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1.  Spinal lumbar synovial cysts. Diagnosis and management challenge 
European Spine Journal  2006;15(8):1176-1182.
Sophisticated and newer imaging capabilities have resulted in increased reporting and treatment options of spinal lumbar synovial cysts (LSS). Most of the patients with lumbar cysts tend to be in their sixth decade of life with a slight female predominance. The incidence of LSS is thought to be less than 0.5% of the general symptomatic population. They may be asymptomatic and found incidentally or the epidural growth of cysts into the spinal canal can cause compression of neural structures and hence associated clinical symptoms. Most of the symptomatic LSS patients present with radicular pain and neurological deficits. Spinal synovial cysts are commonly found at L4-5 level, the site of maximum mobility. They may be unilateral or bilateral and at one or multilevel. MRI is considered the tool of choice for its diagnosis. The etiology of LSS is still unclear, but underlying spinal instability, facet joint arthropathy and degenerative spondylolisthesis has a strong association for worsening symptoms and formation of spinal cysts. Synovial cysts resistant to conservative therapy should be treated surgically. Resection and decompression with or without fusion and instrumentation remains an appropriate option. Synovial cysts may recur following surgery. The optimal approach for patients with juxtafacet LSS remains unclear. The best surgical treatment option for each particular individual should be tailored depending upon the symptoms, radiological findings and other co morbidities.
PMCID: PMC3233964  PMID: 16440202
Lumbar synovial cysts; Spondylolisthesis; Conservative treatment; Surgical treatment; Resection and decompression; Spinal fusion
2.  Midline synovial and ganglion cysts causing neurogenic claudication 
Typically situated posterolateral in the spinal canal, intraspinal facet cysts often cause radicular symptoms. Rarely, the midline location of these synovial or ganglion cysts may cause thecal sac compression leading to neurogenic claudication or cauda equina syndrome. This article summarizes the clinical presentation, radiographic appearance, and management of three intraspinal, midline facet cysts. Three patients with symptomatic midline intraspinal facet cysts were retrospectively reviewed. Documented clinical visits, operative notes, histopathology reports, and imaging findings were investigated for each patient. One patient presented with neurogenic claudication while two patients developed partial, subacute cauda equina syndrome. All 3 patients initially responded favorably to lumbar decompression and midline cyst resection; however, one patient required surgical stabilization 8 mo later. Following the three case presentations, we performed a thorough literature search in order to identify articles describing intraspinal cystic lesions in lateral or midline locations. Midline intraspinal facet cysts represent an uncommon cause of lumbar stenosis and thecal sac compression. Such entities should enter the differential diagnosis of midline posterior cystic lesions. Midline cysts causing thecal sac compression respond favorably to lumbar surgical decompression and cyst resection. Though laminectomy is a commonly performed operation, stabilization may be required in cases of spondylolisthesis or instability.
PMCID: PMC3868712  PMID: 24364023
Midline; Synovial; Ganglion; Intraspinal; Cyst; Neurogenic; Claudication; Laminectomy; Facet
3.  “Juxtafacet cysts”, a misleading name for cystic formations of mobile spine (CYFMOS) 
European Spine Journal  2007;16(9):1499-1505.
To present 58 cystic space-occupying formations of the spinal canal in 53 cases; these formations are called “juxtafacet cysts”. Fifty-Three patients (33 women and 20 men, with an average age of 60.8 years) were evaluated retrospectively by neurosurgery. All of the patients had received simple X-P, computed tomography (CT) and magnetic resonance imaging (MRI) before surgery. The neurological findings were evaluated on admission and in a follow-up review. Surgical intervention was performed on all patients and they underwent gross-total cyst removal. During surgery, the origin of a cyst was well observed. Follow-up data ranged from 6 to 46 months. Patient outcome was graded on a scale of excellent, good, or poor. Histological findings were evaluated. In 53 patients 58 cysts were identified. Four of the patients had multiple cysts. All cysts were associated with mobile spine. Fifty-five cysts were found in the lumbo-sacral region, two cysts were found in the cervico-thoracic region and one cyst in the thoracic region. Forty-two patients presented back pain and 52 patients presented radicular pain. Four patients had a cauda equina syndrome. Sensory disturbance was observed in 24 cases and motor weakness was observed in 21 cases. Claudication was observed in 19 cases. All cases with cervico-thoracic or thoracic cysts presented myelopathy. The duration of these clinical symptoms ranged from 10 days to 10 years. After surgery there was no case of a recurrent cyst during the follow-up period. Thirty-four cases had an excellent outcome, 18 a good outcome, and one a poor outcome. Out of 58 cysts 32 were joint cysts (11 synovial cysts, 21 ganglion cysts). A further 19 were flavum cysts, one was a posterior longitudinal ligament (PLL) cyst and six others were unknown pseudo cysts. In 34 of the cysts we found hemosiderin deposits and in eight amyloid deposits. Present investigation and findings in literature show a clear comparison of these cystic formations and the mobile part of the spine. An anatomical relation to a vertebral joint (“facet”) is only found in some of the cases (32 of 58). Further to that, the name “cyst” is not correct either, because most of the cystic formations are presented without a cell lining on their internal wall and therefore they are pseudo-cystic. We think that these cystic formations should be called “cystic formations of mobile spine” (CYFMOS) rather than “juxtafacet cysts”. A surgical intervention is the best treatment for these cysts if they cause a compression of nerve roots or/and of the spinal cord.
