Ganglion Cysts (Facet Cysts) · involved facet joints in 12 paticnt.s. Facet maneuvers...

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©lyyi. J. li. Lippincott (-ompany Lumbar Intraspinal Synovial and Ganglion Cysts (Facet Cysts) Ten-Year Experience in Evaluation and Treatment Ken Y. Hsu, MD,* James F. Zucherman, MD,* William J. Shea, MD.t and Robert A. Jeffrey, MDt Study Design. This study analyzed the clinical his tory, physical examination, diagnostic studies, and op erative and histoiogic findings in 19 patients with lum bar intraspinal synovial and ganglion facet cysts evaluated and treated over a 10-year period. Objectives. The results were correlated to provide a greater understanding of the nature of lumbar facet cysts and rationale for conservative or surgical treat ments. Summary of Background Data. The 19 patients in cluded 13 women and 6 men ranging in age from 38 to 70 years. 84,4% of the patients presented with radicular pain. 26.3% had significant motor deficit. 68.4% of the "T^ei cysts were found at L4-i'l^, 21.1% at L5-S1, 5.2% at 1.1-L2, and 5.2% at L2-L3. Their clinical pictures, im aging studies, and surgical and histoiogic findings were correlated in a retrospective fashion. Methods. The clinical history and findings on physi cal examination, standard radiography, myelography, computed tomography-myelography, facet anhrogra- phy, post-facet arthrography, magnetic resonance imag ing with and without contrast, and computed tomogra phy scans were reviewed. Results. Bilobed cysts were found on both dorsal and ventral lispecis of the involved facet joints within and outside of the spinal canal on facet arthrography. computed tomography, magnetic resonance imaging, and at the time of surgery in more than 60% of the pa tients. Significant facet degeneration was found in 75% of standard radiographs, and in all of the magnetic res onance imaging and computed tomography scans, in six patients, syniptoms improved with rest, medication, and bracing, Epidural corticosteroid injections provided short-term relief in three out of four patients. Facet cor ticosteroid injections provided good relief in one, par tial relief in one, and no relief in one patient. Surgical decompression in eight patients resulted in three excel lent, four good, and one fair outcome. Conclusions. Most of the lumbar intraspinal facet cysts were associated with significantly degenerated facet joints. Patients with intraspinal facet cysts may respond to conservative treatments if there is no signifi cant neurologic deficit. Surgical decompression and removal of large facet cysts usually are successful in l-roin ".St. .Vlary's .Spmc Center, San Franci.seo, Calilornia, .ind fDc- partincnt of Kadiology and $Dcpartnicnt of I'atlioiogy, St. Mary".*; Hospital and Medical Center, San Franci-scn. Accepted for publication July 19, 1994. Device status category; 1, relieving symptoms. |Key words; facet degeneration, ganglion cysts, intraspinal facet cysts, lumbar spine, sy novial cysts] Spine 1995;20.000-000*~ Synovial and ganglion cysts may arise from periarcicular tissues, most commonly in the extremities at the wrist, knee, ankle, and foot. Juxta-articular cysts in the spine are less common. Intraspinal "synovial cysts" and "gan glion cysts" have been defined, althougli it is not clear whether they are two completely separate entities. His- tologicnily, a true synovia! cyst has a surrounding lining of synovial-likc epithelial cells. A ganglion cyst does not have synovia] lining. !r has a collagenous capsule or fibrous wall surrounding myxoid material. Some au thors have suggested that a synovial cyst may evolve into a ganglion cyst, and others have proposed that a ganglion cyst may develop a synovial lining over cime.'"'^ Histo iogic studies have demonstrated the presence of both sy novial and ganglion cysts within the spine,although the term "intraspinal synovial cyst" is more frequently used in the lircrarurc. because our patients had both syno vial and ganglion cysts rhat were associated with the facet joints, the term "intraspinal facet cysts" will be used in the present report. In general, the literature, which consists of mostly case reports, has emphasized the rarity of this condition in the spine, although wc were able to find more than 65 articles, representing at least 120 cases.The largest reported scries of himbar intraspinal cysts described 10 patients.^'' Over the years, various diagnostic studies have been used to identify intraspinal facet cysts. These include myelography, computed tomography (CT), CT myelog raphy, facet arthrography, post-facet CT arthrography, and magnetic resonance imaging (MRI) with and with out contrast agent. Treatment methods have ranged from bed rest, bracing, percutaneous needle aspiration, and facet corticosteroid injection to surgical removal of rhc cysts. In this report, we present our experience with 19 documented lumbar intraspinal facet cysrs evaluated

Transcript of Ganglion Cysts (Facet Cysts) · involved facet joints in 12 paticnt.s. Facet maneuvers...

