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   Abstract
   Introduction
   Materials and Me...
   Results
   Discussion
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   Acknowledgment
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ORIGINAL ARTICLE
Year : 2006  |  Volume : 54  |  Issue : 1  |  Page : 38-41

Intraspinal synovial cysts: A retrospective study


Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport, Shreveport, Louisiana, USA

Correspondence Address:
Anil Nanda
Department of Neurosurgery, Louisiana State University Health Sciences Center in Shreveport 1501 Kings Highway, PO Box 33932, Shreveport, LA 71130-3932
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0028-3886.24700

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  Abstract 

Background: We report the clinical presentation, radiographic studies, intraoperative findings, histopathological analysis, and post-treatment outcome in 26 patients diagnosed with spinal synovial cysts (SSCs). Aims: To describe the clinical presentation, radiographic studies, operative findings, and postoperative follow-up in 26 patients with SSCs. Settings and Design: The study was retrospective in design, involving chart review. Individual patient data was tabulated and patterns were recognized. Materials and Methods: The charts for 26 patients who underwent surgical extirpation of SSC between April 1993 and October 2002 were retrospectively reviewed. Specifically, initial clinical presentation, pertinent radiographs (X-rays, magnetic resonance imaging, computed tomography), intraoperative findings, histopathology, and postoperative follow-up were noted. Statistical Analysis Used: Patient data was tabulated and analyzed for patterns in demographics, symptoms and histopathology. Results: SSCs were more common in females than males (17:9 ratio). Presenting symptoms were back pain with radiculopathy in 13 (50%), radicular pain in the absence of back pain in 10 (38%), and back pain without radicular pain in three (11%). In addition, 17 patients (65%) had sensory deficit, and 9 (35%) had motor deficit. Most SSCs occurred at the lumbar (19/26) or lumbosacral (5/26) regions, with only 2 (2/26) in the thoracic region. One patient had bilateral SSC at the L4-5 level. Intraoperatively, each cyst was located adjacent to a degenerated facet joint. These lesions could grossly be identified intraoperatively and histopathological confirmation was achieved in all the cases. Conclusions: SSCs are important lesions to consider in the differential diagnosis of lumbar epidural masses and surgical resection leads to significant improvement in the majority of cases.


Keywords: Extradural, facet joint, spine, synovial cyst


How to cite this article:
Acharya R, Patwardhan R V, Smith D R, Willis B K, Fowler M, Nanda A. Intraspinal synovial cysts: A retrospective study. Neurol India 2006;54:38-41

How to cite this URL:
Acharya R, Patwardhan R V, Smith D R, Willis B K, Fowler M, Nanda A. Intraspinal synovial cysts: A retrospective study. Neurol India [serial online] 2006 [cited 2019 Nov 17];54:38-41. Available from: http://www.neurologyindia.com/text.asp?2006/54/1/38/24700



  Introduction Top


We report the clinical presentation, radiographic studies, intraoperative findings, histopathological analysis, and post-treatment outcome in 26 patients diagnosed with SSC. Results from the present study, in the context of findings from other pertinent series, are reviewed.


  Materials and Methods Top


The charts of 26 patients treated for SSCs between April 1993 and October 2002 were retrospectively reviewed. Specifically, clinical presentation (initial history and physical examination), radiographic studies (X-rays and magnetic resonance imaging (MRI) in 26 patients, with computed tomography (CT) in one), intraoperative findings, histopathology, and post-operative follow-up were noted.

Individual data for each patient appears in [Table - 1]. Collectively, specific patterns for SSCs were recognized.

The median age at diagnosis was 55.9years (range = 27 to 80 years). Females were more frequently affected (17:9 ratio) in comparison to males. With respect to distribution of pain, a radicular distribution was the presenting symptom in almost all cases (23/26), accompanied by back pain in 13 cases. Back pain alone was found in only three cases. Sensory deficits were common (17 out of 26 patients, 65%), with motor deficits being less frequent (9 out of 26 patients, 34%) at presentation. The mean duration of symptoms prior to diagnosis was 12.7 months (range = 1 to 36 months).


