Diagnosis and management of juxtafacet cysts

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.

Imaging of intraspinal cystic lesions: A review

Several distinct conditions present as cystic or pseudocystic lesions within the spinal canal. Some of the most common spinal cystic lesions include spinal meningeal cysts, juxtafacet cysts, dermoid/epidermoid cysts, nerve sheath tumors, and syringohydromyelia. Clinical presentation is usually nonspecific and imaging characteristics are frequently overlapping, which may pose a challenging presurgical diagnosis. We provide a pictorial review of cystic intraspinal lesions and discuss the main imaging features that can aid the neuroradiologist in the differential diagnosis. First, we propose a categorization of the lesions according to their location as extradural, intradural extramedullary, and intramedullary. This is a crucial initial step in the diagnostic workup and surgical planning. Second, for each of these locations, we organize the lesions according to their etiology: congenital and developmental disorders, degenerative disorders, traumatic or postsurgical collections, infectious conditions, neoplastic lesions, and other miscellaneous disorders. Finally, we summarize the clinical highlights and MR features that provide important insights for the differential diagnosis. MR is the technique of choice in presurgical evaluation and postsurgery follow-up. It provides accurate lesion localization and characterization and, most of the times, it will allow a confident differential diagnosis. High-resolution three-dimensional T2-weighted sequences and diffusion-weighted imaging can provide important hints in specific cases. Signal correlation with T1-weighted and fat-saturated sequences allows to differentiate true cystic lesions from hemorrhage or fat tissue.

Retro-odontoid Pseudotumor: Two Cases of Intradural Ganglion Cysts Arising From the Odontoid Process with Syringobulbia

BACKGROUND

Ganglion cysts mostly occur in the knuckles and wrists, but they rarely present in the odontoid process and can cause neurological symptoms by compressing the spinal cord. They are mostly localized in the epidural space, but may very rarely appear in the intradural space. There are no reports of cases of intradural ganglion cyst involving syringobulbia.

CASE DESCRIPTION

We report the presentation and management of 2 cases of an intradural ganglion cyst of the odontoid process. Several treatment options for ganglion cysts of the odontoid process have been reported, such as rest and use of a neck collar, posterior decompression and fusion, and transoral anterior decompression. Because our 2 cases progressed rapidly and had severe neurological symptoms, surgical treatment was performed for rapid decompression and definitive pathological diagnosis. The mass was resected as much as possible using the lateral occipital fossa approach, and the operation was completed without dissection of the brain stem or manipulation of the syringobulbia. Postoperatively, neurological symptoms promptly improved, and the syringobulbia reduced.

CONCLUSIONS

For intradural ganglion cysts with syringobulbia, we suggest relief of the compression by resection of the mass and treatment of the syringobulbia in 2 stages, if necessary, to avoid the risk of damage to the brainstem.

Resolution of Symptomatic Lumbar Synovial Cyst After Traumatic Event

BACKGROUND

Synovial cysts are most commonly found in the lumbar spine and are associated with low back pain and radiculopathy. Frequent use of imaging modalities has led to an increase in intraspinal synovial cyst identification. Treatment typically ranges from conservative measures to surgical decompression, but spontaneous resolution has previously been reported. Here, we present the first report of symptomatic lumbar synovial cyst resolution after a traumatic fall.

CASE DESCRIPTION

We present a case of a symptomatic synovial cyst between the fourth (L4) and fifth (L5) lumbar vertebrae identified on magnetic resonance imaging (MRI). The patient presented with right paramedian back pain and right-sided L5 radiculopathy. She underwent unsuccessful trials of antiinflammatory agents and physical therapy. Less than 1 year since initial diagnosis, the patient sustained a mechanic fall followed by resolution of prior symptoms. A subsequent lumbar MRI revealed complete resolution of the intraspinal synovial cyst.

CONCLUSIONS

The diagnosis of synovial cysts are increasing in frequency due to their ease of identification with computed tomography and MRI. For cases of refractory pain and/or neurologic deficits, surgical decompression is usually necessary. In rare instances, synovial cysts may spontaneously regress or resolve secondary to other events. This is the first description of resolution after a traumatic fall. Due to limited data on this topic, this report may provide additional insight into the pathophysiology of synovial cyst formation and resolution.

Interlaminar stabilization and decompression for the treatment of bilateral juxtafacet cysts: Case report and literature review

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Lumbar juxtafacet cysts are typically treated by resection alone or resection combined with posterior instrumentation.

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Resection with instrumentation is associated with a lower rate of recurrence but also with increased cost and morbidity.

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We present a case of bilateral juxtafacet cysts causing neurogenic claudication treated with decompression and interlaminar stabilization.

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Complete symptom resolution was sustained at one-year follow-up.