Page 1: Ganglion Cysts (Facet Cysts) · involved facet joints in 12 paticnt.s. Facet maneuvers withlumbarextension and lateral bending to thesideof the lesion increased the back pain or radicular

©lyyi. J. li. Lippincott (-ompany

Lumbar Intraspinal Synovial andGanglion Cysts (Facet Cysts)Ten-Year Experience in Evaluation and Treatment

Ken Y. Hsu, MD,* James F. Zucherman, MD,* William J. Shea, MD.tand Robert A. Jeffrey, MDt

Study Design. This study analyzed the clinical history, physical examination, diagnostic studies, and operative and histoiogic findings in 19 patients with lumbar intraspinal synovial and ganglion facet cystsevaluated and treated over a 10-year period.

Objectives. The results were correlated to provide agreater understanding of the nature of lumbar facetcysts and rationale for conservative or surgical treatments.

Summary of Background Data. The 19 patients included 13 women and 6 men ranging in age from 38 to70 years. 84,4% of the patients presented with radicularpain. 26.3% had significant motor deficit. 68.4% of the

"T^ei cysts were found at L4-i'l^, 21.1% at L5-S1, 5.2%at 1.1-L2, and 5.2% at L2-L3. Their clinical pictures, imaging studies, and surgical and histoiogic findingswere correlated in a retrospective fashion.

Methods. The clinical history and findings on physical examination, standard radiography, myelography,computed tomography-myelography, facet anhrogra-phy, post-facet arthrography, magnetic resonance imaging with and without contrast, and computed tomography scans were reviewed.

Results. Bilobed cysts were found on both dorsaland ventral lispecis of the involved facet joints withinand outside of the spinal canal on facet arthrography.computed tomography, magnetic resonance imaging,and at the time of surgery in more than 60% of the patients. Significant facet degeneration was found in 75%of standard radiographs, and in all of the magnetic resonance imaging and computed tomography scans, insix patients, syniptoms improved with rest, medication,and bracing, Epidural corticosteroid injections providedshort-term relief in three out of four patients. Facet corticosteroid injections provided good relief in one, partial relief in one, and no relief in one patient. Surgicaldecompression in eight patients resulted in three excellent, four good, and one fair outcome.

Conclusions. Most of the lumbar intraspinal facetcysts were associated with significantly degeneratedfacet joints. Patients with intraspinal facet cysts mayrespond to conservative treatments if there is no significant neurologic deficit. Surgical decompression andremoval of large facet cysts usually are successful in

l-roin ".St. .Vlary's .Spmc Center, San Franci.seo, Calilornia, .ind fDc-partincnt of Kadiology and $Dcpartnicnt of I'atlioiogy, St. Mary".*;Hospital and Medical Center, San Franci-scn.Accepted for publication July 19, 1994.Device status category; 1,

relieving symptoms. |Key words; facet degeneration,ganglion cysts, intraspinal facet cysts, lumbar spine, synovial cysts] Spine 1995;20.000-000*~

Synovial and ganglion cysts may arise from periarciculartissues, most commonly in the extremities at the wrist,knee, ankle, and foot. Juxta-articular cysts in the spineare less common. Intraspinal "synovial cysts" and "ganglion cysts" have been defined, althougli it is not clearwhether they are two completely separate entities. His-tologicnily, a true synovia! cyst has a surrounding liningof synovial-likc epithelial cells. A ganglion cyst does nothave synovia] lining. !r has a collagenous capsule orfibrous wall surrounding myxoid material. Some authors have suggested that a synovial cyst may evolve intoa ganglion cyst, and others have proposed that a ganglioncyst may develop a synovial lining over cime.'"'^ Histoiogic studies have demonstrated the presence of both synovial and ganglion cysts within the spine,althoughthe term "intraspinal synovial cyst" is more frequentlyused in the lircrarurc. because our patients had both synovial and ganglion cysts rhat were associated with the facetjoints, the term "intraspinal facet cysts" will be used in thepresent report.