  Results Top


The majority of SSCs were located in the lumbar (19 out of 26, 73%) or lumbosacral (5 out of 26, 19%) regions, with only two SSC (7%) located in the thoracic region of the spine. One patient had bilateral SSC at L4-5 level (case no 23). Only one patient had history of prior trauma, while six others underwent prior surgery for herniated disc excision, canal stenosis, instability, or a benign lesion. One patient had a disc herniation associated with the SSC. All patients underwent surgical excision of the cyst. Nineteen patients underwent laminectomy, while in five patients, the excision could be accomplished through a hemilaminectomy. One partial facetectomy was also performed. In one patient, the inter-laminar space was wide enough so the cyst was visualized after incising the ligamentum flavum not requiring any bone removal (case no 24). The adherence of some SC to the dura can make the dissection really problematic in some instances (Risk of dural tear, risk of root lesion with the Kerrison, risk of incomplete SC resection). Postoperatively, significant pain relief was noted in practically all patients. Sensorimotor deficits improved in all patients, however, four of the patients continue to demonstrate mild sensory deficits.

Postoperative complications included a cerebrospinal fluid wound leak following resection of a lumbosacral SSC in one patient, which required subsequent intraoperative primary repair and a superficial wound infection, which was treated successfully by a 1-week regimen of antibiotics.

Histopathologically, 11 specimens revealed a true synovial epithelial lining; the remainder were either ganglion cysts (where no epithelial lining was present) or had features of both true synovial and ganglion cysts, as discussed in greater detail in the following section (see "Histopathology" under the Discussion section). Dystrophic calcification was present in the walls of 3 ganglion cysts.


  Discussion Top


In 1877 Baker defined synovial cysts in association with an adjacent degenerated joint.[1] The description of a spinal synovial cyst (SSC), in turn, is credited to Von Gruker, who initially discovered this lesion while performing an autopsy.[1],[2] The clinical presentation, imaging findings, treatment, and prognosis related to these lesions have since been better characterized by numerous studies [Figure - 1]. [1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32] The majority of studies reported thus far describe findings related to a small number of patients, 32. Only three of these studies involve more than 20 patients.[1],[33],[34]

Histopathology

Histopathologically, a continuum is thought to exist between true "synovial cysts" and "ganglion cysts". While both are thought to arise from periarticular tissues, a true synovial cyst is lined by synovium-like epithelial cells, whereas a ganglion cyst has a collagenous capsule, which surrounds myxoid material in the absence of epithelial cells.[15] Due to these qualities, these two lesions are often considered as "juxta-articular cysts," "juxta-facet cysts," or "intraspinal facet cysts."[15],[16] The distinction between true synovial and ganglion cysts is purely pathological and no difference is noted with respect to surgical treatment or prognosis.[33] For our purposes, given the similarities, we use the term spinal synovial cyst for either ganglion cysts, true synovial cysts, or cysts with variable features of each.[1]

In our study, the tissue from each histolopathologically reviewed case revealed a cyst with a thick fibrous wall. In 11 patients the cystic structures were partially lined by synovial cells, hence depicting a "true synovial cyst" [Figure - 2]. In the remaining patients, either no epithelial lining or rare flattened cells with significant chronic inflammatory changes were present. As previously mentioned, such features may represent the continuum between true synovial cysts and ganglion cysts [Figure - 3]. The presence of calcium, as noted in 3 of the ganglion cyst walls, supports the degenerative, metaplastic changes, which may be associated with these lesions. The facetectomy, is definitely not recommendable. The bipolar coagulation of the synovial membrane preserving the interapophyseal joint is also recommended to avoid synovial cyst recurrence.[34] There is no doubt that synovial cysts express a local instability in predisposed individuals, preferably females. However, it is rarely a mobile instability such as in spondylolysis. It behaves like a transient local degenerative instability occurring during a limited period of the lifetime.


  Conclusion Top


Spinal synovial cysts are likely degenerative lesions with a juxta-facet location. Most occur at the lumbar (L4-5) region and are associated with radicular symptoms, which are best visualized by MRI. Our experience supports that with a careful understanding of the anatomy as visualized by imaging studies, surgical decompression can lead to significant improvement in symptoms.


  Acknowledgment Top


The authors thank Ms. Jeanie McGee and Tedd Chambers for their editorial assistance in preparing this work.