PMCID: PMC2200759  PMID: 17203271
Synovial cyst; Pseudo cyst; Ganglion cyst; Juxtafacet cyst; Mobile spine
4.  Spinal synovial cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review 
European Spine Journal  2008;17(6):831-837.
This study is designed based on the retrospective analysis of patients treated in the Neurosurgical Department of two major hospitals and review of the literature. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic lumbar intraspinal synovial cysts. Spinal juxtafacet cysts (synovial and ganglion cysts) are a rare cause of low back and radicular leg pain. Although the relevant reports in the international literature are increasing, the controversy about conservative versus surgical treatment and the need for concomitant fusion still exists. Data from seven patients (age range 58–69 years, mean age 61 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concomitant local pathology, treatment and results of treatment were recorded. A follow-up of at least 6 months (range 6–48 months) was conducted and results were noted. All patients had back pain, while five also experienced unilateral radicular leg pain and one had bilateral leg pain. One patient had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. No fusion was performed. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation. Review of the literature revealed a trend towards surgery, as this is correlated to a more favorable outcome compared with conservative treatment. Fusion should be performed on a case-by-case basis only. Surgery is a safe and effective treatment choice in this increasingly appearing ailment. A prospective, randomized trial should clarify issues under debate.
PMCID: PMC2518989  PMID: 18389295
Intraspinal cyst; Synovial cyst; Surgical treatment; Fusion
5.  Transarticular fusion for treatment of cystic lesion arising from an odontoid fracture 
European Spine Journal  2012;22(1):21-25.
Odontoid fractures are the most common upper cervical spine fracture. There are two mechanisms in which odontoid fractures occur, most commonly hyperflexion of the neck resulting in displacement of the dens anteriorly and hyperextension resulting in posterior dens displacement. Type 2 fractures are the most common and are associated with significant non-union rates after treatment. One possible consequence of an odontoid fracture is a synovial cyst, resulting in spinal cord compression, presenting as myelopathy or radiculopathy. Synovial cysts as a result of spinal fracture, usually of the facet joint, are most common in the lumbar region, followed by the thoracic and then cervical region; cervical cysts are rare. Fracture and subsequent cyst formation is thought to be related to hyper-motion or trauma of the spine. This is reinforced by the appearance of spinal synovial cysts most commonly at the level of L4/5; this being the region with the biggest weight-bearing function. The most common site of cervical cyst formation is at the level of C7/T1; this is a transitional joint subjected to unique stress and mechanical forces not present at higher levels. Treatment of a cervical synovial cyst at the level of the odontoid is challenging with little information available in the literature. The majority of cases appear to implement posterior surgical resection of the cyst, with fusion of adjacent cervical vertebrae to stabilise the fracture, resulting in restricted range of movement.
Case presentation
We describe a case concerning a 39-year-old female who presented with uncertain cause of odontoid fracture, resulting in a cystic lesion compressing the upper cervical spinal cord.
Minimal invasive surgery of C1/C2 transarticular fusion was successfully performed resulting in significant improvement of neurological symptoms in this patient. At 1-year follow-up, the cyst had resolved without surgical removal and this was confirmed by radiological measures.
PMCID: PMC3540314  PMID: 22382724
Transarticular fusion; Odontoid fracture; Cervical cyst; Cystic lesion
6.  Diagnosis and surgical management of intraspinal synovial cysts: report of 19 cases 
OBJECTIVE—Synovial cysts of the vertebral facet joints are a source of nerve root compression. Different surgical procedures are in use, but no consensus has been formed so far as to which method should be used in synovial cysts. To clarify the role of surgical management, the efficacy of operative procedures and factors influencing the outcome in our own series of 19 patients treated between 1994and 1998 were analysed.
METHODS—Nineteen patients with a mean age of 65 years underwent surgery for medically intractable radicular pain or neurological deficits caused by synovial cysts. The patients' records were retrospectively analysed for neurological deficits, cysts diameter, operative approach, segmental hypermobility, and clinical outcome; CT and MRI were analysed for additional degenerative changes.
RESULTS—In 17 patients an excellent result and in two patients a good postoperative result was achieved. Twelve patients were found to have hypermobility of the facet joints and six had spondylolisthesis. There was no correlation between cyst diameter, operative approach, and outcome. No intraoperative or postoperative complications occurred.
CONCLUSIONS—Age and hypermobility may play a part in the aetiology of facet joint synovial cysts. As all operative strategies showed equally good clinical outcome, total excision via a small flavectomy as the least invasive approach should be considered therapy of choice in patients with cysts causing neurological deficits.

