The Role of Imaging in the Management of Cystic Formations of the Mobile Spine (CYFMOS).

PURPOSE OF REVIEW: The purpose of this review is to give a better understanding of the pathogenesis of cystic formations of the mobile spine (CYFMOS) and the correlating imaging findings. This would help with medical decision-making, given the plethora of conservative, interventional, and surgical treatment options. RECENT FINDINGS: There has been a general understanding that CYFMOS are associated with degenerative spine changes. More recent articles however have suggested that identifying detailed imaging characteristics can assist in determining outcomes when CYFMOS are treated with interventional percutaneous methods or surgical decompression with or without concomitant fusion. CYFMOS although uncommon are not a rare finding seen in the spine when there is a background of degenerative spine changes. These cystic lesions are generally symptomatic by exhibiting mass effect on adjacent structure. Most treatments are aimed at decompression by interventional percutaneous or surgical means. Various imaging characteristics of these CYFMOS described in this article including their signal intensity, presence of spinal instability, particular patterns of adjacent degenerative changes, and imaging changes following interventional treatments can help guide physicians when managing these cases.

[Spinal sinovial cysts: Surgical treatment and clinical outcomes in a series of 18 cases]. / Quistes articulares espinales: evolución clínica y resultados según intervención quirúrgica. Revisión de 18 casos.

OBJECT: A series of 18 patients with symptomatic synovial cysts was analysed from May 2009 to November 2013. Different approaches were performed for their removal. MATERIAL AND METHODS: The study included 18 patients, 8 men and 10 women, aged between 50 and 77 years. An analysis was made of the variables including age, gender, symptoms, imaging studies, histopathology, surgery, follow-up, complications, and clinical outcome. RESULTS: An articular synovial cyst was diagnosed in 17 cases, and a ganglion in one cases. The most common symptom was back pain with radiculopathy (94%). Motor deficits occurred in 4 cases (22%), and 1 case (5%) presented with urinary incontinence. The most common level was L4- L5 (67%), with one atypical case observed in the D12 -L1 location. Hemi-laminectomy was performed in 14 cases, with 9 of them having an interspinous spacer (ISP) device inserted. A laminectomy with a fusion procedure was performed in 3 patients and 1 patient had a bilateral decompression using a unilateral approach. The patients were followed-up for between 6 months to 2 years. CONCLUSIONS: Synovial cysts are a cause of radiculopathy/neurogenic claudication. Spinal cysts are commonly found at the L4-L5 level. MRI is the tool of choice for diagnosis. The most common symptom was back pain with radiculopathy. Synovial cysts resistant to conservative therapy should be treated surgically. In our series, surgical resection of symptomatic juxtafacet cysts showed a good clinical outcome, but the optimal approach for patients with juxtafacet cysts remains unclear.

Hemorrhagic lumbar synovial cyst: case report and literature review.

Intraspinal synovial cysts are infrequent causes of back and radicular leg pain. Commonly associated with degenerative spinal disease, the majority of synovial cysts appear in the lumbar spine. Rarely, intracystic hemorrhage can occur through an unclear mechanism. Similarly rare, cysts may also become migratory. The pathogenesis of hemorrhagic synovial cysts remains uncertain and their potential for migration also remains unclear. A 36 year-old male presented to the clinic with 5 months of back pain and leg pain that began after a work-related injury. An initial MRI obtained by another surgeon 3 month prior demonstrated an epidural cystic mass with T1 hypointensity and T2 hyperintensity at L2-L3. With worsening pain, the patient came to our clinic for a second opinion. A second MRI demonstrated resolution of the L2-L3 epidural cystic mass and formation of a new epidural cystic mass at L3-L4 causing compression of the thecal sac. The patient subsequently underwent decompressive hemilaminectomy with cyst removal. We present a case of two lumbar synovial cysts, separated over time and a vertebral level and giving the appearance of a single, migratory cyst. This is the first case of an "occult migratory" synovial cyst with repeat MR imaging capturing spontaneous resolution of the initial cyst and formation of a hemorrhagic cyst one level below. We also present a summary of the 44 cases of hemorrhagic synovial cysts reported in the literature and propose a mechanism that may account for the hemorrhagic and migratory progression in some patients.

