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Updated: Jun 27 2021

Synovial Facet Cyst

Images synovial cyst.jpg synovial cyst mri t2 sagittal.jpg
  • summary
    • Synovial Facet Cysts are degenerative lesions of the lumbar spine that can lead to lumbar spinal stenosis and cause low back pain and radicular symptoms.
    • Diagnosis is made with MRI studies of the lumbar spine.
    • Treatment is a trial of nonoperative management with NSAIDs and physical therapy.  Surgical management is indicated for progressive disabling pain that has failed nonoperative management, and/or progressive neurological deficits.
  • Epidemiology
    • Incidence
      • rare
    • Anatomic location
      • usually in lumbar spine
        • 60% to 89% occur at the L4-L5 level (most mobile segment)
        • ~14% occurrence at L3-4
        • ~12% occurrence at L5-S1
  • Etiology
    • 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
        • cyst composition
          • ganglion cysts
          • flavum cysts
          • serous contents
          • mucoid contents
          • hemorrhagic contents
    • Associated conditions
      • degenerative spondylolisthesis
  • Presentation
    • Symptoms
      • mechanical back pain
      • radicular symptoms (leg pain)
        • rapid onset or sudden deterioration suggests a facet cyst hematoma
      • neurogenic claudication (buttock/leg pain with walking)
    • Physical exam
      • neurovascular
        • may see nerve root deficits at associated spinal levels
  • Imaging
    • Radiographs
      • recommended views
        • required
          • AP lateral, lateral, flexion and extension views of spine
        • findings
          • usually normal
          • look for segmental instability
    • MRI
      • indications
        • significant leg pain
      • views
        • best seen on T2 axial and sagittal images
        • traditionally hyperintense centers with hypointense rims on T2 and hypointense inner cores on T1 sequences
          • peripheral rim enhancement with gadolinium contrast
        • improved detection rate with positional MRI
          • 89% sensitivity when supine
          • 97% sensitivity when standing
            • cysts increase in size while standing
        • high-signal intensity on T2 weighted images
          • synovial content
          • higher success rate with CT guided cyst rupture
        • low-signal intensity on T2 weighted images
          • gelatinous or calcified contents
          • lower success rate with CT guided cyst rupture
  • Treatment
    • Nonoperative
      • NSAIDS, rest, immobilization, physical therapy, epidural steroid injections
        • indications
          • mild symptoms
          • first-line treatment
          • radicular pain without motor weakness
        • outcomes
          • no natural history studies have been conducted to date
      • CT-guided cyst rupture, facet steroid injection, cyst injection
        • indications
          • second-line management after failing conservative measures
          • radicular symptoms correlate with facet cyst location
        • outcomes
          • 50-75% pain relief at 1-year
          • approximately 39% of patients will require surgical intervention at 7 months
    • Operative
      • laminectomy with decompression and cyst excision
        • indications
          • persistent symptoms despite non-operative management
          • unilateral symptoms
            • can be performed in patients with spondylolisthesis with unilateral symptoms as long as they are aware of the higher risk of slip progression
        • outcomes
          • high incidence of recurrent back pain and cyst formation within two years
          • 80-90% success rate in back and leg pain
          • risk of iatrogenic spondylolisthesis
      • facetectomy and instrumented fusion
        • indications
          • some consider first line of surgical treatment due to high recurrence rates
          • symptomatic recurrence following laminectomy with decompression
          • bilateral symptoms
          • central canal stenosis
            • wider decompression will likely lead to iatrogenic instability
          • presence of instability (e.g. degenerative spondylolisthesis)
        • outcomes
          • demonstrated to have the lowest risk of persistent back pain and recurrence of cyst formation in recent studies
          • complete resolution of symptoms in 80-90% of patients
  • Techniques
    • NSAIDS, rest, immobilization, physical therapy, epidural steroid injections
      • technique
        • recommended for 6-8 weeks prior to proceeding with surgical treatment or CT-guided rupture
    • CT-guided cyst rupture, facet steroid injection, cyst injection
      • technique
        • fluoroscopic guidance
          • commonly used
          • secondary surgery rate roughly 50%
        • CT guidance
          • improved visualization of spinal anatomy
          • slightly improved patient outcomes compared to fluoroscopic guidance
    • laminectomy with decompression and cyst excision
      • approach
        • posterior approach to the spine
      • technique
        • unilateral laminotomy and medial facetectomy with a high-speed burr
        • create plane between dura and cyst
        • grab cyst with allis clamp or forceps and apply gentle traction
        • separate cyst from underlying dura with Epstein curet or Woodson elevator
    • facetectomy and instrumented fusion
      • approach
        • posterior approach to the spine
      • technique
        • place pedicle screws at the intersection of the superior border of the transverse process and midline of the superior process
        • perform decompressive laminectomy and facetectomy
        • excise cyst after developing interval between cyst and dura
          • partial excision in cases of cysts adherent to the dura
  • Complications
    • Cyst recurrence
      • incidence
        • high incidence of recurrence with resection alone
      • treatment
        • new studies favor facetectomy and fusion as first line of operative treatment
    • Iatrogenic spondylolisthesis
      • risk factors
        • decompressive laminectomy without fusion
      • treatment
        • posterior instrumented fusion +/- spondylolisthesis reduction
    • Dural tear
      • incidence
      • risk factors
        • revision surgery
        • cyst adherent to dura
          • 50-55% of cases the facet cyst is adherent to the dura
            • limited cyst resection in these cases minimizes dural tear risk
          • partial cyst excision results in 88% success rate for lumbar spinal stenosis while minimizing risk of dural tear
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