Abstract
Hemorrhagic facet cysts are a rare condition including both synovial and ganglion cysts. Here, the authors present the first-ever reported case of a hemorrhagic ganglion cyst of the facet joint at L1 to L2 causing cauda equina syndrome. In this report, a 72-year-old woman presented with symptoms of cauda equina syndrome requiring urgent surgical consideration. Magnetic resonance imaging and computed tomography showed an extradural mass at the L1 to L2 level. Due to the giant size of the cyst, there was severe compression of the thecal sac and nerve roots. The patient underwent interlaminar contralateral decompression and cystectomy using a uniportal endoscopic approach. The patient had a quick postoperative recovery, with postoperative magnetic resonance imaging of the lumbar spine showing recovery of the facet cyst with no sign of recurrence or stenosis. This case demonstrates the successful surgical technique of interlaminar endoscopic contralateral decompression combined with cystectomy, showing that a hemorrhagic ganglion cyst at the facet at L1 to L2 can be removed completely under endoscopic view.
Introduction
Symptomatic hemorrhagic lumbar facet cysts are rare clinical entities. Facet cysts can be classified as either synovial or ganglion cysts, based on the presence or absence of synovial lining on histopathological examination.1 Both types typically occur adjacent to the spinal facet joints and present with similar clinical features and prognoses,2–4 with only 10% of these cysts having hemorrhagic transformation.5 When symptomatic, it is hypothesized that acute intracystic hemorrhage may precipitate sudden expansion of the cyst, resulting in compression of the thecal sac and/or adjacent nerve roots and leading to acute neurological deficits.6,7 The differential diagnosis of hemorrhagic spinal cysts includes hemorrhagic lesions of the ligamentum flavum, posterior longitudinal ligament, and cystic neoplasms or metastatic disease.1,5,8
Here, we present a rare case of a hemorrhagic ganglion cyst at the L1 to L2 level in a 72-year-old woman, resulting in cauda equina syndrome. While a hemorrhagic ligamentum flavum cyst at L1 to L2 has been previously documented,1,8 to our knowledge, this represents the first reported case of a hemorrhagic ganglion cyst at this level with cauda equina syndrome. We describe the clinical, radiological, surgical, and histopathological findings of this case and highlight the successful use of interlaminar contralateral decompression with cystectomy using a uniportal endoscopic approach for management.
Case Presentation
A 72-year-old woman with a chronic history of axial lower back pain presented to our hospital with progressive bilateral lower extremity weakness, neurogenic claudication, and new onset urinary incontinence. She did not endorse any history of major trauma or known coagulopathy. Her symptoms were insidiously progressive, with her ambulatory capacity declining to approximately 10 m. On presentation, she was dependent on crutches for ambulation and required physical assistance to transition from sitting to standing. The patient had observed no meaningful clinical benefit with conservative management to date, including epidural steroid injections, structured physical therapy, nonsteroidal anti-inflammatory drugs (ibuprofen 600 mg 3 times per day), and opioid analgesia (tilidine 100 mg twice per day). Visual analog scale scores were 5/10 for axial back pain and 7/10 for bilateral leg pain. On examination, the patient had a negative straight leg raise bilaterally and an absent right patellar reflex. There was marked thoracolumbar postural deformity, characterized by increased lower thoracic kyphosis and lumbar hyperlordosis. Motor testing revealed significant proximal weakness with 3/5 hip flexion strength and approximately 3/5 knee extension strength bilaterally. Given the findings of incomplete paraparesis and emerging features that were concerning for cauda equina syndrome, emergent imaging and neurosurgical evaluation were pursued.
Magnetic resonance images (MRI) showed a giant extradural intraspinal soft mass at the L1 to L2 level with high signal intensity on T1-weighted images extending from the right side of the facet joint to the spinal canal with compression of the dura mater (Figures 1 and 2A) below the conus medullaris. Contrast was not used in the MRI, as is typical, due to a history of severe allergic reaction to contrast medium. Furthermore, the right side of the facet joint at L1 to L2 showed severe degenerative changes with facet joint effusion (Figure 2). On T2-weighted images (Figure 1B), the soft tissue mass showed low signal intensity. There was multilevel degeneration of the discs and the facet joints throughout the whole lumbar spine, with additional degenerative instability observed at the L4 to L5 level. The computed tomography scan of the upper lumbar spine showed a large cystic lesion with thecal sac compression on sagittal view (Figure 3A) and on axial view (Figure 3B), with a possible origin of the cyst formation from the facet joint or from the thickened ligamentum flavum. A radiological diagnosis of a giant facet cyst with severe dural sac compression was made, and due to the size and location of the cyst, taken alongside the patient’s urgent clinical indication of cauda syndrome, the patient was taken to the operating room for interlaminar contralateral decompression using a uniportal endoscopic approach.