A ganglion cyst derived from a synovial cyst: A case report.

The synovial and ganglion cysts originating from the facet joint have been named under the name of the Juxtafacet cyst by the several researchers. They put forward that the synovial cyst originated from the synovial joint. But, they failed to clarify the pathophysiology of the formation of the ganglion cyst. In this case report, we reported a 67-year-old male patient was referred to the emergency from another center with the complaint of a left leg pain and weakness in the left foot and patient was treated with microchirurgical technique. His patological examination was evaluated a ganglion cyst. We have discussed and explained the pathophysiology of the formation of a ganglion cyst derivered from a synovial cyst. And separately, we have presented the spinal cysts by grouping them under a new classification called a cystic formation of the soft tissue attachments of the mobile spine as well as dividing them into sub-groups.

Lumbar spinal ganglion cyst: A systematic review with case illustration.

PURPOSE: Ganglion cysts are benign soft tissue lesions found in joints, most commonly wrists. The incidence for juxtafacet cysts, the condition under which spinal ganglion cysts are categorized, is between 0.06% and 5.8%. Spinal ganglion cysts often arise in the most mobile segment of the lumbar spine, L4-L5. Patients commonly present with pain, radiculopathy, and weakness. Conservative management is used, but surgical resection is the most common treatment modality. We aim to review the literature and present a rare case of an L2-L3 situated spinal ganglion cyst, treated with maximal safe resection. METHODS: A systematic review of literature was conducted in accordance with PRISMA guidelines. PubMed, Web of Science, and Cochrane databases were queried using Boolean operators and search terms, "spinal ganglion cyst, lumbar ganglion cyst, and lumbar juxtafacet cyst". Presentation, surgical management, and postoperative course of a 29-year-old male with an L2-L3 spinal ganglion cyst are also described. RESULTS: The search yielded 824 articles; 23 met inclusion criteria. These papers consisted of 27 spinal ganglion cyst cases with disaggregated patient data. 63.0% of patients were male, and 53.4 years (range: 23-86) was the average age at presentation. Mean symptom duration was 1.9 years (range: 3 days-12 years). 70.4% of patients reported complete symptom resolution. 14.8% of cases noted neural foramen involvement. CONCLUSIONS: Spinal ganglion cysts are benign lesions typically presenting with radiculopathy. Maximal safe resection is an effective treatment modality with low complication rates. Future studies are needed to understand if neural foramen involvement leads to increased symptom severity.

Management of rare atlantoaxial synovial cyst case with extension to the cerebellopontine angle: illustrative case.

BACKGROUND: Synovial cysts are a common finding in degenerative spine disease, most frequently involving the facet joints of the lumbar spine. Synovial cysts are less common in the cervical spine and rarely involve the atlantoaxial junction. OBSERVATIONS: In this case report, the authors detail a unique presentation of a left atlantoaxial synovial cyst with large intracranial extension into the cerebellopontine angle causing progressive cranial nerve palsies resulting in tinnitus, vertigo, diminished hearing, gait imbalance, left trigeminal hypesthesia, left facial weakness, and dysarthria. The patient underwent a retromastoid craniectomy for resection of the synovial cyst, resulting in improvement and resolution of symptoms. Follow-up occurred at 6 weeks, 3 months, and 5 months postoperatively without recurrence on imaging. LESSONS: The authors describe acute and long-term management of a unique presentation of an atlantoaxial synovial cyst including retromastoid craniectomy, intervals for follow-up for recurrence, and possible treatment options in cases of recurrence. A systematic literature review was also performed to explore all reported cases of craniocervical junction synovial cysts and subsequent surgical management.

