Updated: 6/27/2021

Synovial Facet Cyst

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  • 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 recurrance 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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(OBQ12.167) A 55-year-old man presents with low back pain that has progressed over the last year. He reports the pain is worse with activity, especially when bending forward and lifting objects. He denies any pain in the buttocks or lower extremities. On physical he has age-appropriate motion in the lumbar spine. He is neurologically intact in the lower extremities. Figure A shows his axial and sagittal T2-weighted MRI scans. A histological sample of this lesion would most likely show

QID: 4527
FIGURES:
1

dense, compact concentric lamellae of fibrocollagenous tissue with occasional fibroblast-like chondrocytes

7%

(305/4207)

2

semifluid gelatinous matrix with oval chondrocytes

33%

(1405/4207)

3

ossified nidus surrounded by a radiolucent halo, in turn surrounded by dense, reactive osteosclerosis

2%

(86/4207)

4

irregular fascicles of collagenous stroma with pleomorphic cells with foamy cytoplasm and marked atypia in a storiform pattern

8%

(334/4207)

5

synovial cells covering a stroma with vascular granulation tissue

48%

(2029/4207)

L 4 B

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(SBQ09SP.11) A 58-year-old man returns to your clinic complaining of 2 months right-sided buttock and lateral thigh and leg pain. He previously underwent lumbar laminectomy for similar symptoms. Figure A shows his T2 axial MRI sequence obtained prior to his initial surgery. He is scheduled for new MRI tomorrow. If his new MRI shows similar pathology, what is the most appropriate treatment at this time?

QID: 3374
FIGURES:
1

NSAIDs and physical therapy

11%

(171/1570)

2

Cyst aspiration and epidural steroid injection

9%

(137/1570)

3

Revision lumbar laminectomy

6%

(97/1570)

4

Revision lumbar laminectomy with right-sided foraminotomy

31%

(485/1570)

5

Revision lumbar laminectomy and instrumented fusion

42%

(662/1570)

L 4 C

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

QID: 1244
FIGURES:
1

paracental disk herniation

3%

(94/2882)

2

far lateral disk herniation

2%

(46/2882)

3

facet synovial cyst

88%

(2534/2882)

4

hypertrophic ligamentum flavum

0%

(11/2882)

5

intradural tumor

6%

(173/2882)

L 1 C

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