Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

doi:10.1016/j.spinee.2009.06.010

The Spine Journal

Volume 9, Issue 11, November 2009, Pages 899-904

https://doi.org/10.1016/j.spinee.2009.06.010 Get rights and content

Abstract

Background context

Lumbar facet joint synovial cysts are benign degenerative abnormalities of the lumbar spine. Previous reports have supported operative and nonoperative management. Facet joint steroid injection with cyst rupture is occasionally performed, but there has been no systematic evaluation of this treatment option.

Purpose

To profile the role of facet joint steroid injections with cyst rupture in the treatment of lumbar facet joint synovial cysts.

Study design/setting

Retrospective chart review and long-term follow-up of patients treated for lumbar facet joint synovial cysts.

Patient sample

One hundred one patients treated for lumbar facet joint synovial cysts with fluoroscopically guided corticosteroid facet joint injection and attempted cyst rupture.

Outcome measures

Oswestry Disability Index and numeric rating scale score for back and leg pain.

Methods

A retrospective review and a subsequent interview were conducted to collect pretreatment and posttreatment pain and disability scores along with details of subsequent treatment interventions. Group differences in pain and disability scores were assessed using paired t test. Multiple clinical factors were analyzed in terms of risk for surgical intervention using logistic regression modeling and Cox proportional hazards modeling.

Results

Successful cyst rupture was confirmed fluoroscopically in 81% of cases. Fifty-five patients (54%) required subsequent surgery over a period averaging 8.4 months because of inadequate symptom relief. All patients reported significant improvement in back pain, leg pain, and disability at 3.2 years postinjection, regardless of their subsequent treatment course (p<.0001 in all groups). There was no significant difference in current pain between patients who received injections only and those who underwent subsequent surgery.

Conclusions

This study presents the largest clinical series of nonsurgical treatment for lumbar facet joint synovial cysts. Lumbar facet joint 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.

Introduction

Evidence & Methods

Few studies currently report the outcome of non-surgical treatment of lumbar synovial cysts. This article discusses one non-surgical technique.

In this retrospective case-series review, the authors found that following steroid injection and attempted percutaneous cyst rupture, 55% of patients proceeded to surgical intervention.

As the largest report of non-operative treatment for cysts, this paper is an important step in investigating this technique. The optimum approach to this group of patients will require a comparative study of alternative strategies.

—The Editors

Although synovial cysts arising from lumbar spinal facet joints are among the most common symptom-producing conditions affecting the lumbar spine, there have been very few comprehensive studies published on the natural history, appropriate evaluation, and management of this condition. Synovial cysts have been reported in association with both facet joints and the ligamentum flavum, but most of the facet joint cysts appear to arise from the joint capsule in association with degenerative spondylosis involving the facet joints [1], [2], [3], [4]. Although these cysts are considered benign, when associated with spinal stenosis or direct nerve root compression, persistent neurogenic claudication or sciatica symptoms can result.

There are currently no established guidelines with respect to treatment of symptomatic lumbar synovial cysts. Treatment options have been reported in several clinical series and include steroid injection and cyst aspiration, as well as surgical excision [4], [5]. Nearly all studies of nonsurgical management of lumbar synovial cysts have involved small numbers of patients [6], [7], [8]. Bureau et al. studied 12 percutaneous steroid injections and reported pain relief in 75% of patients, whereas Slipman et al. and Parlier-Cuau et al. studied 14 and 30 steroid injections, respectively, and reported symptomatic relief in up to one-third of the patients. Studies involving larger patient populations have addressed surgical treatment and have recommended decompressive laminectomy and cyst excision with or without concomitant fusion as an effective treatment option [9], [10], [11], [12], [13], [14], [15]. There have been no clinical series that specifically evaluate the technique of facet joint steroid injection with cyst rupture and how this technique relates to the need for subsequent treatment. This treatment technique is thought to provide symptom relief through a reduction in cyst protrusion onto surrounding anatomy and also through the analgesic effects of locally administered steroid, which is released into the epidural space on successful cyst rupture.

In this study, the role of fluoroscopically guided facet joint steroid injection with cyst rupture is examined in 101 symptomatic cases, with particular attention paid to the need for subsequent surgical intervention.

Section snippets

Materials and methods

A retrospective analysis was performed on a consecutive series of 101 patients who underwent fluoroscopically guided percutaneous corticosteroid injection therapy, with attempted cyst rupture as primary treatment for a diagnosis of a lumbar facet joint synovial cyst located within the spinal canal. During this procedure, local infiltration of the skin was conducted with 1% lidocaine, and a 22-G spinal needle was advanced into the facet joint under fluoroscopic control. Depo-Medrol

Results

Initial chart review yielded 129 patients with records of a facet joint steroid injection with attempted cyst rupture as treatment for a lumbar synovial cyst between 1999 and 2005 and current contact information. Of these, 102 patients were successfully contacted (79% response rate), and one was dropped from analysis because the patient did not have a facet joint synovial cyst. Thus, the study sample comprised a consecutive series of 101 patients with a diagnosis of lumbar facet joint synovial

Discussion

This case series reports the clinical outcome of 101 patients with lumbar synovial cysts 3 years after undergoing fluoroscopically guided steroid injection with cyst rupture. This study represents the first large systematic evaluation of this treatment technique, and to the authors' knowledge, this study is also the largest clinical series to date evaluating nonsurgical care of lumbar facet joint synovial cysts. The sample size is sufficient to allow meaningful implementation of multivariate

Acknowledgments

We are grateful for the support of the New England Baptist Hospital over the course of study implementation and data analysis. We also thank Jonathan Erulkar, MD and Robert Banco, MD for helpful discussions in earlier stages of the research; Scott Tromanhauser, MD for feedback on earlier drafts of the manuscript; and Penny Keyl, PhD and Ling Li, MPH for assistance with data analysis.

Patients provided written authorization for release of medical record data and verbal informed consent for both

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Citation Excerpt :
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Clinical StudyOutcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients

Abstract

Background context

Purpose

Study design/setting

Patient sample

Outcome measures

Methods

Results

Conclusions

Introduction

Section snippets

Materials and methods

Results

Discussion

Acknowledgments

Arch Phys Med Rehabil

Lumbar nerve root compression by synovial cysts of the ligamentum flavum. Report of four cases

J Neurosurg

Lumbar intraspinal extradural ganglion cyst

J Neurol Neurosurg Psychiatry

Lumbar intraspinal extradural ganglion cyst

J Neurosurg

Intraspinal synovial cyst causing sciatica

J Bone Joint Surg Am

Synovial cysts of the spine

Neurosurgery

Lumbar facet joint synovial cyst: percutaneous treatment with steroid injections and distention—clinical and imaging follow-up in 12 patients

Radiology

Symptomatic lumbar facet joint synovial cysts: clinical assessment of facet joint steroid injection after 1 and 6 months and long-term follow-up in 30 patients

Radiology

Clinical Study
Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients