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1.  The diagnosis and management of synovial cysts: Efficacy of surgery versus cyst aspiration 
Surgical Neurology International  2012;3(Suppl 3):S157-S166.
The surgical management of lumbar synovial cysts that have extruded into the spinal canal remains controversial (e.g. decompression with/without fusion).
The neurological presentation, anatomy, pathophysiology, and surgical challenges posed by synovial cysts in the lumbar spine are well known. Neurological complaints typically include unilateral or, more rarely, bilateral radicular complaints, and/or cauda equina syndromes. Anatomically, synovial cysts constitute cystic dilatations of synovial sheaths that directly extrude from facet joints into the spinal canal. Pathophysiologically, these cysts reflect disruption of the facet joints often with accompanying instability, and potentially compromise both the cephalad and caudad nerve roots.
Aspiration of lumbar synovial cysts, which are typically gelatinous and non-aspirable, and typically performed by “pain specialists” (e.g. pain management, rehabilitation, radiologists, others) utilizing fluoroscopy or CT-guided aspiration, is associated with 50–100% failure rates. Surgical decompression with/without fusion (as the issue regarding fusion remains unsettled) results in the resolution of back and radicular pain in 91.6–92.5% and 91.1–91.9% of cases, respectively.
After a thorough review of the literature, it appears that the treatment with the best outcome for patients with synovial cysts is cyst removal utilizing surgical decompression; the need for attendant fusion remains unsettled. The use of an alternative treatment, percutaneous aspiration of cysts, appears to have a much higher recurrence and failure rate, but may be followed by surgery if warranted.
PMCID: PMC3422091  PMID: 22905322
Decompression; extruded lumbar synovial cysts; failed aspiration; failed techniques; fusion
2.  Controversies in Chiari I malformations 
Surgical Neurology International  2012;3(Suppl 3):S232-S237.
The diagnosis and management of Chiari I malformations (CMI) remains controversial, particularly since it is often an incidental finding on cervical MR scans performed for neck pain and/or headaches. Recently, some surgeons “over-operated” on asymptomatic patients with Chiari I malformations, or even on those without the requisite radiographic diagnostic features for Chiari I malformations: unfortunately, only a subset were admonished for indiscriminate surgery. Nevertheless, when this hindbrain malformation is truly symptomatic, contributing to impaired cerebrospinal fluid (CSF) circulation, various valid surgical management strategies may be adopted.
This review focuses on the current literature regarding the clinical presentation, diagnosis, and surgical management of Chiari I malformation. Variations in the surgical technique are also presented and critiqued.
The recommended treatment for Chiari I malformations I consists of decompressive suboccipital craniectomy and duroplasty when abnormal cine-flow MRI is observed preoperatively and blockage of CSF flow persists intraoperatively despite bony decompression.
Controversy continues regarding the optimal surgical technique to address Chiari malformations I. Proper diagnostic studies and patient selection are needed to optimize patient outcomes, while avoiding unnecessary surgical procedures.
PMCID: PMC3422094  PMID: 22905329
Chiari malformation I; decompression; duroplasty; operative controversy; suboccipital craniectomy; surgical indications

Results 1-2 (2)