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CASE REPORT
Year : 2016  |  Volume : 30  |  Issue : 3  |  Page : 184-186

Intraspinal synovial cyst presenting with leg radiculopathy


Department of Spine Surgery, Sir Gangaram Hospital, New Delhi, India

Date of Web Publication28-Sep-2016

Correspondence Address:
Umesh Takhelmayum
Department of Spine Surgery, Sir Gangaram Hospital, New Delhi - 110 60
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-4958.191190

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  Abstract 

Intraspinal synovial cysts are rare cystic lesion arising from degenerated facet joint affecting most commonly in lumbosacral spine. They usually present with low back pain with leg radicular pain with or without neurodeficit mimicking prolapsed intervertebral disc. Surgical excision is the treatment of choice.

Keywords: Cysts, disc prolapse, facet joint


How to cite this article:
Takhelmayum U, Acharya S, Gupta P, Palukuri N. Intraspinal synovial cyst presenting with leg radiculopathy. J Med Soc 2016;30:184-6

How to cite this URL:
Takhelmayum U, Acharya S, Gupta P, Palukuri N. Intraspinal synovial cyst presenting with leg radiculopathy. J Med Soc [serial online] 2016 [cited 2020 Oct 31];30:184-6. Available from: https://www.jmedsoc.org/text.asp?2016/30/3/184/191190


  Introduction Top


Intraspinal synovial cysts, also known as juxtafacetal cysts are not commonly encountered intraspinal pathology that often resembles radiculopathy due to prolapsed intervertebral disc. They usually arise from degenerated zygapophyseal joint of spine and sometimes they lie in the spinal canal producing cord or nerve root compression. [1]

We are reporting a case of left 1 st sacral nerve (S1) radiculopathy produced by lumbar intraspinal synovial cyst.


  Case report Top


A 45-year-old female patient presented with low back pain and left leg pain for 4 months. The pain was insidious in onset, slowly progressive and aggravated by movements, bending forward, and lifting heavy object. For the past 1 month, there has been increased in the left leg pain and numbness in the left foot. She had no history of trauma. Her bladder and bowel habits were normal. Physical examination revealed positive left straight leg raising test of 50°, hypoesthesia of left S1 dermatome, tenderness over lumbosacral junction of spine. However, there was no motor weakness. Plain radiographs of lumbosacral spine showed minimal degenerative changes. Magnetic resonance imaging (MRI) revealed a 2 cm cystic lesion originating from the left 5 th lumbar-1 st sacral (L5-S1) facet joint which was hyperintense on T2-weighted image and hypointense on T1-weighted with hypointense thin regular nonenhancing rim and cyst pressing over the dural sac and narrowing of the left neural foramina [Figure 1] and [Figure 2].
Figure 1: Magnetic resonance imaging T2 saggital image showing hyperintense cystic lesion with nonenhancing rim at L5-S1 region

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Figure 2: Magnetic resonance imaging T2 (Axial) image showing cyst arising from left L5-S1 facet joint with narrowing of left neural foramina

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Considering the severity of the pain and numbness, surgical treatment was decided. The patient was operated under general anesthesia with posterior midline incision. Left-sided medial facetectomy was performed, foraminotomy was done, and cyst was resected [Figure 3]. Intraoperatively, the cyst wall appeared communicating with left facet joint, adherent to ligamentum flavum and dural sac. Cyst contained straw colored jelly-like fluid. Resected cyst tissue was sent for histopathological examination (HPE). HPE report suggests cyst lined focally by synovial cells with subepithelial tissue showing chronic inflammation and increased vascularity [Figure 4].
Figure 3: Resected intrasynovial cyst

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Figure 4: Histopathological examination showing cyst lined with synovial cells with inflammatory cells and vascularity

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Postoperatively, the visual analog score (VAS) of leg pain decreases to 2/10 and numbness recovered by 80% on day 1. The patient was mobilized and was discharged on the 1 st postoperative day. After 6 months postoperatively, the patient is comfortable with no leg pain (VAS Score 0/10).