Microcervical Foraminotomy for Cervical Juxtafacet Cysts: Case Series and Literature Review.

BACKGROUND: Juxtafacet cysts are located near or contiguous with the facet joints, and their occurrence is rare in the cervical spine. We report 4 cases of cervical juxtafacet cysts operated by microcervical foraminotomy (MCF) or a combination of MCF and laminoplasty. We simultaneously review previously reported cases in terms of location, clinical findings, and surgical technique. METHODS: Among the patients who underwent spine surgery at our hospital from 2015 to 2019, 4 had cervical juxtafacet cysts. The images and clinical records of the patients were retrospectively assessed. Relevant previous English literature was searched and reviewed using PubMed. RESULTS: In our series, all 4 patients presented with unilateral upper extremity muscle weakness preoperatively. Two patients underwent MCF, and the other 2 underwent a combination of MCF and laminoplasty with resection of the cyst. All showed improvement in muscle strength. In previously reported cases, the rate of muscle weakness was high. A review of previous cases showed that 75 of 139 patients had cysts at C7-T1. The most common surgical techniques consisted of a hemilaminectomy or laminectomy with the addition of posterior fusion in 28 patients. The number of male patients was twice that of female patients; however, the male-to-female ratio was almost the same in patients with cysts in C7-T1. On pathological diagnosis, there were 3 times more synovial cysts than ganglion cysts. The percentage of synovial cysts was higher in patients with radiculopathy, and the percentage of ganglion cysts was higher in patients with myelopathy. CONCLUSIONS: Cervical juxtafacet cysts tend to occur in C7-T1 and cause muscle weakness. Surgical therapy is strongly recommended due to good postoperative improvement. CLINICAL RELEVANCE: The results of this study suggest that microcervical foraminotomy for cervical juxtafacet cysts can provide favorable symptomatic improvement.

A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment.

BACKGROUND: Different procedures have been used for the treatment of lumbar juxtafacet cysts (JFCs). Recently, full-endoscopic cyst excision has been suggested as a reasonable alternative. We performed a meta-analysis to assess the overall rates of favorable outcomes and adverse events for each available treatment and determine the outcome and complication rates concerning spine stability. METHODS: Multiple databases were searched for English-language studies involving adult patients with lumbar JFCs who had been followed for more than 6 months. Outcomes included the proportion of patients with a satisfactory outcome. Adverse events included recurrence and revision rates as well as intraoperative complications. We further stratified the analysis based on the spine's condition (degenerative listhesis vs without degenerative listhesis). RESULTS: A total of 43 studies, including 2226 patients, were identified. Over 80% of patients experienced satisfactory improvement after surgical excision but only 66.2% after percutaneous cyst rupture and aspiration. Overall, recurrence and revision rates were almost double in patients with preoperative degenerative listhesis at the cyst level, especially in the minimally invasive group (2.1% vs 31.3% and 6.8% vs 13.1%, respectively). The rate of full-endoscopic satisfactory outcomes was approximately 90%, with low rates of adverse events (<2%). CONCLUSION: We analyzed the outcome and adverse event rates for each kind of available treatment for JFC. Full endoscopy has outcomes and rates of adverse events that overlap with open and minimally invasive approaches. LEVEL OF EVIDENCE: 2A.

Waste not, want not: Report of a completely calcified C1-C2 juxtafacet cyst and literature review.

BACKGROUND: Calcified juxtafacet cysts in the cervical spine are extremely rate. Such symptomatic cysts commonly cause neck pain, radiculopathy, or even myelopathy. MR and CT studies typically document cord/ root compression. On occasion, some of these cysts will spontaneously regress, while many others may warrant surgical removal. CASE DESCRIPTION: A 70-year-old male presented with a 2-year history of a progressive tetraparesis. The preoperative MR/CT studies showed a C1-C2 left extradural mass occupying more than half of the spinal canal. On MR, it was homogeneously hypointense on both T1- and T2-weighted images, while the CT showed a calcified cyst. Intraoperative and histopathological findings documented a calcified cervical juxtafacet cyst (i.e. ganglion subtype) that was fully excised without sequelae. CONCLUSION: C1-C2 juxtafacet cervical cyst should be considered when a patient presents with myelopathy due to a calcified MR/CT documented paraspinal lesion contributing to significant cervical cord/root compression.