Magnetic resonance imaging of the lumbar spine presenting a large cystic mass with severe compression of the thecal sac in a 72-year-old woman, presenting with incomplete paraparesis. The T1-weighted image (A) shows a hyperintense signal, and the T2-weighted image (B) shows a hypointense signal.
Axial views of the giant facet cyst (margins indicated with red arrows) on the right side at L1–L2 with severe intraspinal and extradural compression of the thecal sac. The T2-weighted image (A) shows the displacement of the thecal sac and degenerative enlargement of the right facet joint with effusion. The axial computed tomographic image of L1–L2 (B) shows severe spondyloarthritis.
Computed tomographic image of the upper lumbar spine shows a large cystic lesion with thecal sac compression on sagittal view (A) and on axial view (B) with a possible origin of the cyst formation from the facet joint or from the thickened ligamentum flavum (red arrows indicate cyst margin).
The procedure was performed under general anesthesia with the patient positioned prone, with hips and knees flexed to reduce lumbar lordosis. A 1-cm skin incision was made approximately 1 cm lateral to the spinous process on the left side at the L1 to L2 level. Under intermittent fluoroscopic guidance, alternating between lateral and anteroposterior views, a 10-mm dilating rod was inserted in a slightly oblique trajectory, directed toward the junction of the lamina and medial facet on the contralateral (right) side. Once the rod reached the intended bony landmarks, the working tube was advanced over it, and the dilator was removed. The endoscope was then introduced through the working channel. We utilized the iLESSYS Delta endoscopic system (Joimax), with an endoscope featuring a 10-mm outer diameter, a 6-mm working channel, and a 15° angle of view (Figure 4A and B). The system permits the use of a diamond burr, Kerrison punches, and a shaver system to facilitate bony resection. Continuous saline irrigation and suction provided a clear endoscopic field. Using a 4.5-mm diamond burr and a large Kerrison punch, we performed decompression. After initial bony resection and cleaning with a radiofrequency probe, a large facet cyst with intraspinal extension was visualized. Upon incision of the cyst, hemorrhagic and mucoid material were released (Figure 5A). Decompression was achieved through piecemeal excision of the cyst contents. Portions of the ligamentum flavum, cyst wall, hypertrophic facet joint, and adjacent lamina were removed using Kerrison punches and forceps. The resected cystic tissue was collected for histological analysis, with an approximate aggregate specimen size of 4 × 3 cm (Figure 5B). Upon completion of the decompression, free floating of the dural sac and epidural space was confirmed. The endoscope and working tube were removed, and the incision was closed with 2 sutures.
Fluoroscopic anterior/posterior (A) and lateral (B) view of endoscopic resection by forceps through the working tube with interlaminar access.
Endoscopic view after opening the cyst (A), which was covered with a fibrous, white-colored capsule and filled with dark red hemorrhage mixed with mucoid fluid. The macroscopic result (B) consists of a 4 × 3–cm red-brown soft tissue (old, coagulated blood) mixed with the white parts of the capsule and flavum.
The pathohistological examination of the removed tissue was performed at the Jena University Hospital, Institute of Pathology. The tissue samples were fixed with formaldehyde solution and embedded in paraffin. Histological sections were stained with hematoxylin and eosin (Figure 6A) and Masson-Goldner (Figure 6B). The samples presented the histological picture of connective tissue with chronic inflammation and microdeposits of siderophages (Figure 6A), parts of ligamentum flavum (Figure 6B), and cartilage with proliferation of chondrocytes. There were no signs of malignant changes or synovial lining cells.
Histological view (magnification 200×) of resected facet cyst with connective tissue with chronic inflammation and microdeposits of siderophages (A). No sign of synovial lining cells (hematoxylin and eosin staining). Degenerated collagenic fibers of the ligamentum flavum and red blood cells stained by Masson-Goldner (B).
The patient experienced a rapid postoperative recovery. By postoperative day 1, she was ambulating independently without limitations. Leg pain had resolved, rated 1/10 on the visual analog scale, though she reported residual low back pain rated at 3/10. At the 2-week follow-up, she was ambulating without crutches and able to rise from a kneeling position. Motor strength had improved, with hip flexion graded at M4 and quadriceps strength at M4 to M5 bilaterally. At the 6-month clinical follow-up, the patient demonstrated full recovery of motor deficits. Intermittent low back pain persisted, although it was less functionally limiting. Follow-up MRI of the lumbar spine showed complete resolution of the facet cyst with no evidence of recurrence or spinal canal stenosis (Figure 7).
The T2-weighted images show complete recovery of the resected facet cyst 14 months after surgery. The sagittal view (A) presented a disc protrusion of L3 to L4 and slight instability of the L4 to L5 level. Both T2 images (A and B) show no sign of cyst recurrence or spinal stenosis at the L1 to L2 level.