PMCID: PMC1763494  PMID: 11118251
7.  Minimally invasive CT guided treatment of intraspinal synovial cyst 
Radiology and Oncology  2014;48(1):35-39.
Intraspinal synovial cysts of vertebral facet joints are uncommon cause of radicular pain as well as neurological deficits. They can be managed both conservatively and surgically.
Case report
A 77-year old polymorbid patient presented with bilateral low back pain which worsened during the course of time and did not respond to the conservative treatment. A diagnosis of intraspinal synovial cyst was made using the magnetic resonance imaging (MRI). Percutaneous computed tomography (CT) guided injection with installation of local anesthetic together with corticosteroid and rupture of the cyst was successfully used. A month after the procedure his pain improved, the usage of analgesics diminished and his over-all quality of life improved.
Percutaneous CT guided lumbar synovial cyst treatment is safe and reliable alternative to the surgical treatment in polymorbid patients with radiculopathy who are not able to tolerate general anesthesia and operation.
PMCID: PMC3908845  PMID: 24587777
intraspinal synovial cyst; polymorbid patient; radiculopathy; pain; percutaneous CT guided treatment
8.  CT Guided Aspiration of a Cervical Synovial Cyst 
Interventional Neuroradiology  2007;13(3):295-298.
Synovial cysts are cystic dilations of synovial sheaths with or without anatomical continuity within a joint space that occasionally involve the lumbar spine. Image-guided aspiration has been used successfully in the management of lumbar synovial cysts. Synovial cysts of the cervical spine are rare, tend to present with myelopathic symptoms, and are classically treated using operative intervention. We report a novel approach for cervical synovial cyst aspiration under CT guidance.
A 66-year-old woman presented to the clinic complaining of severe pain, tingling, and dysesthesia in her right upper extremity in the C5, C6 and C7 nerve root distribution. MR imaging of her cervical spine showed a synovial cyst within the right C6-C7 neural foramen with significant compression and obliteration of the C7 nerve root. The patient underwent CT-guided aspiration of the cyst using a double needle technique, where one needle was used to open up the epidural space while another aspirated the cyst. This was followed by epidural injection of local anesthetic and steroids.
Immediately after injection, the patient experienced complete relief of her right forearm pain, tingling, and dysesthesias. The patient tolerated the procedure well and there were no postprocedure complications. At four year follow-up the patient is free of any symptoms.
Image-guided aspiration of cervical synovial cysts is feasible using CT fluoroscopy. Aspiration of these cysts combined with epidural steroid injection can provide long-lasting symptomatic relief in some patients.
PMCID: PMC3345493  PMID: 20566122
synovial cyst, CT guided treatment, steroid injection
9.  Acute Myelopathy Caused by a Cervical Synovial Cyst 
Synovial cysts of the cervical spine, although they occur infrequently, may cause acute radiculopathy or myelopathy. Here, we report a case of a cervical synovial cyst presenting as acute myelopathy after manual stretching. A 68-year-old man presented with gait disturbance, decreased touch senses, and increased sensitivity to pain below T12 level. These symptoms developed after manual stretching 3 days prior. Computed tomography scanning and magnetic resonance imaging revealed a 1-cm, small multilocular cystic lesion in the spinal canal with cord compression at the C7-T1 level. We performed a left partial laminectomy of C7 and T1 using a posterior approach and completely removed the cystic mass. Histological examination of the resected mass revealed fibrous tissue fragments with amorphous materials and granulation tissue compatible with a synovial cyst. The patient's symptoms resolved after surgery. We describe a case of acute myelopathy caused by a cervical synovial cyst that was treated by surgical excision. Although cervical synovial cysts are often associated with degenerative facet joints, clinicians should be aware of the possibility that these cysts can cause acute neurologic symptoms.
PMCID: PMC4185322  PMID: 25289127
Cervical spine; Synovial cyst; Myelopathy; Radiculopathy; Paralysis
10.  Acute sciatica and progressive neurological deficit secondary to facet synovial cysts: A report of two cases. 
To describe two patients with lumbar facet synovial cysts causing sciatica and progressive neurological deficit.
Clinical Features:
A 52-year-old female with bilateral sciatica and a neurological deficit that progressed to a foot drop; and a 54-year-old female with worsening sciatica and progressive calf weakness were seen at a major tertiary care centre. Diagnostic imaging studies revealed the presence of spinal nerve root impingement by large facet synovial cysts.
Interventions and Outcomes:
Activity modification, gabapentinoid and non-steroidal anti-inflammatory medications were unsuccessful in ameliorating either patient’s symptoms. One patient had been receiving ongoing lumbar chiropractic spinal manipulative therapy despite the onset of a progressive neurological deficit. Both patients eventually required surgery to remove the cyst and decompress the affected spinal nerve roots.