In general, the literature, which consists of mostlycase reports, has emphasized the rarity of this conditionin the spine, although wc were able to find more than 65articles, representing at least 120 cases.The largestreported scries of himbar intraspinal cysts described 10patients.^''

Over the years, various diagnostic studies have beenused to identify intraspinal facet cysts. These includemyelography, computed tomography (CT), CT myelography, facet arthrography, post-facet CT arthrography,and magnetic resonance imaging (MRI) with and without contrast agent. Treatment methods have rangedfrom bed rest, bracing, percutaneous needle aspiration,and facet corticosteroid injection to surgical removal ofrhc cysts.

In this report, we present our experience with 19documented lumbar intraspinal facet cysrs evaluated

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Figure 1. (A) Oblique projection of plain film series demonstrates severe degenerative changes at the right L4-L5 facet of a 57-year-oidwoman. (B) Computed tomography axial view demonstrates partially calcified cyst. Note the presence ofcystic massesventral anddorsalto the degenerated facet joint. (C) Magnetic resonance imaging axial Tl-weighted image (TR 800/TE 30) reveals increased signal intensityof inner rim with low signal emanating from the center ofthecyst. (D) Sagittal T2-weighted image (TR 2000/TE 65) shows uniform decreasein signal intensity in this lesion. (E) Post-facet arthrogram CT scan demonstrates contiguity of the bilobed ventral and dorsal facet cyst.

u-\ rreared over a 10-year period. Our methods haveC\ evolved with the development of new technologies.

V' ,-V- ,\n(• Materials and Methods

Nineteen patients were evaluated and created for lumbar in-craspiiiai facet cysc.>5 between Janii.nry 1982 and June 1992 at St.Mary's HospirnI and Medical Center, San Fraticisco, California.The clinical history, physical examination, diagnostic studies,and operative and iuscologic findings were reviewed. There were1.3 women and 6 men in the study group. Their ages ranged from.38 to 79 years, wirh an average age of .S8. Follow-up withphysical examination and diagnostic studies were performed in14 pariLMUs, wirh a range of follow-up of 1.5 ro 8 years. In fivepacients, follow-up ranged from .? co i 1 months. Fifteen patientswere studied with standard radiogrnphj' of the lumbar spine,inclutling oblititic projcction,s. (Figure.s lA, 2A)

Three of thc.se patients uiidcrwent lumbar myelographyfollowed by CF myclography of the involved areas. (C'Kurc.s.1A;(3C; b;^5.A, P>) Twelve pacients had routine CT scansof the lumbarspine. Qugurcs IB; 2B, D, E; .3B;(6A;l7A;/'8A, B;

(9D, E) ' ^

Nine patients had magnetic resonance examinations of thelumbar spine. (Figures IC, D; 5C; 6B, C; 7B, C; 9A, B, C) andtwo patients were injected with gadolinium dierhylcnetriaminepcnta-aceric acid (Magnevist; Beriex Laboratories, CedarKnolls, New lersey;U'"igurcs lOA^ B.^.

In rhrec pacients, facet arthrograms were performed (Figures IE, 5D) and then CT scans were obtained. All CT scans

were performed on either a General Electric 9800 (GeneralElectric, Milwaukee, WI) or a Technicarc 2060 (Solon, OH)scanner. The magnetic resonance examinations were obtainedusing a General Electric 1.5 Tcsla superconducting unit, a .03Tcsla Fonar (Melville, New York) 500 permanent magnet, ora Resonex (Sunnyvale, California) R4000. All magnetic resonance examinations included Tl-weighccd axial scans (TR600-800, TE 20) and T2-wcighced (TR 2000, TE 80-100)sagittal sequences. The slice thickness varied from 3 co 5 mm,depending on machine and technique used. Additional T2-wcighted axial scans were obtained in three (flip angle, 10°—15°). All patients initially were treated with conservative measures. Eight patients required surgical intervention. Epiduralcorticosteroid injections were performed in four patients. In-

Figuru 2. (A) Lateral radiograph of a ^B-year-oid woman in September 1984 reveals mild degenerative changes at L4-L5. (B) Computedtomography axial image in October 1986 demonstrates noncalcified cyst off right L4-L5. Patient was treated with corticosteroid injectionof facet joint and conservative management, (C) laiBrai radiograph in February 1991 reveals degenerative spondylolisthesis of 14 on 15.Computed tomography scan with (D) axial and (E| sagittal reconstructed images demonstrate severe facet degeneration and bony erosivechanges. The cyst disappeared spontaneously.