Discussion
Spinal facet joint cysts are an uncommon degenerative spinal lesion. They occur most frequently in the lumbar region at levels of greatest motion and stress, such as L4 to L5.7 Upper lumbar levels, on the other hand, are only rarely affected, with L1 to L2 involvement being extremely rare. A review of 43 published cases of hemorrhagic lumbar facet cysts found only 1 case at L1 to L2 (and 1 at S1 to S2), whereas nearly 47% were at L4 to L5.7 While patients with hemorrhagic facet cysts can remain asymptomatic, they often present with symptoms caused by neural compression once their cysts extend into the spinal canal depending on the cyst size and level. The most common symptoms include sciatica, low back pain, sensory disturbances, motor weakness, and absent reflexes. Features of bowel or bladder dysfunction indicative of cauda equina syndrome only occur, however, in about 5% of reported hemorrhagic cyst cases.7 Thus, the present case of a hemorrhagic facet cyst at L1 to L2 causing symptoms of cauda equina syndrome represents an exceptionally rare case.
For diagnosis in our case, MRI characteristics were clearly consistent with intracystic hemorrhage. Typically, nonhemorrhagic facet cysts appear hypointense on T1-weighted imaging and hyperintense on T2-weighted imaging. However, hemorrhagic cysts can vary in signal intensity based on the age and stage of blood products present, with deoxyhemoglobin, methemoglobin, and hemosiderin each producing distinct imaging features.9,10 In this case, the lesion was hyperintense on T1 and hypointense on T2, consistent with subacute to chronic hemorrhage. Furthermore, histopathological analysis revealed no synovial lining, consistent with a diagnosis of ganglion cyst, and the presence of hemosiderin-laden macrophages and signs of both acute and chronic hemorrhage confirmed the hemorrhagic nature of the lesion.
While the hemorrhagic nature of the cyst was clear, imaging, intraoperative, and histopathological findings raised consideration of both a hemorrhagic ligamentum flavum cyst and a facet joint cyst as possible origins. Histological sections demonstrated elements from both the ligamentum flavum and the facet joint (Figure 6B), reflecting the cyst’s anatomical proximity to both structures. However, several key findings support the facet joint as the more likely site of origin. Radiographically, the cyst appeared contiguous with the right L1 to L2 facet joint, which showed severe degeneration and effusion, a feature commonly associated with facet cyst formation.11 Intraoperatively, the cyst was closely associated with the facet capsule, and its location aligned with the area of maximal facet degeneration. Finally, while the computed tomography scan (Figure 3B) suggested a possible connection to the ligamentum flavum, this most likely represents secondary involvement due to the cyst’s expansion or adherence rather than its point of origin.
In regard to our approach used in this case, historically, the standard treatment for a symptomatic facet cyst has been an open surgical decompression with a laminectomy or hemilaminectomy with cyst excision.7 In many cases, a partial medial facetectomy is performed to fully resect the cyst and decompress the nerve root, as was reported in the rare occurrence of a cyst at the L1 to L2 level.1 This conventional approach has a high success rate in relieving symptoms.12 However, traditional open resection has downsides. Removing part of the facet joint can destabilize the motion segment,13 potentially leading to postoperative instability or spondylolisthesis. In fact, a small percentage of patients in large series required subsequent fusion surgery due to mechanical back pain or recurrent cysts linked to an unstable segment.12 Less invasive removal of facet cysts can minimize tissue disruption and preserve stability.
Endoscopic decompression techniques, such as dorsal, foraminal, and transpedicular approaches, have been described for various types of facet cysts,13–17 with comparable outcomes to open surgery. In a prospective study of 74 patients with lumbar facet cysts treated via full-endoscopic (interlaminar or transforaminal) resection, 85% of patients had complete relief of radicular pain, and another 11% had only occasional mild pain, with a low complication rate.18 No patients in that series required subsequent fusion, and functional recovery was rapid.
Conclusion
We successfully employed an interlaminar endoscopic contralateral approach for complete resection of the hemorrhagic ganglion cyst at L1 to L2 (Figure 4A and B). The technique provided excellent visualization, allowed precise decompression, and preserved segmental stability. The patient experienced rapid postoperative recovery, was discharged within 48 hours, and had complete resolution of motor deficits by 6 months. Her favorable outcome is consistent with the previously reported case of cyst removal at the L1 to L2 level1 and further underscores the advantages of minimally invasive endoscopic surgery, particularly for elderly patients with comorbidities.
Acknowledgments
Thanks to the team of the operating theater of the SRH hospital Waltershausen-Friedrichroda for the friendly support.
Footnotes
Funding The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of Conflicting Interests The authors report no conflicts of interest in this work.
Disclosures Sanjay Konakondla reports consulting fees from Arthrex, Globus, and Spineology and payment/honoraria for lectures, presentations, speakers bureaus, manuscript writing, or educational events from Elliquence and Joimax.
- This manuscript is generously published free of charge by ISASS, the International Society for the Advancement of Spine Surgery. Copyright © 2025 ISASS. To see more or order reprints or permissions, see http://ijssurgery.com.
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