Patients with acute sciatica who develop a progressive neurological deficit while under care, require prompt referral for axial imaging and surgical consultation. Primary care spine clinicians need to be aware of lumbar facet synovial cysts as a possible cause of acute sciatica and the associated increased risk of the patient developing a progressive neurological deficit.
PMCID: PMC3430450  PMID: 22997467
synovial cyst; facet joint; progressive neurological deficits, radiculopathy; chiropractic; kyste synovial; facette vertébrale; déficits neurologiques progressifs, radiculopathie; chiropratique
11.  Hemorrhagic Lumbar Synovial Cyst 
Synovial cysts of the lumbar spine are an uncommon cause of back and radicular pain. These cysts most frequently present as back pain, followed by chronic progressive radiculopathy or gradual onset of symptoms secondary to spinal canal compromise. Although less common, they can also present with acute spinal cord or root compression symptoms. We report of a case in which hemorrhaging into a right L2-3 facet synovial cyst caused an acute onset of back pain and radiculopathy, requiring surgical excision.
PMCID: PMC3550429  PMID: 23346333
Lumbar spine; Synovial cyst; Hemorrhage
12.  Synovial Cyst Mimicking an Intraspinal Sacral Mass 
A 68-year-old female had a three-week history of severe low back pain radiating down the posterior left buttocks and left leg exacerbated by standing and walking. Lumbar spine MRI revealed cystic mass with similar intensity to cerebrospinal fluid located on dorsolateral left side of the sacral spinal canal inferior to the S1 pedicle. There was compression of left exiting S1 and traversing S2 nerve roots. Neurosurgery consult was requested to evaluate the cystic mass in the sacral spinal canal. After clinical evaluation, an unusually located synovial cyst was thought possible. Cyst contents were heterogeneous, suggestive of small hemorrhage and acute clinical history seemed reasonable. Left S1 and partial left S2 hemilaminectomy was performed and an epidural, partially hemorrhagic cyst was removed. There was no obvious connection to the ipsilateral L5-S1 facet joint. Pathology revealed synovial cyst, and the patient's leg pain was improved postoperatively. This synovial cyst was unusual as it had no connection with the facet joint intraoperatively and its location in the sacral canal was uncommon.
PMCID: PMC3970337  PMID: 24716025
13.  Brown-Séquard Syndrome Caused by a Cervical Synovial Cyst 
Synovial cysts are recognized as an uncommon cause of radicular and myelopathic symptoms. They are most frequently found in the lumbar region. The cervical spine or cervicothoracic junction is a rare location for a degenerative intraspinal synovial cyst as compared with the lumbar spine. At given cervical spinal levels, synovial cysts probably share clinical features with disc herniation and stenosis. However, the pathogenesis of synovial cysts remains still controversial. Here, we report a rare case of a synovial cyst in the lower cervical spine presented as Brown-Séquard syndrome and include a brief review of the literature. To the best of our knowledge, no previous report has been issued in the English literature on a synovial cyst presenting with Brown-Séquard syndrome. Neurologic function recovered completely after complete removal of the cyst and expansive laminoplasty.
PMCID: PMC4094748  PMID: 25024827
Brown-Séquard syndrome; Synovial cyst; Cervical
14.  Lumbar Facet Joint Synovial Cysts: Does T2 Signal Intensity Predict Outcomes after Percutaneous Rupture? 
Lumbar facet synovial cysts are a cause of back pain and radiculopathy with facet joint degeneration, the most common cause for cyst formation. Typically, LFSCs are T2 hyperintense on MR imaging, but the signal intensity is variable. Treatment options include percutaneous rupture and surgical resection. This study evaluates the relationship between LFSC signal intensity on MR imaging and outcomes as it relates to percutaneous rupture success and need for subsequent surgery.
A retrospective review of 110 patients who underwent CT fluoroscopic-guided rupture of symptomatic LFSCs was performed. The LFSCs were characterized by their T2 signal intensity on MR imaging and divided into 3 groups: high, intermediate, and low T2 signal intensity. The rates of successful cyst rupture and need for subsequent surgery were recorded.
Percutaneous LFSC rupture was technically successful in 87% of all cases. Cyst rupture was successful in 89% and 90% of high and intermediate signal intensity cysts, respectively, and in 65% of low signal intensity cysts (P = .017, .030). High signal intensity cysts had lower postprocedural surgical rates (29%) when compared with intermediate and low signal cyst as a group (P = .045).
T2 hyperintense and intermediate signal intensity LFSCs are easier to rupture, perhaps because the cysts contain a higher proportion of fluid and are less gelatinous or calcified than T2 hypointense cysts. Patients with T2 hyperintense LFSCs are less likely to need surgery.
