Transcript facet cyst treatment and literature

Facet cyst
Satishchandra Gore
www.drgore.in
Mission spine india
Facet cyst
• facet cysts first reported in 1974 by kao.
• terminology has changed but now standardized.
• Cysts have been reported mainly as case studies
with varying clinical presentations.
• anterior intra spinal cysts and which are
symptomatic are rare.
• With MRI detection is on rise.
• May indicate instability.
Pathogenesis
• Definition: Cyst located beside the facet joint and
exhibiting a communication with the joint, as
demonstrated on arthrography and subsequent
computed tomography (CT) of the joint space.
• Result of degeneration of the related facet joint.
• Walls consisted of elastic and collagen fibers
undergoing fibrinoid degeneration, with or without
synovial lining.
• should be called "cystic formations of mobile spine"
(CYFMOS)
•
Christophis, P., S. Asamoto, et al. (2007). ""Juxtafacet cysts", a misleading name for
cystic formations of mobile spine (CYFMOS)." Eur Spine J 16(9): 1499-1505.
Literature review
Doyle, A. J. and M. Merrilees (2004). "Synovial cysts of the lumbar facet joints in a symptomatic population: prevalence on
magnetic resonance imaging." Spine (Phila Pa 1976) 29(8): 874-878.
• synovial cysts are rare.
• MRI prevalence on mri in symptomatic patients
• anterior cysts (prevalence = 2.3%) posterior
(prevalence = 7.3%).
• Statistically significant associations with increased
frequency and severity of facet joint
osteoarthritis and with spondylolisthesis
compared to patients without cysts.
• Posterior cysts are more common than anterior
cysts. Both are related to facet joint osteoarthritis
but not to disc disease.
Case one : foot drop Lt L45
Case Two
• M 65 Dr. Severe sciatica left was relieved with
L45 endoscopic nucleotomy
• Recurrence showed inc size of synovial cyst
• Managed with injection
• No neurodeficit so managed non operatively
• X rays don’t indicate instability
• Patient happy with result of injections
images
Disc L45 Op now cyst L5S1
Steroid injection
Facet arthrography
Treatment may not be needed
• Spontaneous resolution known
• extensive conservative treatment should
always be considered as the first therapeutic
option, provided that there are no severe
neurological deficits.
• This may be added by symptomatic treatment.
• Symptoms are generally radicular,
claudication, backache.
Injection or surgery
• Shah, R. V. and G. E. Lutz (2003). "Lumbar intraspinal synovial cysts:
conservative management and review of the world's literature." Spine J
3(6): 479-488.
–
nonsurgical management in patients with LISC-induced radicular pain does not appear to be as
successful as surgery.
•
Chang, A. (2009). "Percutaneous CT-Guided Treatment of Lumbar
Facet Joint Synovial Cysts." HSS J 5(2): 165-168.
• Then surgery
– Kahilogullari, G., H. Tuna, et al. (2008). "Management of spinal
synovial cysts." Turk Neurosurg 18(2): 211-214.
• Surgery effective
• Ishii, K., M. Matsumoto, et al. (2005). "Endoscopic resection of
cystic lesions in the lumbar spinal canal: a report of two cases."
Minim Invasive Neurosurg 48(4): 240-243.
effective alternative to conventional open surgery for cystic lesions in the
lumbar spine is inter laminar endoscopy.
Surgical excision
• Khan, A. M., K. Synnot, et al. (2005). "Lumbar synovial cysts
of the spine: an evaluation of surgical outcome." J Spinal
Disord Tech 18(2): 127-131.
– Common at the L4-L5 level, the site of maximum instability.
– MRI is the tool of choice for diagnosis.
– underlying spinal instability has a strong association for
formation of spinal cysts and worsening symptoms.
– Synovial cysts resistant to conservative therapy should be
treated surgically.
– Resection and decompression with fusion remain an
appropriate option.
• Pirotte, B., N. Gabrovsky, et al. (2003). "Synovial cysts of the
lumbar spine: surgery-related results and outcome." J
Neurosurg 99(1 Suppl): 14-19.
Surgery and excision
• Dagain, A., R. Dulou, et al. (2008). "[Surgical management of synovial cyst
of the lumbar spine: retrospective study of 52 patients]." Rev Chir Orthop
Reparatrice Appar Mot 94(3): 289-296.
– Role of fusion is questionable
• Deinsberger, R., E. Kinn, et al. (2006). "Microsurgical treatment of juxta
facet cysts of the lumbar spine." J Spinal Disord Tech 19(3): 155-160.
– can be treated effectively with a minimally invasive microsurgical approach.
– when the cysts are associated with spondylolisthesis, minimizing the risk of instability
and the need for fusion.
– In a selected group of patients with persistent low back pain, fusion may become
necessary to improve symptoms.
Xu, R., M. J. McGirt, et al. (2010). "Factors associated with recurrent back pain and cyst
recurrence after surgical resection of one hundred ninety-five spinal synovial cysts: analysis of
one hundred sixty-seven consecutive cases." Spine (Phila Pa 1976) 35(10): 1044-1053.
• Hemilaminectomy or laminectomy for
symptomatic intraspinal synovial cysts.
• immediate improvement in back and leg pain.
• However, within 2 years have an increased
incidence of back pain and cyst recurrence.
• Decompression with instrumented fusion appears
to be associated with the lowest incidences of
cyst recurrence or back pain.
• fusion may be thought about as movement
needs to be eliminated.
New ideas
• Allen, T. L., Y. Tatli, et al. (2009). "Fluoroscopic percutaneous
lumbar zygapophyseal joint cyst rupture: a clinical outcome
study." Spine J 9(5): 387-395.
–
Fluoroscopic percutaneous Z-joint cyst rupture appears to be a safe and effective
minimally invasive treatment option. This procedure should be considered before
surgical intervention.
• Martha, J. F., B. Swaim, et al. (2009). "Outcome of percutaneous
rupture of lumbar synovial cysts: a case series of 101 patients."
Spine J 9(11): 899-904.
– steroid injection with attempted cyst rupture is correlated with
avoiding subsequent surgery in half of treated patients. Successful
cyst rupture does not appear to have added benefit, and it was
associated with worse disability 3 years postinjection. Long-term
outcomes are similar, regardless of subsequent surgery.
Rare presentations
• Gadgil, A. A., S. M. Eisenstein, et al. (2002). "Bilateral
symptomatic synovial cysts of the lumbar spine
caused by calcium pyrophosphate deposition
disease: a case report." Spine (Phila Pa 1976) 27(19):
E428-431.
– Suspect in pts of gout
• Manabe, M., M. Doita, et al. (2006). "Far
lateral extraforaminal facet cyst causing L5
radiculopathy." J Spinal Disord Tech 19(6):
447-450.
Cyst and bleeds
• Hemorrhagic cyst is rare
–
Ramieri, A., M. Domenicucci, et al. (2006). "Lumbar hemorrhagic synovial cysts: diagnosis,
pathogenesis, and treatment. Report of 3 cases." Surg Neurol 65(4): 385-390, discussion 390.
• Bleeding can occur from adjacent tissue
–
Miyatake, N., T. Aizawa, et al. (2009). "Facet cyst haematoma in the lumbar spine: a report of four
cases." J Orthop Surg (Hong Kong) 17(1): 80-84.
• Cyst can give epidural hematoma
–
Wait, S. D., F. D. Jones, et al. (2005). "Symptomatic epidural hematoma caused by lumbar synovial
cyst rupture: report of two cases and review of the literature." Neurosurgery 56(5): E1157; discussion
E1157.