 
  References Top

1.Howington JU, Connolly ES, Voorhies RM. Intraspinal synovial cysts:10 year experience at the Ochsner Clinic. J Neurosurg Spine 1999;91:193-9.  Back to cited text no. 1  [PUBMED]  
2.Hodges SD, Fronczak S, Zindrick MR, Lorenz MA, Vrbos LA. Extradural synovial thoracic cyst. Spine 1994;19:2471-3.  Back to cited text no. 2  [PUBMED]  
3.Abdullah AF, Chambers RW, Daut DP. Lumbar nerve root compression by synovial cysts of the ligamentum flavum:Report of four cases. J Neurosurg 1984;60:617-20.  Back to cited text no. 3  [PUBMED]  
4.Abrahams JJ, Wood GW, Eames FA, Hicks RW. CT guided aspiration biopsy of an intraspinal synovial cyst (ganglion):Case report and review of the literature. AJNR 1988;9:398-400.  Back to cited text no. 4  [PUBMED]  
5.Awwad EE, Martin DS, Smith KR Jr, Bucholz RD. MRI of lumbar juxtaarticular cysts. J Comput Assist Tomogr 1990;14:415-7.   Back to cited text no. 5  [PUBMED]  
6.Awwad EE, Sundaram M, Bucholz RD. Post-traumatic spinal synovial cyst with spondylosis:CT features. J Comput Assist Tomogr 1989;13:334-7.  Back to cited text no. 6  [PUBMED]  
7.Azzam CJ. Midline lumbar ganglion/synovial cyst mimicking an epidural tumor:Case report and review of pathogenesis. Neurosurgery 1988;23:232-4.  Back to cited text no. 7  [PUBMED]  
8.Bhushan C, Hodges FJ 3rd, Wityk JJ. Synovial cyst (Ganglion) of the lumbar spine simulating extradural mass. Neuroradiology 1979;18:263-8.  Back to cited text no. 8  [PUBMED]  
9.Brish A, Payan HM. Lumbar intraspinal extradural ganglion cyst. J Neurol Neurosurg Psychiatry 1972;35:771-5.  Back to cited text no. 9  [PUBMED]  
10.Cudlip S, Johnston F, Marsh H. Subaxial cervical synovial cyst presenting with myelopathy:Report of three cases. J Neurosurg Spine 1999;90:141-4.  Back to cited text no. 10  [PUBMED]  
11.Davis R, Iliya A, Roque C, Pampati M. The advantage of magnetic resonance imaging in diagnosis of lumbar synovial cyst. Spine 1990;15:244-6.  Back to cited text no. 11  [PUBMED]  
12.Franck JI, King RB, Petro GR, Kanzer MD. A posttraumatic lumbar spinal synovial cyst. J Neurosurg 1987;66:293-6.  Back to cited text no. 12  [PUBMED]  
13.Fransen P, Pizzolato GP, Otten P, Reverdin A, Lagier R, de Tribolet N. Synovial cyst and degeneration of the transverse ligament:An unusual cause of high cervical myelopathy. J Neurosurg 1997;86:1027-30.  Back to cited text no. 13  [PUBMED]  
14.Holtzman RN, Dubin R, Yang WC, Rorat E, Liu HM, Leeds NE. Bilateral symptomatic intraspinal T12-L1 synovial cysts. Surg Neurol 1987;28:225-30.   Back to cited text no. 14  [PUBMED]  
15.Hsu KY, Zucherman JF, Shea WJ, Jeffrey RA. Lumbar intraspinal synovial and ganglion cysts (facet cysts). Ten year experience in evaluation and treatment. Spine 1995;20:80-9.  Back to cited text no. 15  [PUBMED]  
16.Kao CC, Winkler SS, Turner JH. Synovial cyst of spinal facet:Case report. J Neurosurg 1974;41:372-6.  Back to cited text no. 16  [PUBMED]  
17.Lemish W, Apsimon T, Chakera T. Lumbar intraspinal synovial cysts:Recognition and CT diagnosis. Spine 1989;14:1378-83.  Back to cited text no. 17  [PUBMED]  
18.Liu SS, Williams KD, Drayer BP, Spetzler RF, Sonntag VK. Synovial cysts of the lumbosacral spine:Diagnosis by MR Imaging. AJNR 1989;10:1239-42.  Back to cited text no. 18  [PUBMED]  
19.Lynn B, Watkins RG, Watkins RG IV, Williams LA. Acute traumatic myelopathy secondary to a thoracic cyst in a professional football player. Spine 2000;25:1593-5.  Back to cited text no. 19  [PUBMED]  [FULLTEXT]
20.Maresca L, Meland NB, Maresca C, Field EM. Ganglion cyst of the spinal canal:Case report. J Neurosurg 1982;57:140-2.  Back to cited text no. 20  [PUBMED]  
21.Maupin WB, Naul LG, Kanter SL, Chang CS. Synovial cyst presenting as a neural foraminal lesion:MR and CT appearance. AJR 1989;153:1231-2.  Back to cited text no. 21  [PUBMED]  
22.Mercader J, Munoz Gomez J, Cardenal C. Intraspinal synovial cyst:Diagnosis by CT. Neuroradiology 1985;27:346-8.  Back to cited text no. 22  [PUBMED]  
23.Munz M, Tampieri D, Robitaille Y, Bertrand G. Spinal synovial cyst:Case report using magnetic resonance imaging. Surg Neurol 1990;34:431-4.  Back to cited text no. 23  [PUBMED]  
24.Onofrio BM, Mih AD. Synovial cysts of the spine. Neurosurgery 1988;22:642-7.  Back to cited text no. 24  [PUBMED]  
25.Patel SC, Sanders WP. Synovial cyst of the cervical spine:Case report and review of the literature. AJNR 1988;9:602-3.  Back to cited text no. 25  [PUBMED]  
26.Silbergleit R, Gebarski SS, Brunberg JA, McGillicudy J, Blaivas M. Lumbar synovial cysts:correlation of myelographic, CT, MR and pathologic findings. AJNR 1990;11:777-9.  Back to cited text no. 26  [PUBMED]  
27.Sypert GW, Leech RW, Harris AB. Posttraumatic lumbar epidural true synovial cyst. Case report. J Neurosurg 1973;39:246-8.  Back to cited text no. 27  [PUBMED]  
28.Trummer M, Flaschka G, Tillich M, Homann CN, Unger F, Eustacchio S. Diagnosis and surgical management of intraspinal synovial cysts:Report of 19 cases. J Neurol Neurosurg Psychiatr 2001;70:74-7.  Back to cited text no. 28  [PUBMED]  [FULLTEXT]
29.Yarde WL, Arnold PM, Kepes JJ, O'Boynick PL, Wilkinson SB, Batnitzky S. Synovial cysts of the lumbar spine:Diagnosis, surgical management, and pathogenesis. Surg Neurol 1995;43:459-64.   Back to cited text no. 29  [PUBMED]  [FULLTEXT]
30.Zorzon M, Skrap M, Diodato S, Nasuelli D, Lucci B. Cysts of the atlantoaxial joint:excellent long-term outcome after posterolateral surgical decompression. J Neurosurg 2001;95:111-4.  Back to cited text no. 30  [PUBMED]  
31.Brown C, Stambough JL. Epidural hematoma secondary to a rupture of a synovial cyst. Spine J 2005;5:446-50.   Back to cited text no. 31  [PUBMED]  [FULLTEXT]
32.Khan AM, Synnot K, Cammisa FP, Girardi FP. Lumbar synovial cysts of the spine:an evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-31.  Back to cited text no. 32  [PUBMED]  [FULLTEXT]
33.Lyons MK, Atkinson JL, Wharen RE, Deen HG, Zimmerman RS, Lemens SM. Surgical evaluation and management of lumbar synovial cyst:the Mayo Clinic experience. J Neurosurg 2000;93:53-7.  Back to cited text no. 33    
34.Pirotte B, Gabrovsky N, Massager N, Levivier M, David P, Brotchi J. Synovial cysts of the lumbar spine:surgery-related results and outcome. J Neurosurg 2003;99:14-9.  Back to cited text no. 34  [PUBMED]  


    Figures

[Figure - 1], [Figure - 2], [Figure - 3]

    Tables

[Table - 1]

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