PMCID: PMC3801423  PMID: 23449657
15.  Sacral laminoplasty and cystic fenestration in the treatment of symptomatic sacral perineural (Tarlov) cysts: Technical case report 
Perineural cysts of the sacrum, or Tarlov cysts, are cerebrospinal fluid (CSF)-filled sacs that commonly occur at the intersection of the dorsal root ganglion and posterior nerve root in the lumbosacral spine. Although often asymptomatic, these cysts have the potential to produce significant symptoms, including pain, weakness, and/or bowel or bladder incontinence. We present a case in which the sacral roof is removed and reconstructed via plated laminoplasty and describe how this technique could be of potential use in maximizing outcomes.
We describe technical aspects of a sacral laminoplasty in conjunction with cyst fenestration for a symptomatic sacral perineural cyst in a 50-year-old female with severe sacral pain, lumbosacral radiculopathy, and progressive incontinence. This patient had magnetic resonance imaging (MRI) and computed tomography (CT)-myelographic evidence of a non-filling, 1.7 × 1.4 cm perineural cyst that was causing significant compression of the cauda equina and sacral nerve roots. This surgical technique was also employed in a total of 18 patients for symptomatic tarlov cysts with their radiographic and clinical results followed in a prospective fashion.
Intraoperative images, drawings, and video are presented to demonstrate both the technical aspects of this technique and the regional anatomy. Postoperative MRI scan demonstrated complete removal of the Tarlov cyst. The patient's symptoms improved dramatically and she regained normal bladder function. There was no evidence of radiographic recurrence at 12 months. At an average 16 month followup interval 10/18 patients had significant relief with mild or no residual complaints, 3/18 reported relief but had persistent coccydynia around the surgical area, 2/18 had primary relief but developed new low back pain and/or lumbar radiculopathy, 2/18 remained at their preoperative level of symptoms, and 1/18 had relief of their preoperative leg pain but developed new pain and neurological deficits.
Sacral laminoplasty and microscopic cystic fenestration is a feasible approach in the operative treatment of this difficult, and often controversial, spinal pathology. This technique may be used further and studied in an attempt to minimize potential surgical morbidity, including CSF leaks, cyst recurrence, and sacral insufficiency fractures.
PMCID: PMC3205499  PMID: 22059124
Laminoplasty; perineural cyst; sacral; Tarlov cyst
16.  A case of sacral hydatid cyst 
Hydatid cyst of bone constitutes only 0.5-2% of all hydatidoses. The thoracic spine is the most common site of spinal hydatidoses. Primary hydatid cyst of the sacral spinal canal is rare.
A 19-year-old man had cauda equina syndrome with pelvic pain 15 days ago, the pelvic radiography shows a lytic image depend on the left sacral wing. MRI showed an intra-pelvic cystic image invading the sacrum T1 hypointense and T2W hyperintense. The Hydatid serology was positive.Surgical treatment consisted of a wide drainage of hydatid cavity dug in the left sacral wing, and by which it communicated intra pelvic, with removal of the entire cyst by gentle aspiration, abundant rinsing with hypertonic saline, release and sacred roots encompassed in a puddle of fibrosis hydatid.The evolution was good with recovery of perineal sensation and anal tone. The sacroiliac joint was considered stable and did not require synthesis or reconstruction.
Hydatid cysts predominantly occur in liver and lungs. Involvement of other organs is uncommon. Neither surgery nor medical therapy is generally effective for bone, especially spinal hydatidosis. The initial treatment of choice is surgical excision for neural decompression and establishing diagnosis. Albendazole is the drug of choice against this disease, when suspected, presurgical use of Albendazole in Echinococcus infestations reduces risk of recurrence and/or facilitates surgery by reducing intracystic pressure.
A missed diagnosis of hydatid cyst could be devastating. Hence, hydatid cyst should be kept as a differential diagnosis, when encountered with a cystic lesion of sacrum. In addition, longterm follow-up is mandatory as recurrence is high despite use scolicidal agents.
PMCID: PMC4064476  PMID: 24912110
Hydatid cyst; Sacral; Surgery
17.  Ganglion Cyst of the Posterior Longitudinal Ligament Causing Lumbar Radiculopathy 
Degenerated conditions such as herniated disc or spinal stenosis are common etiologies of lumbar radiculopathy. Less common etiologies include spinal extradural cyst such as synovial cysts and ganglion cysts. Ganglion cyst of the posterior longitudinal ligament (PLL) of the spine is a rare entity that can result in classical sciatica. Posterior longitudinal ligament cyst has no continuity with the facet joint and has no epithelial lining. Two young male patients presented with unilateral sciatica and were found to have intraspinal cystic lesions causing lumbar radiculopathy. Magnetic resonance imaging demonstrated rounded, cystic lesions (i.e., hypointense on T1- but hyperintense on T2-weighted images) adjacent to minimally dehydrated, nonherniated disc spaces in both cases. These patients underwent posterior decompression and cysts were excised, and their sciatic symptoms were completely resolved. Histological examination showed typical features of ganglion cysts in these cases.
