Original ArticleEndoscopic Surgical Treatment of Lumbar Synovial Cyst: Detailed Account of Surgical Technique and Report of 11 Consecutive Patients
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.
References (32)
- et al.
Minimally invasive tubular resection of lumbar synovial cysts: report of 40 consecutive cases
World Neurosurg
(2016) - et al.
Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: systematic review of reported postoperative outcomes
Spine J
(2010) - et al.
Endoscopic posterior cervical foraminotomy as a treatment for osseous foraminal stenosis
World Neurosurg
(2016) - et al.
Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy
J Orthop Res
(2005) Lumbar juxtafacet cysts: simply an extension of the lumbar degenerative process
World Neurosurg
(2012)- et al.
Lumbar intraspinal synovial cysts: conservative management and review of the world's literature
Spine J
(2003) - et al.
Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience
J Neurosurg
(2000) - et al.
Synovial cyst of spinal facet. Case report
J Neurosurg
(1974) - et al.
Lumbar intraspinal synovial and ganglion cysts (facet cysts). Ten-year experience in evaluation and treatment
Spine
(1995) - et al.
Spinal lumbar synovial cysts. Diagnosis and management challenge
Eur Spine J
(2006)
A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment
J Neurosurg
Resolution of a synovial cyst of the lumbar spine without surgical therapy—a case report
Zentralblatt fur Neurochirurgie
Spontaneous resolution of a symptomatic synovial cyst of the lumbar spine
Br J Neurosurg
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 cysts treated by CT-guided intracystic and intra-articular steroid injections
Eur Radiol
A new endoscopic spine system: the first results with “Easy GO”
Acta Neurochir
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.