Elsevier

World Neurosurgery

Volume 103, July 2017, Pages 122-132
World Neurosurgery

Original Article
Endoscopic Surgical Treatment of Lumbar Synovial Cyst: Detailed Account of Surgical Technique and Report of 11 Consecutive Patients

https://doi.org/10.1016/j.wneu.2017.02.075Get rights and content

Background

Lumbar synovial cysts (LSCs) are an uncommon cause of radiculopathy and back pain. Open surgical treatment is associated with extensive bone resection and muscle trauma. The endoscopic tubular–assisted LSC resection has not been described in detail. Here the authors assessed the effectiveness of this technique for LSC resection.

Methods

Eleven patients (4 female and 7 male patients) were operated on via an ipsilateral approach for resection of LSC using an endoscopic tubular retractor system. Preoperative magnetic resonance imaging was evaluated for signs of degeneration and instability. At follow-up a standardized questionnaire including the Oswestry Disability Index and functional outcome according to MacNab criteria was conducted. Additionally, a personal examination with particular reference to back and leg pain was performed.

Results

The mean follow-up was 10.5 months. Preoperatively, spondylolisthesis grade 1 was noted in 4 patients (36.4%). Ten patients had bilateral facet joint effusion (90.9%). At follow-up 10 patients reported being free of leg pain (90.9%), eight patients reported no back pain (72.7%), ten patients had full motor strength (90.9%), and 9 patients had no sensory deficit (81.8%).

Nine patients reported an excellent or a good clinical outcome (81.8%). The mean Oswestry Disability Index was 4.7%. None of the patients developed new mechanical low back pain or required subsequent fusion procedure.

Conclusion

The endoscopic tubular–assisted procedure is a safe way to treat LSC. It offers complete resection of LSC and achieves good clinical outcome by preserving muscle and ligamentous and bony structures, which prevents delayed instability.

Introduction

Lumbar synovial cysts (LSCs) are a relatively uncommon cause of spinal canal stenosis and nerve root compression. LSCs are extradural herniations of the facet joint synovium between 2 adjacent vertebral bodies.1, 2 Most commonly, they occur at level L4-5, followed by level L5-S1, and are located ventral to the ligamentum flavum and dorsolateral to the dural sac.1, 3, 4 Due to their typical localization within the spinal canal, LSCs may impinge on exiting or traversing nerve roots and cause neurogenic claudication, radiculopathy, and back pain.

It has been reported that LSCs are associated with facet joint degeneration and some degree of spinal instability.5, 6, 7

Due to the nature of LSCs, a spontaneous resolution is highly unlikely even though cases of spontaneous resolution have been reported.8, 9 The ideal surgical treatment remains controversial. Image-guided aspiration or steroid injection achieves pain relief for a short-term period.10, 11 However, the surgical resection of LSCs is believed to be a definite treatment to achieve permanent relief of symptoms. Traditionally, open laminectomy or partial laminectomy with medial facetectomy is performed for resection of the LSC.

LSCs can be adhesive to the dura; therefore surgical resection might be associated with complication such as nerve injury, cerebrospinal fluid (CSF) leaks, and delayed instability.1 Delayed instability might lead to further surgical treatment with lumbar fusion.

Since 1997, tubular-assisted procedures have been successfully performed for the treatment of degenerative cervical changes, lumbar disk herniation, lumbar spinal stenosis, and lumbar intradural extramedullary tumors.12, 13, 14, 15, 16 Compared with open microsurgical procedures, tubular-assisted techniques are associated with several advantages such as a shorter length of hospitalization, less blood loss, less postoperative pain medication, and lower postoperative inflammatory markers.17, 18

Additionally, trauma to ligamentous and bony structures is minimized, which might decrease the risk of delayed instability. Tubular-assisted procedures can be performed by using either an endoscope or an operating microscope for visualization. For 10 years, high-definition endoscopy has been available, allowing for superior intraoperative visualization compared with the former standard-definition endoscopy.19

To the best of the authors' knowledge, there has been no report of a series of >4 patients treated for LSC via an endoscopic tubular–assisted procedure.20

The purpose of this study is to report clinical outcome after using endoscopic LSC resection and to present the surgical technique in detail.

Section snippets

Patient Population

A prospectively collected database of endoscopic spine procedures was searched for patients who underwent treatment of LSC.

Inclusion criteria for this study were complete endoscopic video recording of the procedure, a complete set of preoperative evaluations including detailed neurologic examinations with special focus on leg and back pain, a histopathologic report of the specimen, no previous lumbar spine surgery, and a preoperative magnetic resonance imaging (MRI) scan.

Postoperatively,

Results

Between October 2014 and October 2016, 11 patients (4 male and 7 female) were identified from the database and all met the inclusion criteria. The mean age at endoscopic procedure was 59.0 years (range 30–80 years). The mean follow-up was 10.5 months (range 1–24 months).

The histopathologic report of the intraoperative specimen revealed a true synovial cyst with synovial cell lining and xanthochromatic change in all cases.

Preoperative MRI revealed a unilateral synovial cyst in all cases. The

Discussion

The ideal treatment for LSC remains controversial regarding surgical technique and approach. Although traumatic causes of LSC have been reported, the majority of LSCs are caused by degenerative disease.1, 3, 24

The mean age of patients suffering from symptomatic LSC is in the 60s without a clear male or female predilection.1, 5, 7 Our results, with a mean age of 59 years and with 4 male and 7 female patients, are similar to those in the literature.

Subsequent segmental instability on the base of

Conclusion

An endoscopic tubular–assisted procedure is a safe way to treat an LSC. It offers complete resection of the LSC and achieves good clinical outcome by preserving the muscle and ligamentous and bony structures, which prevents delayed instability.

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  • Cited by (0)

    Supplementary digital content available online.

    Conflict of interest statement: Joachim Oertel is a consultant of the Karl Storz company. There has been no financial support for this work that could have influenced its outcome.

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