Complete Resolution of a Large Hemorrhagic Lumbar Synovial Cyst Following Spinal Fusion Alone.

The authors reported complete regression of a large hemorrhagic lumbar synovial cyst following posterior spinal fusion without direct cystic resection. A 64-year-old woman suffered from sudden onset of the left buttock pain radiating to the left leg after waking up in the morning following the previous history of a minor accident 2 months ago. Magnetic resonance imaging (MRI) of the lumbosacral spine showed a large extradural round mass originating from the left facet joint at the level of L3-L4. The mass was hyperintense on T1-weighted images and hypointense on T2-weighted images, probably compatible with hemorrhagic joint-related cyst. Surgical treatment was chosen for her because of persistent left radicular pain with no responding to medications. The patient underwent decompressive laminectomy, subtotal facetectomy, instrumented fusion, and only tissue biopsy due to severe adherence of the mass and dura. Histopathological examination was consistent with a hemorrhagic synovial cyst. The radicular pain completely disappeared after the surgery. Follow-up MRI of the lumbosacral spine obtained 6 months after the surgery demonstrated complete resolution of the hemorrhagic cyst. Complete resolution of hemorrhagic synovial cyst seems to correlate with subtotal facetectomy, probably resulting in leakage of cyst content and subsequent resorption of the cyst wall. In addition, hematoma within the synovial cyst may resolve spontaneously over time.

Simultaneous Presence of Juxtafacet Cyst and Ligamentum Flavum Hematoma.

Juxtafacet cysts and ligamentum flavum hematoma have the potential to cause acute root or spinal cord compression despite their low incidences. Their simultaneous presence with acute nerve compression has not been reported. Herein, we present a case who reported with low back and leg pain to the emergency department.

Cervical C7 ganglion cyst causing compressive myelopathy: A rare case report.

BACKGROUND: Juxtafacet cysts, synovial and ganglion cysts, emanate from the facet joints. Patients with these cysts are typically asymptomatic but may rarely present with radiculopathy and/or myelopathy. CASE DESCRIPTION: A 72-year-old female presented with a 1-month history of progressive lower extremity weakness (left more than right), numbness, and urinary incontinence. Notably, she also had a C7 sensory level to pin appreciation of 1-month duration. The magnetic resonance imaging showed an extradural C7 cystic lesion whose capsule enhanced with gadolinium, causing severe cord compression. The patient underwent a left C7 hemilaminectomy for complete excision of the cyst; postoperatively in 2-weeks duration, she regained full neurological function. The final histopathology was consistent with a ganglion cyst. CONCLUSION: Cervical juxtafacet cysts rarely cause compressive myelopathy. They may be readily diagnosed and resected with excellent postoperative outcomes.

Symptomatic Lumbar Juxtafacet Cyst Treated by Full Endoscopic Surgery.