PMCID: PMC2864825  PMID: 20461173
Ganglion cyst; Intervertebral disc; Posterior longitudinal ligament
18.  Rare ligamentum flavum cyst causing incapacitating lumbar spinal stenosis: Experience with 3 Chinese patients 
Three Chinese patients suffered from severe lumbar spinal stenosis with debilitating symptoms due to a rare condition of ligamentum flavum cysts in the midline of the lumbar spine. This disease is distinct from synovial cyst of the facet joints or ganglion cysts, both intraoperatively and histopathologically. Magnetic Resonance imaging features of the ligamentum flavum cyst are also demonstrated. We share our surgical experiences of identification of the ligamentum flavum cysts, decompression and excision for two of the patients with demonstrably good recovery. This disease should be considered in the differential diagnosis of an extradural instraspinal mass in patients with lumbar spinal stenosis.
PMCID: PMC2988014  PMID: 21047439
19.  Microdecompression for lumbar synovial cysts: an independent assessment of long term outcomes 
Outcomes of surgical intervention for lumbar synovial cysts have been evaluated in the short and intermediate term. Concerns regarding cyst recurrence, the development of late instability at the involved level, and instability/stenosis at adjacent levels (when concomitant) fusion is performed suggest that long term follow-up is needed. This study aims to fill that void.
Forty-six patients operated by a single surgeon not involved in the study were followed up long term at an average of 9.7 years (range 5 to 22 years) post-operatively. All patients underwent decompression (+/- concomitant arthrodesis in the presence of associated degenerative spondylolisthesis) using the operative microscope for magnification/illumination. Outcomes were assessed using a customized questionnaire evaluating: relief of pain/claudicant symptoms, numbness/parasthesias, and weakness; as well as late onset low back pain, new radicular symptoms, need for additional surgery, and patient satisfaction. Outcomes in patients with or without fusion were compared as well.
87% of patients noted resolution of their pre-operative pain, numbness, and weakness. 28% of patients developed late onset low back pain. 17% developed late onset radicular symptoms in a new nerve root distribution. 15% required subsequent additional surgery. 89% of patients were satisfied with the surgical outcome. No differences were found for any outcome measure between patients undergoing concomitant fusion and those undergoing decompression alone using the two-sample t-test.
This study provides outcome data at an average of nearly ten years post-operative. This information should allow surgeons to provide realistic expectations for their patients regarding outcomes and should enhance the informed consent and surgical decision-making process.
PMCID: PMC1853071  PMID: 17407585
20.  Lumbar facet joint effusion in MRI: a sign of instability in degenerative spondylolisthesis? 
European Spine Journal  2011;21(2):276-281.
The term “segmental instability” of the lumbar spine is not clearly defined, especially as it relates to degenerative spondylolisthesis (DS) and rotational translation (RT). We investigated whether facet joint effusion on conventional supine MRI indicated increased abnormal motion in DS and RT.
160 patients (119 female, 41 male, mean age 68.8 years, range 38.8–89.3 years) who had undergone decompression only or decompression with instrumented fusion for degenerative spondylolisthesis with different degrees of narrowing of the spinal canal were identified retrospectively from our spine surgery database. All had preoperative upright X-rays in AP and lateral views as well as supine MRI. The imaging studies were assessed for the following parameters: percent of slippage, absolute value of facet joint effusion, facet angles, degree of facet degeneration and spinal canal central narrowing, disc height, presence of facet cysts and the presence of rotational translation in the AP X-ray.
40/160 patients showed no facet joint effusion, and in these the difference in the values for the % slip on upright X-ray and % slip on supine MRI was ≤3%. A further 12 patients also showed a difference ≤3%, but had some fluid in the joints (0.44 ± 0.38 mm). In 108 patients, the difference in the % slip measured on X-ray and on MRI was >3% (mean 10.6%, range 4–29%) and was associated with a mean facet effusion size of 2.15 ± 0.85 mm. The extent of effusion correlated significantly with the relative slippage difference between standing and supine positions (r = 0.64, p < 0.001), and the extent of the left/right difference in effusion was associated with the presence of rotational translation (RT 1.31 ± 0.8 mm vs. no-RT 0.23 ± 0.17 mm, p < 0.0001).
Facet joint effusion is clearly correlated with spontaneous reduction of the extent of slippage in the supine position compared to the upright position. Also, the greater the difference in right and left facet effusion, the higher the likelihood of having a RT. Future studies should assess whether analysis of facet joint effusion measured on routine MRI can help in decision-making regarding the optimal surgical treatment to be applied (decompression alone or combined with fusion).
PMCID: PMC3265597  PMID: 21932065
Lumbar spine; Facet joint effusion; Magnetic resonance imaging; Degenerative spondylolisthesis; Rotational translation
21.  Clinical Manifestations of Synovial Cysts 
Western Journal of Medicine  1980;133(2):99-104.
