our findings lead us to advocate for early decompression rather than prolonged conservative treatment, for pre- and postoperative dynamic imaging, and for fusion in selected cases as an initial surgical consideration.

Chiropractic management of a patient with lumbar spine pain due to synovial cyst: a case report

INTRODUCTION

The purpose of this study is to report the findings resulting from chiropractic care using flexion distraction spinal manipulation for a patient with low back and radicular pain due to spinal stenosis caused by a synovial cyst.

CASE REPORT

A 75-year-old man presented with low back pain radiating to the right anterior thigh and down the left posterior leg of 3 years' duration. Physical and imaging examinations showed a synovial cyst-induced spinal stenosis at the right L3-L4 level and bilateral L4-L5 spinal stenosis.

INTERVENTION AND OUTCOMES

Flexion distraction spinal manipulation and physiological therapeutics were applied at the levels of stenosis. After 4 visits, the patient noted total absence of the right and left lower extremity pain and no adverse reaction to treatment. After 3 months of treatment and 16 visits, his low back and buttock pain were minimal; and he had no leg pain.

CONCLUSION

Lumbar synovial cyst and stenosis-generated low back and radicular pain was 80% relieved in a 75-year-old man following Cox flexion distraction spinal manipulation.

Juxtafacet cysts of the lumbar spine: a positional MRI study

BACKGROUND/AIMS

Juxtafacet cysts (JFC) are related to facet joint degeneration. Supine MRI is routinely used to evaluate JFC. However, some JFC are missed and found only intraoperatively. The present study addresses positional MRI features and factors leading to variation in the size of JFC.

METHODS

Fifty patients in whom positional MRI had been performed were investigated retrospectively and 67 distinct intraspinal or intraneuroforaminal were JFC found. Signal intensity, size of the JFC, the presence and variance of a vertebral slip and the angular movement of affected segments were assessed in supine, neutral sitting, flexion (sitting) and extension (standing). The overall movement of the spine and the lordosis angle in different positions were measured.

RESULTS

JFC varied in size in segments with unstable slip and increased angular movement (variation of the angle in the affected segment in function: 13.3 degrees compared to 8.7 degrees). JFC with bright signals tended to vary in size compared to JFC with intermediate or low signal intensity (all: p < 0.001). Joint effusion and displacement of effusion lead to formation and variations in the size of JFC. JFC were most prominent in extension: 6.7 mm, less prominent in supine: 5.5 mm and in neutral sitting position: 4.6 mm (all p < 0.05). The detection rate for JFC was 97% for extension, 89% for supine and 78% for neutral sitting.

CONCLUSIONS

The detection rate of JFC improves with increasing lordosis of the spine and under weight-bearing conditions, particularly when standing. Unstable slipping or increased angular movement affects the size of JFC.

Intraspinal Ganglion Cyst

The pathogenesis of juxtafacet cysts is closely related to degenerative instability of the lumbar spine and degenerative changes in the ligamentum flavum and the facet joint. A 56-year-old man presented with severe right thigh pain and numbness for 1 month after a laminar fracture of the L4 spine. Magnetic resonance imaging revealed a heterogenous cystic mass surrounding the facet joint between the fourth and fifth lumbar vertebrae on the right side. Conservative therapy was unsuccessful and the lesion was removed by surgical decompression alone without fusion. The histological examination showed a fragmented, cystic wall-like structure composed of myxoid degenerative tissue without lining epithelium. Here we present this case of a ganglion cyst that appeared to be associated with facet joint instability.

Minimally invasive magnetic resonance imaging-guided free-hand aspiration of symptomatic nerve route compressing lumbosacral cysts using a 1.0-Tesla open magnetic resonance imaging system

PURPOSE

To evaluate the feasibility of minimally invasive magnetic resonance imaging (MRI)-guided free-hand aspiration of symptomatic nerve route compressing lumbosacral cysts in a 1.0-Tesla (T) open MRI system using a tailored interactive sequence.

MATERIALS AND METHODS

Eleven patients with MRI-evident symptomatic cysts in the lumbosacral region and possible nerve route compressing character were referred to a 1.0-T open MRI system. For MRI interventional cyst aspiration, an interactive sequence was used, allowing for near real-time position validation of the needle in any desired three-dimensional plane.

RESULTS

Seven of 11 cysts in the lumbosacral region were successfully aspirated (average 10.1 mm [SD ± 1.9]). After successful cyst aspiration, each patient reported speedy relief of initial symptoms. Average cyst size was 9.6 mm (±2.6 mm). Four cysts (8.8 ± 3.8 mm) could not be aspirated.

CONCLUSION

Open MRI systems with tailored interactive sequences have great potential for cyst aspiration in the lumbosacral region. The authors perceive major advantages of the MR-guided cyst aspiration in its minimally invasive character compared to direct and open surgical options along with consecutive less trauma, less stress, and also less side-effects for the patient.