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Figure 3. (A) Myelogram localizing posterolateral extradural defect at L5-S1 on the riaht side in a 72-vpar niri wnmpn /ri rnmnMtoH

o°™mTpJtient 'arge cyst occupying approximately 50% of the spinal canal. (C) Post-myelogram CT scan-axial view

jcciions of corticosteroid into the involved facet joints wereperformed in ihrcc pacient.s (|-igi,re 9I-). i-indings were incidental in three patients. Seven surgical specimens were histo-

logicaliy examined. Patients' clinical history, physical cxami-nntion. imaging modalities, and operative and histologicfindings were correlated in a retrospective fashion.

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iiiinimrnPrrmTm® 41 5,. >r *: -

contiguous with facet vacuum demonstrates development of a cyst with air in the central cavity that is

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Figure 5. (A) Oblique projectionfrom lumbar rriYelogram in a 48-

tyoar-old woman reveals charac-torisiic extradural posteroiatern!defect on subarachnoid column

of dye. (B) Computed tomograpfiymyelogram documents 14 mmnoncalcified cyst on the left atL4-L5. (Cj Tl-weighted MR! (TR1000/TE 30) reveals homogenousincreased signal intensity in thiscyst. This lesion was not identified on T2-weighted sagittal sequence. (D) Post-facet arthro-gram CT scan with patient proneclearly demonstrates communication between cyst and facetjoint.

T

• Results

Nineteen incraspinal facet cysts were identified in 19patients. Thirteen of the involved facet cysts were identified nt L4-L5, four at L5-S1, and one each at Ll-12and L2-L3. Seven patients reported only radicuiar pain,

/I

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Figure 6. (A) Computed tomography axial scan through L4-L5 demonstrates typical cyst extending from the degenerative left L4-L5 facetjoint of a 62-year-old man. Note faint calcification in the rim of the cyst. (B) Magnetic resonance imaging axial Tl-weighted images (TR833; TE 11) demonstrate cyst with increased signal intensity when compared with the cerebrospina! fluid and poorly defined rim. (C)Magnetic resonance imaging sagittal T2-weighted images (TR 1000; TE 30/70) demonstrate the difficulty in identifying this cyst. Notedecreased signal of the cyst rim and T2 prolongation of cyst contents.

B

lasting 6 weeks to 29 months and averaging 8 months.Nine patients complained of back and lower extremit)'pain. Three patients had only back pain. In the above 12 •f'"patients, the duration of back pain was 3 months to 20years, with an average of 7 years.

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Figure 7. (A) Axial image from CT scan of a 53-year-old woman in April 1991 demonstrates only degenerative changes at the right L4-L5facet joint. No cyst is evident. (Bj Magnetic resonance imaging axial Tl-weighted image (TR 817/TE 11) obtained in September 1991demonstrates increased signal intensity in the cyst compared with the cerebrospinal fluid. (C) Sagittal T2-weighted images (TR 2000/TE30/80) from the same study fails to demonstrate this cyst. (D) Surgical specimen stained with indigo carmine. (E) Histologic examinationof the surgical specimen revealed that most of its wall contained fibrous connective tissue without synovial lining. (Hematoxylin-eosin,original magnification x350.) (F) Histologic examination of the base of the cyst adjacent to the facet joint where the synovial cells wereevident. (Hematoxylin-eosin. original magnification xlBO)

Physical examination revealed tenderness over theinvolved facet joints in 12 paticnt.s. Facet maneuverswith lumbar extension and lateral bending to the side ofthe lesion increased the back pain or radicular pain infive patients. In one patient, manual compression of theinvolved facet joint caused reproduction of radicularpain. The straight leg raising test was positive in seven.Femoral nerve stretch test was positive in five. Significant motor deficits were noted in five patients. Sensorychanges were found in eight patients.