  Discussion Top


Intraspinal synovial cysts are the cystic lesion arising from posterior aspect of degenerated zygoapophyseal joint. It may occur at any segment of the spine except sacrum. Other terminology used earlier were juxtafacetal cyst or intraspinal facetal cyst. [2] They are most commonly seen in the L4-L5 region (68.4%), L5-S1 (21.1%), L1-L2 (5.2%), and L2-L3 (5.2%). [1],[3] These cyst developed as a result of arthritic and degenerative changes of facet joint leading to capsular lesion and herniation of synovial membrane. [4] Another reason is the mechanical load on the lumbar spine and the site of maximum mobility. Lumbar intraspinal synovial cyst is commonly seen in the sixth decade of life with female preponderance. [2] The most common presentation is the intermittent low back pain with radicular leg pain with absence of motor and sensory symptoms. Neurogenic claudication is the next common reported symptoms (10-44%) after painful radiculopathy. [5],[6] Plain X-ray has a little role in the diagnosis, but they are useful in excluding spondylosis, degenerative spondylolisthesis and other lytic lesions. MRI is the imaging modality of choice for the diagnosis of synovial cyst with the sensitivity of 77%. Computer tomography (CT) and CT myelogram have the sensitivity of 56% and 42%, respectively. [1] On MRI, it is seen as well circumscribed, smooth, extradural lesion adjacent to facet joints with low-intensity signal in T1-weighted and high-intensity signal in T2-weighted images. Histopathologically, juxtafacetal cysts are lined with synovial cells unlike ganglion cysts which do not have synovial cells. They contain serous or gelatinous fluid. [7]

The management of symptomatic cyst is still debated. Various management options include conservative treatment with bed rest, analgesics, brace, steroid injection, and cyst aspiration. [2] The reports of conservative treatment are disappointing. [3],[8] Only few studies reported complete resolution of cyst spontaneously. [4],[9] Synovial cysts not responding to conservative treatment with persistent radicular leg pain should be treated surgically. Surgical excision is the gold standard of treatment. [6],[10],[11] Resection and decompression with or without fusion or instrumentation are other treatment options. In our case, we did a surgical excision of synovial cyst with medial facectomy.


  Conclusion Top


Intraspinal facetal cysts are synovial cyst arising from facet joint commonly seen in lumbar spine. It should be one of the differential diagnoses in patient with low back pain and radiculopathy. MRI is the imaging of choice for diagnosis. Surgical excision is the treatment of choice in symptomatic cyst.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Salmon BL, Deprez MP, Stevenaert AE, Martin DH. The extraforaminal juxtafacet cyst as a rare cause of L5 radiculopathy: A case report. Spine (Phila Pa 1976) 2003;28:E405-7.  Back to cited text no. 1
    
2.
Karaeminogullari O, Sahin O, Demirörs H, Tandogan R. Symptomatic lumbar intraspinal synovial cyst: A case report. Acta Orthop Traumatol Turc 2006;40:85-8.  Back to cited text no. 2
    
3.
Hsu KY, Zucherman JF, Shea WJ, Jeffrey RA. Lumbar intraspinal synovial and ganglion cysts (facet cysts). Ten-year experience in evaluation and treatment. Spine (Phila Pa 1976) 1995;20:80-9.  Back to cited text no. 3
    
4.
Swartz PG, Murtagh FR. Spontaneous resolution of an intraspinal synovial cyst. AJNR Am J Neuroradiol 2003;24:1261-3.  Back to cited text no. 4
    
5.
Kaneko K, Inoue Y. Haemorrhagic lumbar synovial cyst. A cause of acute radiculopathy. J Bone Joint Surg Br 2000;82:583-4.  Back to cited text no. 5
    
6.
Khan AM, Girardi F. Spinal lumbar synovial cysts. Diagnosis and management challenge. Eur Spine J 2006;15:1176-82.  Back to cited text no. 6
    
7.
Kalevski SK, Haritonov DG, Peev NA. Lumbar intraforaminal synovial cyst in young adulthood: Case report and review of the literature. Global Spine J 2014;4:191-6.  Back to cited text no. 7
    
8.
Shah RV, Lutz GE. Lumbar intraspinal synovial cysts: Conservative management and review of the world's literature. Spine J 2003;3:479-88.  Back to cited text no. 8
    
9.
Mercader J, Muñoz Gomez J, Cardenal C. Intraspinal synovial cyst: Diagnosis by CT. Follow-up and spontaneous remission. Neuroradiology 1985;27:346-8.  Back to cited text no. 9
    
10.
Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: Clinical presentation, the role of spinal instability, and treatment. J Neurosurg 1996;85:560-5.  Back to cited text no. 10
    
11.
Lyons MK, Atkinson JL, Wharen RE, Deen HG, Zimmerman RS, Lemens SM. Surgical evaluation and management of lumbar synovial cysts: The Mayo Clinic experience. J Neurosurg 2000;93 1 Suppl: 53-7.  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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