Synovial cysts: to fuse or not to fuse?

doi:10.1016/j.spinee.2010.05.010

The Spine Journal

Volume 10, Issue 9, September 2010, Pages 817-819

https://doi.org/10.1016/j.spinee.2010.05.010 Get rights and content

COMMENTARY ON: Bydon A, Xu R, Parker SL, et al. Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systemic review of reported postoperative outcomes. Spine J 2010;10:820–826 (in this issue).

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Cited by (11)

Simple Microsurgical Extirpation as a Method of Choice in Treating Symptomatic Spinal Facet Joint Cysts: A Retrospective Case Series
2023, World Neurosurgery
Facet joint cysts (FJCs) are a cause of radiculopathy, back pain, cauda equina syndrome, and/or claudication. They mostly affect the lumbar spine in the elderly, prevailing in women, and are connected to spinal degeneration and instability. We aimed to evaluate the safety and efficacy of open surgical decompression and cyst excision without a subsequent fusion.
We evaluated neurologic symptoms and potential signs of spinal instability on preoperative versus postoperative radiological examination. We performed a histological assessment of the extirpated cysts. Statistical analysis was then performed.
Of a total of 66 patients, 44 were included in the present study. The average age was 61.2 years. Female patients prevailed (61.4%). The mean follow-up was 5.3 years. The segment most frequently affected by a FJC was L4-L5 (65.9%). Cyst resection led to significant relief from neurologic symptoms for most patients. Thus, 95.5% of our patients reported their postoperative outcome as excellent. Preoperatively, 43.2% and 47.4% of patients had had radiographic signs of instability on magnetic resonance imaging and signs of spondylolisthesis on dynamic radiographs in the operated segment, respectively, with 54.5% manifesting signs of spondylolisthesis in the same segment on a postoperative dynamic radiograph. Despite spondylolisthesis progression, no patient required reoperation. Histologically, pseudocysts without synovium were more frequent than were synovial cysts.
Simple FJC extirpation is a safe and effective method for resolving radicular symptoms, with excellent long-term outcomes. It does not lead to the development of clinically significant spondylolisthesis in the operated segment; thus, no supplementary fusion with instrumented stabilization is required.
Five-Year Outcomes After Decompression and Fusion Versus Decompression Alone in the Treatment of Lumbar Synovial Cysts
2022, World Neurosurgery
Citation Excerpt :
As such, many investigators have supported concomitant fusion as the most effective treatment option.9,10,14,15,34 However, the use of concomitant fusion has remained controversial owing to the longer operative times, decreased mobility, and risk of adjacent segment disease.10,14,31,35 Furthermore, the existing literature comparing concomitant fusion and standalone decompression largely consists of small retrospective studies with short follow-up periods.5,7,9,15
Spinal synovial cysts are acquired, fluid-filled lesions of the facet joint that most commonly occur in the lumbar spine. They are thought to arise from degenerative changes and to result from segmental instability. Although the treatment of these lesions has been studied, the long-term implications and effects of the different strategies for surgical intervention (i.e., decompression and fusion vs. decompression alone) have not yet been elucidated or established.
Using an all-payer database with 53 million patient records (MARINER-53), patients with a diagnosis of lumbar synovial cysts were identified. Patients who had undergone lumbar fusion versus laminectomy were matched 1:1 using binomial and gaussian logistic regression models to evaluate the need for future lumbar surgery within 5 years after their index procedure.
No statistically significant differences were noted between the 5-year rates of subsequent intervention, additional laminectomy, or fusion among patients who had undergone index decompression and fusion (n = 51; 10.5%) versus decompression alone (n = 43; 8.8%; P = 0.39). Furthermore, no significant differences were found in the odds of intervention type after index decompression and fusion versus decompression alone (subsequent laminectomy: odds ratio, 0.59; 95% confidence interval, 0.32–1.09; subsequent fusion: odds ratio, 1.14; 95% confidence interval, 0.64–2.02).
Patient-specific factors and surgeon–patient-shared decision-making should be used when planning interventions for these lesions. However, synovial cysts might not require a fusion procedure for presumed instability. Further investigation is required, using randomized and prospective studies, to further evaluate the effective treatment of this entity.
The Results of Microsurgery without Fusion for Lumbar Synovial Cysts: A Case Series of 50 Patients
2020, World Neurosurgery
Citation Excerpt :
In the series by Weiner et al.,12 17% of patients who had fusion associated with cyst withdrawal required long-term surgery at adjacent levels. Gupta and Lutz39 consider it risky to recommend preventive fusion to reduce the rate of relapse of the cyst, especially when one considers that the risk of relapse is low. Bruder et al.,1 in a review article with 2798 cases, found a 2.2% relapse rate and a 2.8% late fusion rate.
The treatments described for spinal synovial cysts range from percutaneous puncture to arthrodesis. There is a fear of postoperative instability after surgical resection of cysts, mainly when they are associated with degenerative spondylolisthesis. The objective of the article is to address the postoperative instability and recurrence rate of the symptoms after microsurgery without fusion.
We report a consecutive series of 50 patients with lumbar synovial cysts operated on with microsurgery without arthrodesis. Functional status was assessed postoperatively by the MacNab success scale and by self-assessment using the Weiner scale, the 36-item short-form health survey (SF-36), and the Oswestry scale. The presence of preoperative and postoperative instability was determined with static and dynamic lumbar spine X-rays before surgery and in the last follow-up at 2 years to evaluate the presence of spondylolisthesis before and after surgery. Facet inclination angle and stage of disc degeneration at the level of the cysts were evaluated. Disc degeneration was defined by the modified Pfirrmann grading system.