In 10 of the 15 patients, standard radiographs demonstrated degenerative changes at the involved facetjoints manifested by joint space narrowing and bonyovergrowth (Figure lA). Facet subliixation and degenerative spondylolisthesis were identified in three. Threemyelograms demonstrated posterolaceral extradural filling defects in three patients (Figure .3A).

On CT scan, the density of tlie facet cysts variedsignificantly. In five ofthe patients, the scan appeared tobe completely cystic. In two of tiic patients, a rim ofcalcification was identified, suggesting ossificationwithin the capsule (Figure 6A). Diffuse calcification wasscattered throughout the cyst in three patients (FiguresIB; 9D, E). In two patients, a focal globular area ofcalcification was identified within the contents of thecyst itself. The cysts varied in size from 5 to 16 mm.Erosion of the cortical bone in the adjacent articulatingfacets was identified in one patient, and in another, airwa,s identified witliin the cy.sr and communicated withair within die facet joint. All of the facet cysts wereidentified as extradural masses adjacent to the facetiigamcntum flavum within the spinal canal. Compression of the dura] sac or nerve roots was identified in allpatients. In eight patients, the soft tissue mass appearedto involve both the dorsal mferolatcral and the ventral

superior-medial aspects of the involved facet joints.These bilobed or dumbbell shaped lesions were otherwise similar in their CT appearance (Figure IB).

The magnetic resonance appearance of the facet cystson Tl-weighted axial scans was characteristic. In allinstances, independent of CT density, the facet cystswere of increased signal intensity compared with thecerebral spinal fluid on Tl-weighted axial scans (Figure6B). Signal intensity was nearly the same or slightlyincreased when compared with the adjacent iigamcntumflavuin. The cysts were of variable signal intensity on allT2-wcighted sequences (Figures 9B, IOC). At times, thefacet cysts were extremely difficult to identify on sagittalT2-weightcd sequences because of partial volume averaging and their variable signal intensity (Figures 6C,7C). The capsule of the cyst had a well-defined, lowsignal intensity on Tl- and T2-weighced sequences inonly two patients. These patients had densely calcifiedrims on CT scans.

injection of contrast material in the facet joints ofthree patients followed by CT scanning confirmed thecontinuity of the cysts with the involved facet joints(Figures IE, 5D). In these three patients, similar findingswere noted at the time of surgery. They were found tohave dorsal involvement of the cyst at the facet joint(i^MgureJJ). As the paraspinal musculature was elevated,cystic material was found emerging from the facet jointbefore the spinal canal was exposed. Indigo carminesolution injected into the dorsal component of the cysticmass subsequently was found within the ventral component in the spinal canal. In our experience, indigocarmine localization of the synovial cyst facilitated complete surgical resection (Figure 7D).

Significant calcification noted within the cystic masson CT was confirmed intraoperativeiy in two patients.A

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chalk-like substancewas found alongwith gelatinous ormucinous material within the mass at the time of surgery. In the others, no apparent calcification was visualized during surgery. Degenerated mucinous materialwas found ro be enclosed in the fibrous cyst wall. Thecystic ma.sscompressed the diiral snc or the nerve root inall cases. The dural sac had adhered to the cyst wail inthree cases.

Histologic examination of the surgical specimens infour patients revealed that the cyst wall contained fibrous connective tissue without synovial lining. In onecyst, mostof its wall was fibrous and devoid of synoviallining cells, except at the base adjacent to the facet jointwhere the synovial cells were evident (Figures 7E, F). Inthe others, the internal surface of the fibrous wall waslined with a layer of synovial-type cells. Amorphousprotcinaceous substance was found in the cyst interior.Occasionally, hcmosidcrin deposits, small fragments ofcalcified structure, bone, or cartilage were found.

Other significant spinal pathologies were found in thelumbar spine of eight patients. Those included severespinal stenosis in two, stenosis and disc herniation intwo, multilevel disc degeneration and herniations inthree, and tumor metastasis in one.

S t

figure 8. (A, B) Soft tissue and bone windows from CT study of a70-year-old man demonstrate calcification botii within the cystand along its rim.

