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http://upload.orthobullets.com/topic/2066/images/facet synovial cyst.jpg
http://upload.orthobullets.com/topic/2066/images/facet synovial cyst mri t2 sagittal.jpg
Introduction
  • A degenerative lesion of the lumbar spine that often presents with radicular symptoms
  • 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
        • some consider first line of surgical treatment due to high recurrance rates
        • symptomatic recurrance following laminectomy with decompression
      • 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 
 

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