BACKGROUND: Juxtafacet cysts (JFCs) include both synovial and ganglion cysts adjacent to a spinal facet joint or arising from the ligamentum flavum of the spinal facet joints. Various treatments have been proposed; however, a surgical approach appears to be most effective. The aim of this study was to review patients with lumbar JFCs treated using a full endoscopic approach and elaborate the details of the surgical routes and techniques and their merits and pitfalls. METHODS: All patients with lumbar JFCs underwent complete endoscopic cyst removal. Muscle power, visual analog scale score, modified MacNab criteria score, and magnetic resonance imaging were assessed during follow-up. RESULTS: The study enrolled 8 patients. Five patients received an interlaminar approach, 2 patients received a transforaminal approach, and 1 patient received a transfacet approach. Visual analog scale scores decreased from a mean of 7.75 (range, 5-10) before surgery to 0.625 (range, 0-2) after surgery, and modified MacNab criteria score ranged from good to excellent after surgery. No neurologic injuries were observed. CONCLUSIONS: JFCs could be effectively treated by full endoscopic surgery. The type of approach should be based on the anatomic site of the lesion and the condition of the patient. The interlaminar approach is appropriate for cysts located in the lower segment with larger interlaminar space. The transforaminal or transfacet approach is preferred for patients for whom general anesthesia is a high risk.

Midline Ligamentum Flavum Cyst of Lumbar Spine.

BACKGROUND: Ligamentum flavum cysts are thought to develop due to facet joint hypermobility; however, the etiology of these lesions is not completely elucidated. These cysts may lead to compressive pathologies of the spine requiring surgical intervention. CASE REPORT: We report the case of a 63-year-old male with chronic back pain and progressive neurogenic claudication for 6 months. He was found to have a ligamentum flavum cyst situated along the dorsal midline of the lumbar spinal canal contributing to spinal stenosis. The patient underwent a decompressive L4 laminectomy and en bloc excision of the ligamentum flavum cyst with complete resolution of his symptoms postoperatively. CONCLUSIONS: We suggest that chronic mechanical stress leads to degeneration of the ligamentum flavum and contributes directly to cyst formation.

Acute lumbosacral hemorrhagic ganglion cyst after transforaminal epidural steroid injection.

Epidural steroid injection is one of the most commonly used non-surgical treatments for degenerative lumbar vertebral disease. Its use has increased as degenerative lumbar vertebral disease has increased in frequency. Concomitant complications are being reported more often. In this report, we report a rare case of iatrogenic hemorrhagic cyst following epidural steroid injection. The patient underwent operative treatment with complete resolution of his symptoms.

Surgical Treatment of Spinal Synovial Cysts in Elderly Patients: Symptoms, Treatment Course, and Outcome in Patients >75 Years of Age.

BACKGROUND: 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. METHODS: 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. RESULTS: 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%). CONCLUSIONS: 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.

Surgical treatment of cervical subaxial intraspinal extradural cysts using a full-endoscopic uniportal posterior approach.

PURPOSE: Symptomatic intraspinal extradural cysts of the cervical subaxial spine are rare, but usually require surgery. Conventional posterior decompression is the gold standard. However, there is increasing experience with endoscopic surgical techniques. The purpose of the study is to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the posterior approach in patients with symptomatic intraspinal extradural cysts of the cervical subaxial spine. METHODS: Seven consecutive patients with a subaxial location of symptomatic intraspinal extradural cysts were decompressed in a full-endoscopic uniportal technique via the posterior approach between 2009 and 2015. Imaging and clinical data were collected in follow-up examinations for 18 months. RESULTS: In all cases, the cyst was completely removed and adequate decompression was achieved using the full-endoscopic uniportal technique. One patient developed a dural leak that was sutured and covered intraoperatively. No other complications requiring treatment were observed. All patients had a good clinical outcome with stable regression of the radicular and central nerve pain or neurological deficits. The imaging follow-up showed sufficient decompression in all cases. No evidence was found of increasing instability during the follow-up period. CONCLUSION: The full-endoscopic uniportal operation with a posterior approach allows the resection of the cyst and can minimize trauma and destabilization and has technical benefits and a low complication rate. It is an alternative surgical method that can offer advantages and is considered by the authors to be the surgical technique of choice for cervical subaxial intraspinal extradural cysts.

Synovial cysts of the spine: long-term follow-up after surgical treatment of 141 cases in a single-center series and comprehensive literature review of 2900 degenerative spinal cysts.

