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Research ArticleEndoscopic Minimally Invasive Surgery

A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment

Enrico Giordan, Paolo Gallinaro, Altin Stafa, Giuseppe Canova, Roberto Zanata, Elisabetta Marton and Jacopo Del Verme
International Journal of Spine Surgery February 2022, 16 (1) 124-138; DOI: https://doi.org/10.14444/8181
Enrico Giordan
1 Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Veneto, Italy
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Paolo Gallinaro
1 Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Veneto, Italy
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Altin Stafa
2 Department of Neuroradiology, Aulss2 Marca Trevigiana, Treviso, Italy
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Giuseppe Canova
1 Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Veneto, Italy
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Roberto Zanata
1 Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Veneto, Italy
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Elisabetta Marton
1 Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Veneto, Italy
3 Department of Neuroscience, University of Padova, Padova, Italy
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Jacopo Del Verme
1 Department of Neurosurgery, Aulss 2 Marca Trevigiana, Treviso, Veneto, Italy
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    Figure 1

    Flow diagram summarizing the process of study selection.

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    Figure 2

    Forest plot for open surgery overall outcomes. ES, effect size.

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    Figure 3

    Forest plot for minimally invasive overall outcomes. ES, effect size.

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    Figure 4

    Forest plot for full endoscopy overall outcomes. ES, effect size.

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    Figure 5

    Forest plot for percutaneous fluoroscopic- or CT-guided overall outcomes. ES, effect size.

Tables

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    Table 1

    Summary of the characteristics of the included studies.

    AuthorsYearJournalDesignRecruitment Interval N Inclusion /Exclusion CriteriaOutcome MeasurementCohort Characteristics
    Hellinger S et al22 2020 Journal of Spine Surgery P2008–201448
    1. Radiculopathy unresponsive to >12 wk of conservative care

    2. MRI scans showing foraminal or lateral recess stenosis

    VAS scores,MacNab scoresFull endoscopy: transforaminal or interlaminar (local anesthesia and monitored sedation)
    Tacconi L et al13 2020 World Neurosurgery P2017–201935
    1. A single-level unilateral lumbar JFC

    2. Cysts localized in the paramedian, paraforaminal, or intraforaminal location

    3. Invalidating radicular pain for >6 wk

    4. Adequate imaging (MRI)

    5. Failed percutaneous or conservative treatment

    NPRS scores, MacNab scoresFull endoscopy: transforaminal or interlaminar (local anesthesia and monitored sedation)
    Kyung-Hoon K et al14 2019 Pain Physician R 40Lumbar JFC resistant to conservative treatment Full endoscopy: transforaminal (local anesthesia and monitored sedation)
    Hahn P et al23 2018 Orthopedic Proceedings P 60Single-level lumbar JFCs Microsurgical vs full-endoscopic approach
    Heo DH et al24 2018 World Neurosurgery R201610
    1. Radicular leg pain refractory to conservative management methods

    2. No concomitant segment instability or suspected infectious disease

    ODI scores, VAS scoresEndoscopy, contralateral biportal approach a (epidural/general anesthesia)
    Siu CK et al25 2018 Journal of Clinical Neuroscience R2000–201546
    1. Patients with lumbar JFCs

    2. Grade I listhesis

    SF-12 values46 HL
    Oertel J M et al26 2017 World Neurosurgery P2014–201611
    1. Detailed neurologic examinations focused on leg and back pain

    2. Histopathologic report of the specimen

    3. No previous lumbar spine surgery

    4. A preoperative MRI scan

    NPRS scores, MacNab scoresFull endoscopy, interlaminar (general anesthesia)
    Bruder M et al27 2017 Journal of Neurosurgery: Spine R1997–2004140
    1. Patients with lumbar JFCs

    2. Not specified exclusion criteria

    NPRS scores, MacNab scores38 L, 102 HL
    Denis DR et al2 2016 International Journal of Spine Surgery R2003–201453
    1. Lumbar JFCs with or without concomitant grade 1 degenerative spondylolisthesis

    2. Patients without instability on standing flexion-extension radiographs

    3. >6 wk of conservative management

    MacNab scoresMini-invasive surgery: ipsilateral approach
    Birch BD et al28 2016 World Neurosurgery R1999–201540Symptomatic JFCsMacNab scoresMini-invasive surgery: ipsilateral approach
    Eshraghi Y et al7 2016 Pain Physician R2006–201330Patients with moderate to severe lumbar radiculopathyNPRS scoresFluoroscopic-guided rupture (local anesthesia)
    Zhenbo Z et al29 2016 European Spine Journal R2000–201224
    1. Lumbago and refractory radiculopathy originated from JFCs