Of the 19 patients, 11 received nonsurgical treatments. Because the facet cysts were incidental findings inthree, no treatment was directed to this condition inthese patients. In six patients, symptoms improved withconservative treatment, including rest, medication, andbracing. Two patients were not included in follow-up.Epidurai corticosteroid injections in four patients provided significant but short-term relief lasting 3 weeks to2 months. One patient had no relief of symptoms. Facetcorticosteroid injections were performed in three patients, with one having good relief, one partial relief,and one no relief. A 48-year-oid woman received a facetinjection for an L4-L5 facet cyst documented on CTscan (Figure 2B). After the injection, her symptoms improved for 5 months. However, more back pain subsequently developed. Repeat CT scan 4.3 years later revealed the disappearance of the cysr and development ofprogressive degenerative changes with erosion of sub-chondral bone and formation of cavities (Figures 2D, E).Serial radiographs over 6 years demonstrated a gradualdevelopmentof degenerative spondylolisthesisatL4-L5(Figure 2C).

Surgical decompression with removal of the facetcysts was performed in eight patients. We rated theresults as follows.

Excellent: complete resolution of symptoms.Good: marked improvement, occasional pain, occasional use of pain medication.

Fair: some improvement, need for pain medications,significant functional restrictions.

Poor: no change in symptoms, or worse.

There were three excellent results, four good results,and one fair result. The patients with excellent resultshad predominantly lower extremity pain of less than 1year duration. The patient with a fair result had an8-year history of low back pain and a 16-month historyof lower extremity pain with associated severe degenerative disc disease and spinal .stenosis.

• Discussion

A literature review showed chat most intraspinal synovia! or ganglion cysts in the lumbar spine occur atL4-L5 and occasionally ar L5-S1 and L3-L4.'~^'^ In thepresent study, 68.4% were at L4-L5, 21.1% at L5-S1,5.2% at L1-L2, and 5.2% at L2—L3. Increased jointmorion may predispose ro facet joint osreoartliritis, degenerative spondylolisthesis, and cyst formation at theL4-L5 level, which generally has the most motionwithin the lumbar spine.

Degenerative arthritic changes and increased jointmotion may lead ro proliferation or herniation of articular tissue through a joinr capsule defect, resulting incyst formation.^" Altliough the term "intra.spinal synovial cyst" is commonly used in the literature, previousstudies have demonstrated the presence of lumbar juxta-

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which may accoun, fo. .he .agae.ic raaonan^Vsig'arcto^^ ta'L'eT"articular cysts with and without synovial lining ceilsi.nularly, our series iuid hoth types „i cysts Notablyone cyst sliowcd boti, features with most of its wall'liurely fibrous, except for the base of the cyst whichc ntnined synovia! lining cells. It was not clear t'virc^er

ticatiMi, residual synovium. Ycc, the /indine of both

^ai"c;:':„d"'"thes::nenot entirer"'''""'' 'S-'-'Slio" or fibrous cyst)arc not entirely separate entities

PilnabkiT"'"''"'"">1 betenderness over the involved facet joints. WithmI a coniptcssion. rntlicninr j.ain cot,Id be tepro-diiccd ,n one patient with CT scan, and MRI docu

v^Tcyst'c» the synovia cyst. Compression of the dorsal aspect of the cvstprobably cansed transmission of dnid pre sure to thevcnttal portion of the cyst, testilting mnerve root ittn

ration. In eight patients, the bilobed configuration of thecysts was documented on MRI, CT, post-facet CT ar-

wcr"^" Ji' "u'i'" Cystic massesvcrc found on the dorsal and ventral aspects of severely(Ic.gcncrated and hypcrtrophied facet joints, liven conventional radiographs showed marked degenerativeacct arthritis m75% of those who had standard radio

graphs. Serial radiographs in one patient over aS-yearperiod also documented the gradual development of(cgenerative spondylohstlicsis in the involved levelThese findings suggest that cysts may be one manifestation n, the progression and spectrum of facet degenera-five changes.

inrm'r' l7 diagnosis of" erarth " Tt '"yelography, CT scan,facet arthrogram-CT scan, and MRI. Magnetic reso-

"ancc imaging appears to offer the best means of visu-ahrmg the cyst, especially with the use of contrast agent.

