The appearances of lumbar intraspinal synovial cysts

doi:10.1016/S0009-9260(05)80658-0

Clinical Radiology

Volume 44, Issue 6, December 1991, Pages 397-401

https://doi.org/10.1016/S0009-9260(05)80658-0 Get rights and content

Intraspinal synovial cysts most commonly occur in the lower lumbar spine and may cause radicular symptoms. Eight symptomatic patients are described, each of whom had a single synovial cyst with associated facet joint degeneration. Four were at the L4–5 level and two each at L3–4 and L5–S1. Myelography in four patients revealed a posterolateral indentation on the contrast column in each case. Computed tomography (CT) revealed a structure of similar or greater density than the thecal sac in six cases and of gas density in one case. Two of the former cases also contained gaseous elements, three cases had a mildly dense rim and in the eighth case calcification was demonstrated within the cyst. One cyst resolved after facet joint injection with local anaesthetic and steroid.

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Cited by (44)

Full-endoscopy with intraoperative O-arm navigation for cervicothoracic gas-containing hemorrhagic synovial cyst: A case report
2022, North American Spine Society Journal
Citation Excerpt :
Our study also considers imaging differential diagnosis of ligamentum flavum cysts and synovial cysts. Synovial cysts show low signal intensity areas with smoothly circumscribed layers on T1- and T2-weighted MRI with calcification on CT [16–18]. To further ensure the diagnosis, intra-articular injection of contrast media for the histopathologic examination can be performed [14,19,20].
Synovial cysts are benign fluid-filled sacs commonly found in the degenerative lumbar spine. Few studies have reported the detailed epidemiology and standardized therapy for this disease. Conservative treatment is recommended if synovial cysts are asymptomatic or show mild clinical symptoms. If percutaneous facet joint steroid injections are ineffective or neurologic symptoms are aggravated, the open decompression with additional fusion is the reasonable surgical strategy to remove the pain generator. Furthermore, the synovial cysts that occur at the cervicothoracic spine are infrequently, especially accompanied by hemorrhagic radiographic evidence. Therefore, we describe the efficacy and safety of the full-endoscopy surgical procedure assisted by intraoperative O-arm navigation guidance to manage C7/T1 spinal synovial cysts.
We describe a 71-year-old male patient diagnosed with cervicothoracic hemorrhagic synovial cysts. The pathologic site is located at the posterior side of the C7 vertebral body to the medial side of the C7-T1 left facet joint. Herein is described a step-by-step protocol for the full-endoscopic procedure via the posterior approach to remove the lesions under intraoperative O-arm navigation guidance.
The patient was successfully treated via full-endoscopic removal of the synovial cysts guided by intraoperative O-arm navigation. Intraoperative bleeding of 30 mL occurred, and the operative time was 150 minutes. The patient's sensory strength improved, and no opioid medicine was required with no complications postoperatively. One-year follow-up magnetic resonance imaging (MRI) and computed tomography (CT) scans showed no synovial cyst recurrence.
Full-endoscopy assisted with intraoperative O-arm navigation guidance improves precision and safety in treating patients with synovial cysts of the cervicothoracic spine. The O-arm navigation system improves the efficiency and safety of intraoperative positioning at the cervicothoracic lesion and reduces radiation exposure to the surgeons. Meanwhile, this technique preserves the range of cervicothoracic motion and facilitates the patient return to normal life.
The incidence of dural tears after complete resection of lumbar synovial cysts and the relation to the outcome
2016, Clinical Neurology and Neurosurgery
Citation Excerpt :
They were achieved with microsurgical removal of the cyst without laminectomy or fusion. Without fusion, the degenerative changes of the joints may progress after decompressive procedures [21]. Nevertheless, no prospective study exists comparing the outcomes after decompression alone versus decompression with fusion [7].
Synovial cysts in the lumbar spine are uncommon causes of radicular pain. In cases where conservative treatment fails, surgical resection is recommended. Dural adhesions are common intraoperative findings; therefore, the removal of the cyst may sometimes result in dural tears. The frequency of dural tears is greater with synovial cysts than in other lumbar surgeries. Clinical parameters and characteristics seen on magnetic resonance imaging were assessed to investigate the correlation between the outcome after surgery of lumbar synovial cysts and dural tears.
This study was designed as a retrospective practice audit. Patient data were drawn from an electronic medical record system. Included were consecutive patients after microsurgical resection of symptomatic lumbar synovial cysts between May 2013 and November 2015. The surgical report was evaluated retrospectively regarding the extent of decompression and cyst resection as well as surgery-related complications. Pre-operative magnet resonance imaging was assessed concerning the reason for compression of the neural structures, the dimension of the cyst, and the signal of the cyst content in T2 images. In a follow-up examination about four weeks after surgery, the patient satisfaction index was evaluated.
Forty-four consecutive patients after resection of a lumbar synovial cyst met the inclusion criteria. The mean patient satisfaction index was 2.0 ± 1.0. Twenty-nine patients of the 38 patients with follow-up (76.3%) with a satisfaction index of 1 or 2 were rated as favorable. One revision surgery was necessary because of a cerebrospinal fluid fistula. Furthermore, in 4 patients an incidental durotomy occurred without any symptoms after surgery. Accordingly, the rate of dural tears was 11.4%. Dural tears were significantly more common in patients with a satisfaction index of 3 or 4 (P = 0.04). Sixty percent of the patients with dural tears were operated on in level L5/S1 compared to 3 patients without a dural tear (P = 0.008). There was no statistically significant difference between the different patient subgroups in any other analyzed parameter.
Dural tears were found significantly more often in patients without a good outcome; they appear to portend a poorer prognosis. The level L5/S1 was significantly more often affected. During surgery, it should be considered whether to remove the cyst completely and risk a dural tear, or to leave residuals of the cyst wall if otherwise a good decompression is achieved.
Treatment of spinal synovial cysts
2013, World Neurosurgery
Citation Excerpt :
On magnetic resonance imaging (MRI), these cysts appear as well-circumscribed extradural lesions in close proximity to the facet joints (30). These lesions are hypointense on T1-weighted and hyperintense on T2-weighted sequences because of the proteinaceous content of the cyst (25, 31, 50). The cystic wall often enhances on T1-weighted contrast-enhanced images (Figures 1 and 2).
Spinal synovial cysts are a known cause of back pain and radiculopathy. With the advent of high-resolution imaging techniques, synovial cysts are increasingly diagnosed. There are a variety of treatment options for these lesions.
A systematic literature review of published articles reporting outcomes after nonsurgical and surgical management of spinal synovial cysts was performed.
There were 51 published studies regarding the treatment of synovial cysts identified. Treatment modalities include observation, steroid injections, percutaneous cyst aspiration, hemilaminectomy or bilateral laminectomy with and without instrumented fusion, and minimally invasive cyst excision.
Based on review of the treatment modalities and outcomes, recommendations for the management of patients with synovial cysts are proposed. Observation can be considered in cases where there is no intractable pain. High-risk surgical patients with intractable pain may consider corticosteroid injection or percutaneous cyst aspiration; however, the failure rate of such a procedure approaches 50%. Patients with intractable pain are candidates for surgical resection of the symptomatic cyst. In cases of significant neurologic deficit, motor weakness, back pain, multiple synovial cysts, or spondylolisthesis, bilateral laminectomy and instrumented fusion may offer the best long-term outcome.
Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: Systematic review of reported postoperative outcomes
2010, Spine Journal
Citation Excerpt :
Although infrequently large cysts that may require a complete facetectomy may necessitate a concurrent stabilization procedure, the notion that segmental instability and hypermobility plays an underlying pathoetiological role in synovial cyst formation may also support the role for fusion. Knox and Fon [101] demonstrated that greater than 85% of spinal synovial cysts were associated with degenerative changes of the facet joint beyond those associated with normal aging, and these degenerative changes may progress after decompressive procedures. Other findings supporting the spinal hypermobility theory of synovial cyst pathogenesis include mechanical back pain in addition to radiculopathy, increased facet T2 signal on magnetic resonance imaging, and facet joint widening [2,4,5,18–20,22,27,29,31,37,40,41,44,69,70,74,75,92,97,98,100,102–108].
With improvements in neurological imaging, there are increasing reports of symptomatic spinal synovial cysts. Surgical excision has been recognized as the definitive treatment for symptomatic juxtafacet cysts. However, the role for concomitant fusion and the incidence of recurrent back pain and recurrent cyst formation after surgery remain unclear.
To determine the cumulative incidence of postoperative symptomatic relief, recurrent back and leg pain after cyst resection and decompression, and synovial cyst recurrence.
Systematic review of the literature.
All published studies to date reporting outcomes of synovial cyst excision with and without spinal fusion.
Cyst recurrence and Kawabata, Macnab, Prolo, or Stauffer pain scales.
We performed a systematic literature review of all articles published between 1970 and 2009 reporting outcomes after surgical management of spinal synovial cysts.
Eighty-two published studies encompassing 966 patients were identified and reviewed. Six hundred seventy-two (69.6%) patients presented with radicular pain and 467 (48.3%) with back pain. The most commonly involved spinal level was L4–L5 (75.4%), with only 25 (2.6%) and 12 (1.2%) reported synovial cysts in the cervical or thoracic area, respectively. Eight hundred eleven (84.0%) patients were treated with decompressive surgical excision alone, whereas 155 (16.0%) received additional concomitant spinal fusion. Six hundred fifty-four (92.5%) and 880 (91.1%) patients experienced complete resolution of their back or leg pain after surgery, respectively. By a mean follow-up of 25.4 months, back and leg pain recurred in 155 (21.9%) and 123 (12.7%) patients, respectively. Sixty (6.2%) patients required reoperation, of which the majority (n=47) required fusion for correction of spinal instability and mechanical back pain. Same-level synovial cyst recurrence occurred in 17 (1.8%) patients after decompression alone but has been reported in no (0%) patients after decompression and fusion.
Surgical decompression results in symptomatic resolution in the vast majority of patients; however, recurrent back pain occurs in a significant number of patients. Cyst recurrence occurs in less than 2% of patients but has never been reported after cyst excision with concomitant fusion. The lack of cyst recurrence after concomitant fusion supports the need to investigate the value of fusion of the involved motion segment in the treatment of symptomatic synovial cysts of the spine.
Assessment and Characteristics of Intraspinal Cystic Lesions
2006, Seminars in Spine Surgery
Citation Excerpt :
There are only a few reports of such cysts in the upper spine.128-131 The preference for the L4-L5 level (64 to 80%), the most hypermobile in the spine,124,132,133 spondylolisthesis in 33%, and facet joint hypermobility found in 60% of the patients suggest that hypermobility is an important etiological factor. Synovial cysts of the vertebral facet joints mimicking lumbar disc herniation by causing nerve root compression are an entity first described by Schollner in 1967.126
Procedure-based nonsurgical management of lumbar zygapophyseal joint cyst-induced radicular pain
2005, Archives of Physical Medicine and Rehabilitation
Sabers SR, Ross SR, Grogg BE, Lauder TD. Procedure-based nonsurgical management of lumbar zygapophyseal joint cyst–induced radicular pain.
To evaluate the success of fluoroscopically guided, contrast-enhanced lumbar zygapophyseal joint (Z-joint) aspiration and steroid injection combined with transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar Z-joint cyst–induced radicular pain.
Retrospective case series with independent follow-up.
Institutional, referral center.
Twenty-three patients referred to a single provider for procedure-based management of radicular pain believed secondary to lumbar Z-joint cyst. Inclusion criteria consisted of lumbar radicular pain that was consistent with the level and side of the Z-joint cyst as a causative lesion.
Eighteen patients were treated with a fluoroscopically guided, contrast-enhanced Z-joint aspiration and steroid injection at the level of the causative cyst coupled with a fluoroscopically guided, contrast-enhanced TFESI over the level of the presumably irritated spinal nerve.
Patient satisfaction, and whether or not surgery was performed.
Fifty percent of patients treated with the procedure had significant long-term benefit and avoided surgical intervention at an average follow-up of 9.9 months.
Fluoroscopically guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar Z-joint cyst–induced radicular pain.