    2. Confirmed by CT or MRI

    3. No lumbar canal stenosis, disc herniation, tumor, or infection

    JOA scores, VAS scores24 hemilaminoplasty
    Alimi M et al30 2015 Journal of Neurosurgery: Spine R2004–2011110
    1. No preoperative spondylolisthesis and mechanical back pain

    2. No instability on flexion/extension films

    ODI scores, VAS scores, MacNab scoresMini-invasive surgery: ipsilateral approach
    Sukkarieh HG et al31 2015 Journal of Neurosurgery: Spine R2010–201413 Patients without a previous history of spinal surgeryVAS scores, MacNab scoresMini-invasive surgery: contralateral approach
    Knafo S et al32 2015 Journal of Spinal Disorder & Techniques R2004–201023
    1. Patients with lumbar JFCs

    2. Not specified exclusion criteria

    MacNab scores8 HL; 2 L + F, 2 L, 8 IL;3 METRX
    Komp M et al33 2014 Surgical Innovation P2009–201074
    1. No back pain

    2. No spondylolisthesis more than Meyerding grade I;

    3. No spinal stenosis or disc herniations at higher levels on the same side

    VAS scores, German version of the North American Spine Society scale, Oswestry low back pain scaleFull endoscopy: transforaminal/interlaminar(general anesthesia)
    Ortiz O et al34 2013 Journal of NeuroInterventional Surgery R 20
    1. Unilateral lower-extremity radiculopathy with or without lower back pain

    2. Not responders to conservative management

    NPRS scoresTandem or coaxial percutaneous CT-guided (local and intravenous anesthesia)
    Cambron SC et al11 2013 American Journal of Neuroradiology R2004–2011154
    1. Lower-extremity radiculopathy corresponding to the JFCs

    2. MR imaging <2 mo before initial percutaneous rupture

     CT-guided cyst aspiration and rupture (local anesthesia and intravenous sedation)
    Ganau M et al3 2013 Neurologia Medica-Chirurgica R2000–200915No specified exclusion criteriaMacNab scores12 HL; 5 L
    Ha SW et al35 2012 Journal of Korean Neurosurgical Society R2007–20108
    1. Unilateral radicular leg pain

    2. No history of previous lumbar surgery

    3. Failure of appropriate conservative treatment

    4. Neither instability nor spondylolisthesis

    VAS scoresFull endoscopy: transforaminal(epidural anesthesia)
    James A et al36 2012 Journal of Spinal Disorders & Techiques R2006–200916Conservative treatment attempted for at least 3 moVAS scores, MacNab scoresMini-invasive: contralateral approach
    Amoretti N et al11 2012 European Radiology R2006–2010120
    1. JFCs on MRI (fluid, hemorrhagic, or calcification sign)

    2. Imaging findings consistent with the clinical symptoms

    3. VAS with a score >6/10

    VAS scores, ODI scoresCT-guided cyst aspiration and rupture (local anesthesia and intravenous sedation)
    Landi A et al37 2012 Neurosurgical Review R1995–200715No preexistence of spinal instability in preoperative assessmentReported percent of patients with complete vs partial satisfaction6 L; 9 HL
    Schulz M et al16 2011 Ortophade P 45Sciatica or claudication caused by lumbar JFCs Microsurgically vs percutaneous cyst rupture
    El Shazly A et al38 2011 Asian Journal of Neurosurgery R2003–200813Patients without previous spinal fusionMacNab scores13 L
    Matsumoto M et al39 2010 Minimally Invasive Neurosurgery P 7Ineffective conservative treatmentJOA scoresMicroendoscopic
    Xu R et al40 2010 Spine R1990–2009174
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

     54 HL; 40 L; 21 FC in situ F; 60 FC and instrumented F
    Allen TL et al10 2009 The Spine Journal R2004–200740
    1. No calcified JFCs

    2. No previous cyst aspiration procedure

    3. No multifactorial low back pain or symptoms associated with other underlying lumbar pathologies

    NRS-11 scores, RMDQ scores, satisfaction questionnaireFluoroscopic-guided cyst rupture
    Martha JF et al9 2009 The Spine Journal R1999–2005101
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    NPRS scores, ODI scoresFluoroscopic-guided rupture(local anesthesia)
    Terao T et al41 2007 Neurologia Medica-Chirurgica R1998–200610
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Scores: excellent/good/ poor10 L
    Weiner BK et al42 2007 Journal of Orthopaedic Surgery and Research R1984–200146
    1. patients with lumbar JFCs