Although synovial cysts are most commonly associated with rheumatoid arthritis and osteoarthritis, they may occur in many other conditions. The clinical manifestations of these cysts are numerous and may result from pressure, dissection or acute rupture. Vascular phenomena occur when popliteal cysts compress vessels, and result in venous stasis with subsequent lower extremity edema or thrombophlebitis. Rarely, popliteal cysts may cause arterial compromise with intermittent claudication. Neurological sequelae include pain, paresthesia, sensory loss, and muscle weakness or atrophy. When synovial cysts occur as mass lesions they may mimic popliteal aneurysms or hematomas, adenopathy, tumors or even inguinal hernias. Cutaneous joint fistulas, septic arthritis or osteomyelitis, and spinal cord and bladder compression are examples of other infrequent complications. Awareness of the heterogeneous manifestations of synovial cysts may enable clinicians to avoid unnecessary diagnostic studies and delay in appropriate management. Arthrography remains the definitive diagnostic procedure of choice, although ultrasound testing may be useful.
PMCID: PMC1272219  PMID: 7233900
22.  Spinal shortening and monosegmental posterior spondylodesis in the management of dorsal and lumbar unstable injuries 
Patients with spinal injuries have been treated in the past by laminectomy in an attempt to decompress the spinal cord. The results have shown insignificant improvement or even a worsening of neurologic function and decreased stability without effectively removing the anterior bone and disc fragments compressing the spinal cord. The primary indication for anterior decompression and grafting is narrowing of the spinal canal with neurologic deficits that cannot be resolved by any other approach. One must think of subsequent surgical intervention for increased stability and compressive posterior fusion with short-armed internal fixators.
To analyze the results and efficacy of spinal shortening combined with interbody fusion technique for the management of dorsal and lumbar unstable injuries.
Materials and Methods:
Twenty-three patients with traumatic fractures and or fracture-dislocation of dorsolumbar spine with neurologic deficit are presented. All had radiologic evidence of spinal cord or cauda equina compression, with either paraplegia or paraparesis. Patients underwent recapping laminoplasty in the thoracic or lumbar spine for decompression of spinal cord. The T-saw was used for division of the posterior elements. After decompression of the cord and removal of the extruded bone fragments and disc material, the excised laminae were replaced exactly in situ to their original anatomic position. Then application of a compression force via monosegmental transpedicular fixation was done, allowing vertebral end-plate compression and interbody fusion.
Lateral Cobb angle (T10–L2) was reduced from 26 to 4 degrees after surgery. The shortened vertebral body united and no or minimal loss of correction was seen. The preoperative vertebral kyphosis averaged +17 degrees and was corrected to +7 degrees at follow-up with the sagittal index improving from 0.59 to 0.86. The segmental local kyphosis was reduced from +15 degrees to −3 degrees. Radiography demonstrated anatomically correct reconstruction in all patients, as well as solid fusion.
This technique permits circumferential decompression of the spinal cord through a posterior approach and posterior interbody fusion.
PMCID: PMC3122988  PMID: 21716869
Injury; laminoplasty; spine; shortening; spondylodesis
23.  Endoscopic Foraminal Decompression for Failed Back Surgery Syndrome under local Anesthesia 
The most common causes of failed back surgery are residual or recurrent herniation, foraminal fibrosis and foraminal stenosis that is ignored, untreated, or undertreated. Residual back ache may also be from facetal causes or denervation and scarring of the paraspinal muscles.1–6 The original surgeon may advise his patient that nothing more can be done on the basis of his opinion that the nerve was visually decompressed by the original surgery, supported by improved post-op imaging and follow-up studies such as EMG and conduction velocity studies. Post-op imaging or electrophysiological assessment may be inadequate to explain all the reasons for residual or recurrent symptoms. Treatment of Failed back surgery by repeat traditional open revision surgery usually incorporates more extensive decompression causing increased instability and back pain, therefore necessitating fusion. The authors, having limited their practice to endoscopic MIS surgery over the last 15-20 years, report on their experience gained during that period to relieve pain by endoscopically visualizing and treating unrecognized causative patho-anatomy in FBSS.7
Thirty consecutive patients with FBSS presenting with back and leg pain that had supporting imaging diagnosis of lateral stenosis and /or residual / recurrent disc herniation, or whose pain complaint was supported by relief from diagnostic and therapeutic injections (Figure 1), were offered percutaneous transforaminal endoscopic discectomy and foraminoplasty over a repeat open procedure. Each patient sought consultation following a transient successful, partially successful or unsuccessful open translaminar surgical treatment for disc herniation or spinal stenosis. Endoscopic foraminoplasty was also performed to either decompress the bony foramen for foraminal stenosis, or foraminoplasty to allow for endoscopic visual examination of the affected traversing and exiting nerve roots in the axilla, also known as the “hidden zone” of Macnab (Figure 2).8, 9 The average follow up time was, average 40 months, minimum 12 months. Outcome data at each visit included Macnab, VAS and ODI.
A diagnostic and therapeutic epidural gram may help identify unrecognized lateral recess stenosis underestimated by MRI. An excellent result from a therapeutic block lends excellent prognosis for a more lasting and “permanent” result from transforaminal endoscopic lateral recess decompression.