The mean Oswestry index was 12 ± 12.6% (median 8, 0–53). Based on the MacNab scale, 98% were considered excellent and good. The Weiner scale showed that low back pain was present in 16% of patients postoperatively. There was significant improvement of leg strength and pain in 96% and 94%, respectively. Only 3 patients were reoperated on with late fusion. Total surgical resection was obtained in all cases, with a late fusion rate of only 6% and no recurrence at the operated site.
The microsurgical treatment for synovial cysts without arthrodesis presented excellent and good results in the majority of cases. It is necessary to carry out prospective randomized studies to clarify the best therapeutic options.
Surgical Treatment of Spinal Synovial Cysts in Elderly Patients: Symptoms, Treatment Course, and Outcome in Patients >75 Years of Age
2018, World Neurosurgery
Citation Excerpt :
The youngest patient with a juxtafacet cyst was 14 years old,19 and the oldest patient was 86 years old.20 Degenerative changes are common to all explanations for the development of spinal synovial cysts in older patients,4,5,21-23 whereas trauma seems to play a more important role in younger patients.24,25 To rule out different mechanisms in cyst development between both groups, we included only patients >50 years old in this study.
With the aging of our society comes a rising number of elderly patients with progressive degeneration of the spine associated with synovial cysts. Surgical treatment may be particularly challenging in elderly patients because of comorbidities.
Patients treated in our department between 1999 and 2014 for spinal synovial cysts were screened. The 28 patients ≥75 years old were classified as elderly and were compared with 96 patients 50–74 years old. No patient underwent fusion as part of cyst resection.
Despite a significantly higher frequency of muscle reflex changes in elderly patients at presentation, symptoms, cyst levels, rate of complications, and surgical method were not different between groups. Cyst adherence to the dura and subtotal resection were observed significantly more often in the elderly group (18% vs. 3%; P < 0.05). Outcome according to the Oswestry Disability Index was classified as no disability or minimal disability in 85% of the elderly group and in 82% of the control group. Recurrent cyst and delayed fusion rates were lower in the elderly group (4% and 4%) compared with the control group (7% and 8%).
The clinical course of elderly patients with surgical treatment of spinal synovial cysts did not differ compared with younger patients. Good or excellent results could be achieved and persisted for a long time in most cases. Fusion should be performed only in cases of severe instability. Nonaggressive cyst removal in cases of dural attachment enables low cerebrospinal fluid fistula rates without increasing cyst recurrence rates.
Microsurgical resection of juxtafacet cysts without concomitant fusion—Long-term follow-up of 74 patients
2017, Clinical Neurology and Neurosurgery
Citation Excerpt :
In our study three of five patients with a cyst recurrence at the same level showed very good results with a solely re-decompression (Case 2, 3 and 5, Table 3). Gupta et al. have already warned of overtreatment and pointed out that patients are “seeking less invasive not more invasive treatment options” [23]. In the majority of patients without distinct criteria of instability we regard solitary microsurgical decompression with resection of juxtafacet cysts as adequate primary surgical treatment due to the overall good clinical outcome and the low incidence of secondary lumbar fusion surgery.
We report on our experience with treating juxtafacet cysts focusing on clinical outcome, rate of recurrence and secondary surgery, especially fusion.
This retrospective study evaluates patients who underwent surgical resection of juxtafacet cysts without concomitant fusion from 2002 to 2013 with a minimum follow-up of one year.
Complete follow-up is available in 74 patients. Mean follow-up in all 74 patients was 69 ± 34 months (range, 14–140 months). Mean ODI was 14.9%. 68 patients (91.9%) were pleased with the results and would undergo surgery again. Three patients (4.1%) underwent secondary resection because of cyst recurrence at the same site. Four patients (5.4%) needed secondary fusion.
In patients without evident clinical and radiological criteria of instability we regard surgical resection of juxtafacet cysts without concomitant fusion as adequate primary treatment due to good outcome and low incidence of secondary symptomatic instability.
Management strategies for patients with spinal synovial cysts
2013, World Neurosurgery
Citation Excerpt :
There was a dural tear in 2 patients (10%), highlighting the relative frequency of that complication. It has been found that 92.5% of patients who undergo surgery for symptomatic synovial cysts have complete resolution of back or leg pain in the immediate postoperative period (7). However, on continued follow-up it was seen that about 21.9% of patients had recurrence of back pain and 12.7% of them had recurrence of leg pain (6) at 25.4 months after the index intervention.

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CommentarySynovial cysts: to fuse or not to fuse?

Spine J

Rev Chir Orthop Reparatrice Appar Mot

Spine J

Spine J

Spine J

Anatomisch und funktionnelle Untersuchunge über den Bandscheibenprolaps

Langenbecks Arch Klin Chir

Spinal extradural benign synovial or ganglion cyst: case report and review of the literature

Neurosurgery

Lumbar intraspinal synovial and ganglion cyst (facet cyst): ten-year experience in evaluation and treatment

Spine

Intraspinal synovial cysts: magnetic resonance imaging

Radiology

Commentary
Synovial cysts: to fuse or not to fuse?