Synovial Facet Cyst

Introduction

A rare cause spinal stenosis in the lumbar spine
Epidemiology
- incidence
  - rare
- location
  - usually in lumbar spine
    - 60% to 89% occur at the L4-L5 level (most mobile segment)
Pathophysiology
- possible etiologies
  - trauma (controversial)
  - microinstability of the facet leading to
    - extruded synovium through joint capsules
    - myxoid degeneration of collagen tissue
    - proliferation of fibroblasts with increased hyaluronic acid production
Associated conditions
- degenerative spondylolisthesis

Presentation

Symptoms
- mechanical back pain
- radicular symptoms (leg pain)
- neurogenic claudication (buttock/leg pain with walking)
Physical exam
- may see nerve root deficits at associated spinal levels

Imaging

Radiographs
- recommended views
  - required
    - AP lateral, lateral, flexion and extension of spine
  - findings
    - usually normal
    - look for segmental instability
MRI
- indications
  - significant leg pain
- views
  - best seen on T2 axial and sagittal images

Treatment

Nonoperative
- NSAIDS, rest, immobilization
  - indications
    - mild symptoms
- CT guided aspiration
  - technically challenging and usually not effective
Operative
- laminectomy with decompression
  - indications
    - classical first line for symptomatic intraspinal synovial cysts
  - outcomes
    - high incidence of recurrent back pain and cyst formation within two years
- facetectomy and instrumented fusion
  - indications
    - significant symptoms that have failed nonoperative management
    - first line of surgical treatment
  - outcomes
    - demonstrated to have the lowest risk of persistent back pain and recurrence of cyst formation in recent studies

Complications

Cyst recurrence
- high incidence of recurrence with resection alone
- new studies favor facetectomy and fusion as first line of operative treatment

TAG

(OBQ04.139) A 60-year-old male has right leg radicular pain with hip abductor and EHL weakness. A MRI is shown is figures A-C. What is the source of this patient's symptoms? Topic

Review Topic

FIGURES: A

1. paracental disk herniation
2. far lateral disk herniation
3. facet synovial cyst
4. hypertrophic ligamentum flavum
5. intradural tumor

PREFERRED RESPONSE ▶

DISCUSSION: Juxtafacet cysts are uncommon causes of radicular pain and are often associated with significant spinal degenerative disease. Previous studies have not focused on the outcome of patients who have undergone resection. Banning et al performed a retrospective review of patients who underwent lumbar juxtafacet cyst resection. Thirty-three lumbar juxtafacet cysts were resected from 29 patients. Cysts most commonly arose at the L4-L5 level (51%). Incidental durotomy was the most common surgical complication occurring in 3 cases (9%). Twenty patients (83%) reported improvement in pain, and 16 (67%) reported an improved level of function. All respondents reported some degree of improvement in their condition after surgery. They recommend surgical resection as the treatment of choice with low rates of complications, recurrences, and residual complaints.

REFERENCES:

1. Banning CS, Thorell WE, Leibrock LG. Patient outcome after resection of lumbar juxtafacet cysts. Spine. 2001 Apr 15;26(8):969-72. PMID:11317123 (Link to Abstract)

Question Authors:

Paul D. Kim MD, Patrick McCulloch MD, Derek Moore,

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Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Banning CS, Thorell WE, Leibrock LG. Patient outcome after resection of lumbar juxtafacet cysts. Spine. 2001 Apr 15;26(8):969-72. PMID:11317123 (Link to Abstract)

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