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Original PaperThe appearances of lumbar intraspinal synovial cysts

Lumbar nerve root compression by synovial cysts of the ligamentum flavum

Journal of Neurosurgery

CT-guided needle aspiration biopsy of an intraspinal synovial cyst (ganglion): case report and review of the literature

American Journal of Neuroradiology

Intraspinal synovial cyst simulating spinal stenosis

Spine

Symptomatic intraspinal synovial cysts: opacification and treatment by percutaneous injection

American Journal of Roentgenology

Lumbar intraspinal extradural ganglion cyst

Journal of Neurology, Neurosurgery and Psychiatry

Radiologic recognition of symptomatic spinal synovial cysts

American Journal of Neuroradiology

Bilateral synovial cysts creating spinal stenosis: CT diagnosis

Journal of Computer Assisted Tomography

Lumbar intraspinal ganglion cyst

Acta Neurochirurgica

Gas-filled intraspinal synovial cyst

Spine

Intraspinal synovial cysts: natural history and diagnosis by CT

Radiology

Synovial cyst of the cervical spine

Neurosurgery

Intraspinal synovial cysts: MR imaging

Radiology

Reversible cause of back pain and sciatica in rheumatoid arthritis: an apophyseal joint cyst

Arthritis and Rheumatism

Original Paper
The appearances of lumbar intraspinal synovial cysts