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Decompression followed by interlaminar stabilization may be a reasonable alternative for some patients.

Introduction

Lumbar juxtafacet cysts (JFCs) are a common cause of lumbar radiculopathy which tend to occur in areas of increased facet mobility. While resection alone is a possible treatment, recent publications suggest that laminectomy alone for JFCs may not yield as favorable an outcome as laminotomies reinforced with posterior dynamic hardware. The Coflex^® is a novel interlaminar stabilization device that has been shown to achieve comparable results to rigid fusion in the management of lumbar stenosis in patients with no more than grade one anterolisthesis, and superior performance compared to laminectomy alone when a combined outcome score was used. We describe the combined use of dynamic posterior element fusion with primary cyst resection in the management of bilateral JFCs.

Presentation of case

A 71-year-old man who developed a progressive left L4 radiculopathy along with new urinary incontinence was found to have bilateral L3/4 JFCs causing significant lumbar stenosis and neurogenic claudication. After treatment with primary cyst resection and interlaminar stabilization, the patient experienced complete symptom resolution and was discharged to inpatient-rehabilitation on post-operative day 1.

Discussion

While current recommendations for the management of juxtafacet cysts causing progressive neurologic symptoms include surgical cyst removal and lumbar decompression with or without fusion, the role of dynamic interlaminar stabilization has not been explored.

Conclusion

Direct decompression followed by interlaminar stabilization may represent an alternative for patients to simultaneously benefit from a decompression of their juxtafacet cysts while affording posterior element reconstruction.

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.

Spontaneous Resolution of Lumbar Facet Joint Cyst

BACKGROUND

Juxtafacet cysts (JFCs) are uncommon spinal lesions that can cause neural compression and are typically managed surgically. Rarely, JFCs can spontaneously resolve.

CASE DESCRIPTION

We present the case of a spontaneously resolving right L4/5 JFC in an otherwise fit and well 60-year-old female. She presented with progressive chronic lower back pain and intermittent sciatica. She had no neurologic deficit. The patient was keen to avoid surgical intervention. After 19 months her symptoms had significantly improved, and repeat magnetic resonance image demonstrated complete resolution of the lesion.

CONCLUSIONS

While surgery to remove a JFC ± spinal stabilization remains the mainstay and definitive treatment for symptomatic JFCs, patients without neurologic deficit may be safely managed conservatively pending possible spontaneous resolution. Spontaneous resolution may reflect the natural history of the condition.

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.

Spontaneous resolution of symptomatic lumbar synovial cyst

Lumbar synovial cyst arises from the facet joint and can lead to back pain, radiculopathy, neurogenic claudication or even cauda equina syndrome. Although most surgeons would consider surgery to be the treatment of choice, the natural history of the disease process remains unknown and uncertainty still exists regarding optimal management of this controversial entity. We illustrate a case of large L5/S1 synovial cyst for which surgery was initially planned. However, it resolved spontaneously without any treatment. We also provide a brief literature review regarding conservative, surgical and minimally invasive management of symptomatic lumbar synovial cyst with special reference to patient outcome.

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.

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.

Lumbar L4-L5 ganglion cyst with hemicauda equina syndrome. Report of a case and review of the literature

Mostly associated with degenerative facet joints and spondylolisthesis, symptomatic lumbar juxta facet cysts - ganglion and synovial cysts are uncommon lesions of the spine. They can mimic herniated discs, causing low back pain, radiculopathy or even cauda equina syndrome; also some of them are associated with spinal instability. Referring to a case with hemicauda equina syndrome where microsurgical decompression was performed with very good result; alternative treatment solutions are discussed: conservative therapy for symptomatic lesions is often unsuccessful, spinal fusion should be made for those cases with spinal instability, although there are reports of spontaneous resolution of these cysts as well as the symptoms associated with them.

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).

Cervical juxtafacet cyst after anterior cervical discectomy and fusion

Anterior cervical discectomy and fusion (ACDF) is a common neurosurgical procedure, and the benefits, long-term outcomes, and complications are well described in the literature. The development of a juxtafacet joint cyst resulting in radiculopathy is a rare outcome after ACDF and merits further description. The authors describe a patient in whom a juxtafacet joint cyst developed after ACDF procedures, resulting in surgical intervention. When a juxtafacet joint cyst develops after ACDF, symptoms can include radiculopathy, neck pain, and neurological symptoms such as paresthesias and motor weakness. The presence of a juxtafacet joint cyst implies instability in that region of the spine. Patients with this pathological entity may require decompression of neural elements and fusion across the segment involved with the cyst.