Kambin's Triangle provides access to the “hidden zone” of Macnab by foraminoplasty. The foramen and lateral recess is decompressed by removing the ventral aspect and tip of the superior articular process to gain access to the axilla between the traversing and exiting nerve. FBSS contains patho-anatomy in the axilla between the traversing and exiting nerve that hides the pain generators of FBSS.
The average pre-operative VAS improved from 7.2 to 4.0, and ODI 48% to 31%. While temporary dysesthesia occurred in 4 patients in the early post-operative period, all were happy, as all received additional relief of their pre-op symptoms. They were also relieved to be able to avoid “open” decompression or fusion surgery.
Conclusions / Level of Evidence 3
The transforaminal endoscopic approach is effective for FBSS due to residual/recurrent HNP and lateral stenosis. Failed initial index surgery may involve failure to recognize patho-anatomy in the axilla of the foramen housing the traversing and the exiting nerve, including the DRG, which is located cephalad and near the tip of SAP.10 The transforaminal endoscopic approach effectively decompresses the foramen and does not further destabilize the spine needing stabilization.11 It also avoids going through the previous surgical site.
Clinical Relevance
Disc narrowing as a consequence of translaminar discectomy and progressive degenerative narrowing and spondylolisthesis (Figure 3) as a natural history of degenerative disc disease can lead to central and lateral stenosis. The MRI may underestimate the degree of stenosis from a bulging or a foraminal disc protrusion and residual lateral recess stenosis. Pain can be diagnosed and confirmed by evocative discography and by clinical response to transforaminal diagnostic and therapeutic steroid injections.12 Foraminal endoscopic decompression of the lateral recess is a MIS technique that does not “burn bridges” for a more conventional approach and it adds to the surgical armamentarium of FBSS.
Cadaver Illustration of Foraminal Stenosis (courtesy of Wolfgang Rauschning). As the disc narrows, the superior articular process impinges on the exiting nerve and DRG, creating lateral recess stenosis, lumbar spondylosis, and facet arthrosis.
PMCID: PMC4325507
Failed Back Surgery Syndrome(FBSS); Hidden zone; Foraminal decompression; Recurrent herniation; Lateral stenosis; Foraminal osteophyte
24.  Spontaneous resolution of symptoms associated with a facet synovial cyst in an adult female – a case report 
Facet cysts are implicated in neural compression in the lumbar spine. Surgery is the definitive treatment for symptomatic facet cysts since the failure rate for conservative treatment is quite high; however, the role of physical/manual medicine practitioners in the management of symptomatic facet cysts has not been well explored. This case report will add to the body of evidence of spontaneous resolution of symptoms associated with facet cysts in the chiropractic literature.
A 58 year old female presented with acute low back and right leg pain which she attributed to a series of exercise classes that involved frequent foot stomping. Physical examination did not elicit any objective evidence of radiculopathy but MRI and CT scans revealed a facet cyst impinging on the right L5 nerve root. Injections and surgery were recommended; however, the patient’s radicular symptoms completely resolved after three months without surgical intervention.
There is currently a paucity of data in the literature regarding the chiropractor’s role in the management of symptomatic facet cysts. The case presented here has added to this literature and possible areas for future research have been explored.
PMCID: PMC3581007  PMID: 23483069
facet; cyst; lumbar spine; facette; kyste; rachis lombaire
25.  Surgical removal of extravasated epidural and neuroforaminal polymethylmethacrylate after percutaneous vertebroplasty in the thoracic spine 
European Spine Journal  2006;16(Suppl 3):326-331.
Although extravasations of polymethylmetharylate during percutaneous vertebroplasty are usually of little clinical consequence, surgical decompression is occasionally required if resultant neurologic deficits are severe. Surgical removal of epidural polymethylmetharylate is usually necessary to achieve good neurologic recovery. Because mobilizing the squeezed spinal cord in a compromised canal can cause further deterioration, attempts to remove epidural polymethylmetharylate in the thoracic region need special consideration. A 66-year-old man had incomplete paraparesis and radicular pain on the chest wall after percutaneous vertebroplasty for osteoporotic compression fracture of T7. Radiological studies revealed polymethylmetharylate extravasations into the right lateral aspect of spinal canal that caused marked encroachment of the thecal sac and right neuroforamina. Progressive neurologic deficit and poor responses to medical managements were observed; therefore, surgical decompression was performed 4 months later. After laminectomy and removal of facet joints and T7 pedicle on the affected side, extravasated polymethylmetharylate posterior and anterior to the thecal sac was completely removed without retracting the dura mater. Spinal stability was reconstructed by supplemental spinal instrumentation and intertransverse arthrodesis with banked cancellous allografts. Myelopathy and radicular pain gradually resolved after decompression surgery. The patient was free of sensory abnormality and regained satisfactory ambulation two years after surgical decompression.
PMCID: PMC2148084  PMID: 17053943
Vertebroplasty; Polymethylmethacrylate; Epidural extravasations; Thoracic myelopathy; Surgical removal

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