At the end of the last decade several publications on lumbar Juxtafacet cysts have led to reconsideration of its incidence in lumbar spine degenerative diseases. Doyle and Merrilees reported a retrospective MRI study of 303 patients with symptomatic (low-back pain or radiculopathy) degenerative lumbar spine disease and found a synovial cyst in almost 10% of the cases.[14
Cysts may be asymptomatic and found incidentally. Most of the symptomatic patients present with radicular pain and neurologic deficits. A history of low back pain invariably precedes the radicular pain. In addition, clinical syndromes such as caudaequina, lateral recess, and spinal stenosis syndromes have been described.[15
In our series, all patients had back pain (100%), while ten also experienced unilateral radicular leg pain (77%), and one had bilateral leg pain (8%). Two patients had neurogenic claudication (15%). However, sensory loss in three patients (23%) and motor weakness in two patients (15%) were also presenting symptoms. Our findings were consistent with reports found in other surgically treated cases in the literature.[5
MRI is the tool of choice for diagnosis of Juxtafacet cysts.[13
] The majority of the cysts in this study have occurred at the L4–L5 level (54%), which corresponds with the data from other studies. The predilection for cysts to occur adjacent to this facet joint level has been attributed to the amount of degenerative spondylosis and spinal instability (the site of maximum instability).[13
] No radiological evidence of instability had been observed in any of our patients preoperatively.
These cysts can, on rare occasions, hemorrhage and bleed into the surrounding soft tissues and/or the spinal canal, causing acute compression of the nerve root.[17
] Intracystic hemorrhage can be predicted radiologically by an MRI (inhomogeneous center In T2-weighted images and irregular hyperintensity in T1-weighted images).[10
] In our study intracystic hemorrhage was demonstrated in two patients (15%). This finding did not, however, correlate with the acute onset of symptoms.
Although relevant reports in the international literature are increasing, the controversy about conservative versus surgical treatment and the need for concomitant fusion still exists. The optimal treatment is not known. There is one case report of a cyst that resolved spontaneously.[11
] Conservative treatment has been proposed by certain authors, including bed rest, medications, and orthopedic corsets, but with disappointing results and are not reported to be efficacious.[20
Steroid injection was described as an alternative procedure for management of intraspinal Juxtafacet cysts. There is little information available on the efficacy and outcome with treatment of lumbar facet joint synovial cysts by percutaneous, fluoroscopic, facet joint steroid injections, with cyst distention and rupture. However, these treatments often show short-term improvement or no improvement at all. Also complications such as dural puncture, spinal nerve injury, bleeding, and infection have been reported.[20
Surgical treatment is largely recommended in all cases of intractable pain or neurologic deficit.[7
] The current therapy for Juxtafacet cysts includes excision of the mass and lumbar decompression. In our series, all patients underwent laminectomy and resection of the cyst, 10 patients had partial hemilaminectomy, and three patients had bilateral decompressive laminectomies, one of them presented with bilateral radiculopathy and the other two presented with neurogenic claudication.
Many authors reported that no difference in surgical outcome was found between patients having fusion and those who did not have it.[25
] While others concluded that, a concomitant fusion procedure may be performed in selected cases.[9
Métellus et al
] has concluded that there is no reliable criterion that allows the development of a symptomatic spinal instability to be predicted in patients with preoperative spondylolisthesis, and therefore, fusion as a first line procedure is still debatable. Others have mentioned an association between spinal cysts and spondylolisthesis/instability and better surgical outcomes in patients having fusion than in those who did not have it.[13
In our series no radiological evidence of instability was observed in any patient preoperatively. Concomitant fusion was not performed in any of the patients. However, subsequent fusion was required in only one patient, who developed symptomatic spondylolisthesis two years after surgery.
Our study presents a long-term follow-up (4.2 years±1.43 STD) for surgical excision of Juxtafacet cysts, without concomitant spinal fusion. We reported excellent to good results in 92% of the patients with a satisfaction rate of 80%. The main limitation of our study was the limited number of cases, which did not allow assessment of the statistical significance of the surgical outcome. However this is due to the low incidence of cases with low back pain or lumbar radicular pain attributed to isolated juxtfacet cyst without other pathology.