    2. no specified exclusion criteria

    VAS scores, satisfaction questionnaire46 HL
    Sehati N et al43 2006 Neurosurgical Focus R2003–200519
    1. >6 wk of nonoperative management

    2. No previous surgery at the JFCs level or at adjacent spinal segments

    MacNab scoresMini-invasive surgery: ipsilateral approach
    Acharya R et al1 2006 Neurology India R1993–198226
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Reported percent of satisfactory relief15 L, 9 HL
    Metellus P et al44 2006 Acta Neurochirrgica R1992–199877
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Scores: excellent/good/ poor51 HL + PF + MF; 26 L + F + MF
    Deinsberger R et al15 2006 Journal of Spinal Disorder & Techniques R2002–200430
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    MacNab scores26M MF; 4 L+MF
    Sandhu FA et al45 2004 Neurosurgery R1999–200325
    1. Detailed neurological examinations

    2. Dynamic radiological studies of the lumbosacral spine

    3. Preoperative MRI imaging

    MacNab scoresMini-invasive surgery: ispilateral approach
    Epstein NE et al46 2004 Spine R 80
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Short Form (36) Health Survey values, MacNab scores80 L
    Pirotte B et al47 2003 Journal of Neurosurgery: Spine R1990–200146
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Reported patients with satisfactory relief12 IL, 24 HL 10 L
    Bureau NJ et al12 2001 Radiology R1995–200012
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    MacNab scoresFluoroscopic- and CT-guided cyst rupture
    Salmon B et al48 2001 Acta Neurochirgica R1989–199728
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Reported percent of satisfactory relief28 L
    Banning C S et al46 2001 Spine R1993–199829
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Measurement: completely improved/better—still some problems/no change/worse29 L or HL
    Trummer M et al49 2001 Journal of Neurology, Neurosurgery, and Psychiatry R1994–199819Intractable radicular pain or neurological deficits caused JFCsMacNab scores6 HL; 5 L; 8 IL
    Lyons MK et al50 2000 Journal of Neurosurgery: Spine R1974–1996194
    1. Patients with lumbar JFCs

    2. No specified exclusion criteria

    Reported patients with excellent or good scores159 MF, 23 TF, 12 unknown
    • aPercutaneous biportal full-endoscopic procedure under continuous irrigation.

    • CT, computerized tomography; F, fusion; FC, facetectomy; HL, hemilaminectomy; IL, interlaminar approach; JFC, juxtafacet cyst; JOA, Japanese Orthopaedic Association; L, laminectomy; M, medial; METRX, Micro Endoscopic Spine Surgery Retractor; MF, medial facetectomy; MRI, magnetic resonance imaging; NPRS, numeric pain rating score; NRS-11, 11-point numeric rating scale; ODI, Oswestry disability index; P, prospective; PF, posterior fixation; R, retrospective; RMDQ, Roland Morris Disability Questionnaire; SF-12, 12-Item Short Form; TF, total facetectomy; VAS, visual analog scale.

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    Table 2

    Methodological quality evaluation.