OBJECTIVE Synovial cysts of the spine are rare lesions, predominantly arising in the lumbar region. Despite their generally benign behavior, they can cause severe symptoms due to compression of neural structures in the spinal canal. Treatment strategies are still a matter of discussion. The authors performed a single-center survey and literature search focusing on long-term results after minimally invasive surgery. METHODS A total of 141 consecutive patients treated for synovial cysts of the lumbar spine between 1997 and 2014 in the authors' department were analyzed. Medical reports with regard to signs and symptoms, operative findings, complications, and short-term outcome were reviewed. Assessment of long-term outcome was performed with a standardized telephone questionnaire based on the Oswestry Disability Index (ODI). Furthermore, patients were questioned about persisting pain, symptoms, and further operative procedures, if any. Subjective satisfaction was classified as excellent, good, fair, or poor based on the Macnab classification. RESULTS The approach most often used for synovial cyst treatment was partial hemilaminectomy in 70%; hemilaminectomy was necessary in 27%. At short-term follow-up, the presence of severe and moderate leg pain had decreased from 93% to 5%. The presence of low-back pain decreased from 90% to 5%. Rates of motor and sensory deficits were reduced from 40% to 14% and from 45% to 6%, respectively. The follow-up rate was 58%, and the mean follow-up period was 9.3 years. Both leg pain and low-back pain were still absent in 78%. Outcome based on the Macnab classification was excellent in 80%, good in 14%, fair in 1%, and poor in 5%. According to the ODI, 78% of patients had no or only minimal disability, 16% had moderate disability, and 6% had severe disability at the time of follow-up. In this cohort, 7% needed surgery due to cyst recurrence, and 9% required a delayed stabilization procedure after the initial operation. CONCLUSIONS Surgical treatment with resection of the cyst provides favorable results in outcome. Excellent or good outcome persisting for a long-term follow-up period can be achieved in the vast majority of cases. Complication rates are low despite an increased risk of dural injury. With facet-sparing techniques, the stability of the segment can be preserved, and resection of spinal synovial cysts does not necessarily require segmental fusion.

Microsurgical resection of juxtafacet cysts without concomitant fusion-Long-term follow-up of 74 patients.

OBJECT: We report on our experience with treating juxtafacet cysts focusing on clinical outcome, rate of recurrence and secondary surgery, especially fusion. METHODS: 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. RESULTS: Complete follow-up is available in 74 patients. Mean follow-up in all 74 patients was 69±34months (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. CONCLUSIONS: 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.

Atlantoaxial Synovial Cyst: Case Report and Literature Review.

BACKGROUND: Degenerative cystic lesions of atlantoaxial joints are rare and generally believed to be due to mechanical instability. There is currently no consensus on the management of such lesions in symptomatic and asymptomatic patients. Both conservative and surgical strategies have been described. Surgery may involve anterior or posterior approaches with and without decompression and instrumentation. METHODS: We present a case report of a 45-year-old man who presented with new onset weakness and ataxia. Physical examination revealed decreased motor function in all extremities as well as positive Hoffman sign and ankle clonus bilaterally. An MRI of cervical spine showed a large atlantoaxial, T-2 hyperintense cystic lesion with cord compression and cord signal changes. RESULTS: A C1 partial laminectomy was performed with resection of the cyst and C1-2 instrument fusion. Intra-operatively, the cystic lesion was found to be anatomically connected to the right C1-2 atlantoaxial joint with pathology showing fibroconnective tissue and chronic inflammatory changes. Post-operatively there were no complications and the patient was discharged to a rehabilitation facility. The patient was regaining gait and hand function by 3 months after surgery. CONCLUSIONS: Atlantoaxial synovial cysts are rare and the optimal surgical approach has not been determined. We further conducted a literature review and found a total of 70 other cases of atlantoaxial synovial cysts reported to date in the literature. We attempt to analyze available data and evaluate anterior versus posterior approaches and the need for decompression, amount of cyst resection, and instrumentation.