A ganglion cyst in the second lumbar intervertebral foramen

Ganglion cysts usually arise from the tendon sheaths and tissues around the joints. It is usually associated with degenerative arthritic changes in older people. Ganglion cyst in the spine is rare and there is no previous report on case that located in the intervertebral foramen and compressed dorsal root ganglion associated severe radiculopathy. A 29-year-old woman presented with severe left thigh pain and dysesthesia for a month. Magnetic resonance imaging revealed a dumbbell like mass in the intervertebral foramen between second and third lumbar vertebrae on the left side. The lesion was removed after exposure of the L2-L3 intervertebral foramen. The histological examination showed fragmented cystic wall-like structure composed of fibromyxoid tissue but there was no lining epithelium. A ganglion cyst may compromise lumbar dorsal root ganglion when it located in the intervertebral foramen. Although it is very rare location, ganglion cyst should be included in the differential diagnosis for intervertebral foraminal mass lesions.

Technical and imaging report: fluoroscopic guidance for diagnosis and treatment of lumbar synovial cyst

Lumbar synovial cysts can be a source of low back pain with or without radiculopathy depending upon the size and location of the mass. Options for treatment range from analgesics to surgery, depending upon the degree of nerve root or spinal cord impingement. Attempts at minimally invasive treatment such as computed tomography-assisted aspiration and cyst rupture are documented in the radiology literature with varying degrees of reported success. This case report is the first to document the fluoroscopically-guided management of a lumbar synovial cyst in the pain medicine literature and highlights the knowledge and technical skills required when treating such cases.

Lumbar synovial cyst in an adolescent: case report

BACKGROUND

Spinal extradural cysts are a rare cause of spinal cord or nerve root compression which tends to occur in the elderly but rarely reported in the under 20s.

HISTORY

A 14-year-old girl with a 9-month history of left radicular pain was found to have an intraspinal cystic lesion causing radicular compression. MRI showed a 1.1-cm extradural cystic lesion with a low signal on T1 and high signal on T2-weighted images lying in the spinal canal at the L4 vertebral body level. The patient underwent an L4 hemi-laminectomy and excision of a synovial cyst, and the radicular pain completely regressed.

DISCUSSION

We discuss the pathogenesis, radiological techniques, and management of synovial cyst in a pediatric patient.

CONCLUSION

Intraspinal ganglion cysts are extremely rare in children and only two other cases have been reported previously. They are benign lesions, frequently presenting radiculopathy, and should be considered in the differential diagnosis, in patients with low back pain and radiculopathy.

Lumbar synovial cyst in a adolescence: case report

BACKGROUND

Spinal extradural cysts are a rare cause of spinal cord or nerve root compression which tends to occur in the elderly but rarely reported in the under 20s.

HISTORY

A 14-year-old girl with a 9-month history of left radicular pain was found to have an intraspinal cystic lesion causing radicular compression. Magnetic resonance imaging showed a 1.1-cm extradural cystic lesion with a low signal on T1-weighted images and high signal on T2-weighted images lying in the spinal canal at the L4 vertebral body level. The patient underwent an L4 hemilaminectomy and excision of a synovial cyst, and the radicular pain completely regressed.

DISCUSSION

We discuss the pathogenesis, radiological techniques and management of synovial cyst in a paediatric patient

CONCLUSION

Intraspinal ganglion cysts are extremely rare in children and only two other cases have been reported previously. They are benign lesions, frequently presenting radiculopathy, and should be considered in the differential diagnosis in patients with low back pain and radiculopathy.

Spinal injection procedures: a review of concepts, controversies, and complications

The field of spinal injection procedures is growing at a tremendous rate. Many disciplines are involved, including radiology, anesthesiology, orthopedics, physiatry and rehabilitation medicine, as well as other specialties. However, there remains tremendous variability in the assessment of patients receiving these therapies, methods for evaluation of outcome, and in the understanding of where these procedures belong in the triaging of those who require surgery. In this article, we attempt to highlight the biologic concepts on which these therapies are based, controversies that have arisen with their increasing use, and a description of complications that have been reported.

Pigmented villonodular synovitis originating from the lumbar facet joint: a case report

The authors successfully treated a rare case of pigmented villonodular synovitis (PVNS) that originated from the lumbar facet joint (L4-5). A 43-year-old man presented with a complaint of left severe sciatica causing difficulty in walking. Magnetic resonance imaging (MRI) demonstrated an extradural mass on the left side at L4 and the mass compressed the dural tube and was continuous with the left L4-5 facet joint. A computed tomography myelogram revealed an extradural defect of contrast medium at the L4 level and an erosion of the L4 lamina. A total synovectomy with unilateral osteoplastic laminectomy was performed. The histological findings were a diagnosis of PVNS. The patient's symptoms resolved completely and the MRI at postoperative 3 years demonstrated no recurrence of PVNS. It is important to totally remove the synovium, which is the origin of PVNS in order to prevent the recurrence. We think that our procedure is reasonable and adequate for lumbar PVNS.