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faLt joint. The^cysTrim is^bTacfo'̂ n enhancement centrally within the cyst of the left L4-L5

Yiih ec reported five cases of intraspinal synovialcysts evaluated with noncontrast MRI and MRI usinggadolmium dicthyienctriaminc pcnta-acctic acid. Theydemonstrated early enhancement of the solid component and cyst periphery, delayed enhancement of thecysr, persi.ycnt enhancement of the .solid component andcyst cap.siilc, enhancement of the facet joint, and recognition of possible connection between the cyst and theloint space. Yuh er nl speculated chat the MRI solidcomponent represented the isolated dense hypervascular

K.HsCC

Figure 11_ Illustration of lumbar facet cyst visualized at the time of

lli il emprnfn f dorsal portion(11) IS emerging from the same facet joint.

fibrous connective tissue, which showed immediate andpersistent enhancement.

Although synovia! cysts are fairly characteristic, appearance of similar soft tissue mass in the epidural spacerequires consideration in the differential diagnosis ofextruded or sequestered disc fragment, metastatic tumor, meningioma, schwannoma, ncurofibroma withcystic degeneration, arachnoid cyst, perineural cyst, anddcrmoid cyst. Kao et al'̂ ' classified cxtradural intraspinal cysts into the following three groups.

1. l^erineural cysts (arising from dorsal root ganglion).2. Arachnoid cysts (pedicle attachment to spinal duranear nerve root).3. juxta-facec cysts (ganglion and synovial cysts attached to periarticiilar connective ris.sue of facetjoints).

Not all intraspinal synovial cysts are symptomatic, asshown by incidenrni findings in three of our patients.Spontaneous reduction or resolution of the cyst mayoccur with rest or bracing. Facet injection or a.spirationmay be attempted if the cyst is not calcified. Administration ofcorticosteroids with orwithout local anesthetics into the adjacent facet joint may improve or resolveciic problem. Computed tomography scans pre- andpost-facet injection in one patient in our series demonstrated the disappearance of the cysr after the intra-nriiciilar corticosteroid injection. Epidural corticosre-

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roid injections provided symptomatic relief of up to 2months in three of four patients in our study.

Such response to epidurai injections may lead thephysician astray regarding the actual diagnosis. Whenthe cyst is partially or completely calcified, there is lesslikelihood ofspontaneous shrinkage with aspiration orcorticosteroid injection. Surgical decompression is indicated in the face of intractable pain and especially withsignificant neurologic deficit orcaudn eqiiina syndrome.Surgical decompression generally produces good reliefftom the radiciilar pain. Ifthere also is significant instability with spondyloiisthesis, fusion in addition to decompression may be necessary.

References

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giiidcd needle aspiration biopsy of an intraspinal synovial cyst(ganglion): Ca.se report and review of the literature. AJNR AmJ Ncuroradlol 1988;9:398-400.

3. Awwad EE, Martin DS, Smith KR Jr, bucholz RD. MRImaging of lumbar juxtaarticular cysts, j Comput Assist To-mogr 1990;14:415-7.4. Awwad EE, Sundaram M, bucholz RD. Post traumatic

spinal .synovial cyst with .spondylolysis: CT features. J ComputAssist Tomogr 1989;13:334-7.5. Azzam CJ. Midlinc lumbar ganglion/synovial cyst mim

icking an epidurai tumor: Case report and review of patho-genc.sis. Neurosurgery i988;23:2.)2-4.

6. b.iuin JA, Hanley EN. Intraspinal synovial cyst simulatingspinal stenosis. Spine 1986;]1:487-9.

7. Bhushan C, Hodges F, Wityk J. Synovial cyst (ganglion)ofthe lumbar spine simulating cxtradiiral ma.ss. Ncuroradiol-ogy 1979;18:263-8.

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AQ-1 AL): abstract had to be shortened to fit journal format.AQ-2 AU: figures have been renumbered to preserve proper numerical citation in the text. NOTE: this is a

requirement of this journal.AQ-3 AU: 'scanner' OK to describe machines.'AQ-4 AU: R4000 what.'AQ-5 AU: 12 patients mentioned in this paragraph.' Clarify.AQ-6 AU: inferohucral OK.'AQ-7 AU: signal intensity of what? Sentence is unclear.

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