    AuthorsDesignRepresentatives of Exposed CohortSelection of Nonexposed CohortAscertainment of ExposureAssesment of OutcomeLength Follow-Up
    Hellinger S et al22 ●●●●●●●●
    Tacconi L et al13 ●●●●●●●
    Kyung-Hoon K et al14 ●●
    Hahn P et al23*●●●●
    Heo DH et al24 ●●●●●
    Siu CK et al25 ●●●●●●●
    Oertel JM et al26 ●●●●●●●
    Bruder M et al27 ●●●●●●●
    Denis DR et al2 ●●●●●●
    Birch BD et al28 ●●●●
    Eshraghi Y et al7 ●●●●
    Zhenbo Z et al29 ●●●●●●●
    Alimi M et al30 ●●●●●●●●●
    Sukkarieh HG et al31 ●●●●●●
    Knafo S et al32 ●●●
    Komp M et al33 ●●●●●●●●●
    Ortiz O et al51 ●●●
    Cambron SC et al11 ●●●●●
    Ganau M et al3 ●●●●
    Ha SW et al35 ●●●●●
    James A et al36 ●●●●
    Amoretti N et al11 ●●●●●●●
    Landi A et al37 ●●●●●
    Schulz M et al16 ●●●●
    El Shazly A et al38 ●●●●
    Matsumoto M et al39 ●●●●●
    Xu R et al40 ●●●●
    Allen TL et al10 ●●●●●●●
    Martha JF et al9 ●●●●●
    Terao T et al41 ●●●●
    Weiner BK et al39 ●●●●
    Sehati N et al43 ●●●●
    Acharya R et al1 ●●●
    Metellus P et al44 ●●●●●
    Deinsberger R et al15 ●●●●
    Sandhu FA et al45 ●●●●
    Epstein NE et al46 ●●●●●
    Pirotte B et al47 ●●●●
    Bureau NJ et al12 ●●●
    Salmon B et al48 ●●●●
    Banning CS et al46 ●●●●
    Trummer M et al49 ●●●●
    Lyons MK et al50 ●●●●●
    • Design: One dot for prospective or randomized controlled trials. Representatives of exposed cohort: One dot for study reporting detailed inclusion criteria, two dots for studies reporting detailed inclusion and exclusion criteria. Selection of non-exposed cohort: One dot for each study reporting a control group. Ascertainment of exposure: One dot for the authors confirming the intraoperative presence of a JFC, two dots if the histological confirmation was reported and an accurate JFC description provided. Assesment of outcome: One dot for each different clinical score utilized by authors for measuring postoperative outcomes. Length of follow-up: One dot if the follow-up was more than 24 months.

    • View popup
    Table 3

    Summary of outcomes and adverse events for each treatment modality.

    VariableOpen SurgeryMinimally InvasiveFull EndoscopicPercutaneous CystRupture and Aspiration P Value < 0.05
    N 1112279263497 
    Age, y, mean (range)63 (54.4–73)65.3 (62–72.4)49.2 (23.1–68.6)63.2 (58.7–68.2) 
    Sex, male51.9%55.6%52.9%57.8% 
    Follow-up, mo, mean (range)39.5 (8.3–116.4)24.0 (11.5–79)27.5 (18–55.5)24.2 (11–44.5) 
    Preoperative degenerative listhesis, %33.6%21.1%8.3%3.9% a,b,c,d,e,f
    Satisfactory outcome, % MacNab excellent—good scores (95% CI)93.0% (88.3%–96.7%)82.7% (61.2%–97.5%)90.9% (83.8%–96.4%)66.2% (52.9%–78.4%) c,e,f
    Recurrence, % (95% CI)1.4% (0.3%–3.2%)2.3% (0.3%–5.5%)3.0% (0.0%–9.9%)34.3% (20.3%–49.6%) c,e,f
    Revisions, % (95% CI)3.0% ( 1.3%–5.3%)3.6% (1.0%–2.3%)2.2% (0.0%–8.3%)29.8% (18.9%–42%) c,e,f
    Developing postoperative instability, % (95% CI)3.5% ( 0.6%–8.0%)3.2% (0.2%–8.4%)0%/ 
    Intraoperative/procedural adverse events, % (95% CI)1.1% ( 0.1%–3.0%)8.4% (2.7%–16.3%)1.8% (0.0%–5.3%)0.1% (0.0%–1.2%) a,d,c,e,f
    • Significant differences between: a = open vs minimally invasive; b = open vs full endoscopic; c = full-endoscopic vs percutaneous cyst aspiration and rupture; d = minimally invasive vs full endoscopic; e = minimally invasive vs percutaneous cyst aspiration and rupture; f = full-endoscopic vs percutaneous cyst aspiration and rupture; / : not reported.

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A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment
Enrico Giordan, Paolo Gallinaro, Altin Stafa, Giuseppe Canova, Roberto Zanata, Elisabetta Marton, Jacopo Del Verme
International Journal of Spine Surgery Feb 2022, 16 (1) 124-138; DOI: 10.14444/8181

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A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment
Enrico Giordan, Paolo Gallinaro, Altin Stafa, Giuseppe Canova, Roberto Zanata, Elisabetta Marton, Jacopo Del Verme
International Journal of Spine Surgery Feb 2022, 16 (1) 124-138; DOI: 10.14444/8181
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Keywords

  • juxtafacet cyst
  • lumbar
  • synovial cyst
  • endoscopic
  • spine
  • minimally invasive
  • percutaneous
  • cyst rupture

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