Abstract
Spinal synovial cysts are cystic dilatations of the synovial membrane that may arise at all levels of the spine. We describe our experience, paying attention to diagnosis, surgical treatment, and long-term follow-up. Between 1995 and 2007, 18 patients were surgically treated. Of these, three patients were excluded from the study because they presented spinal instability at pre-operative assessment. All patients were evaluated pre-operatively with CT, MRI, and dynamic X-rays, and underwent surgery for removal of the cyst by hemilaminectomy and partial arthrectomy. All patients were evaluated with early MRI and had a minimum 2-year follow-up by dynamic X-rays. None of the patients required instrumented fusion due to the absence of radiological signs of instability on the pre-operative dynamic tests. In all patients, there was an immediate resolution of the symptoms, with evidence of complete removal of the cysts on post-operative MRI. At 2-year follow-up, all patients underwent dynamic X-rays and responded to a questionnaire for evaluation of outcome. None of them showed signs of relapse. The gold standard for treatment is surgery, even though other conservative treatment regimens have been proposed. Correct surgical strategy relies on pre-operative assessment of biomechanical stability for deciding whether patients need instrumented fusion during cyst removal. Patients with no instability signs are suitable for hemilaminectomy with partial arthrectomy, preserving 2/3 of the medial portion of the articular facet, because this represents a valid option of treatment with a low risk of complications and a low rate of relapse.
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Imad N. Kanaan, Riyadh, Kingdom of Saudi Arabia
The manuscript represents a retrospective analysis of 15 cases of unilateral lumbar synovial cysts treated with microsurgical excisions and subjected to 2-year follow-ups and outcome study. Synovial cystic dilatation juxtaposing the spinal facet joint is caused by overproduction of synovial fluid and thinning of the overlying facet joint capsule. It occurs mostly in older age in association with advanced degenerative osteoarthritis. The osseous confines of the lateral recess often magnify the degree of impingement on neural structures, and hemorrhage may lead to urgent condition as reported by the authors.
Spinal synovial cyst is relatively rare as correctly stated by the authors but becoming a well-documented cause of compressive radiculopathy and lumbar spine stenosis, thanks to the use of modern imaging facilities of MRI and CTs. The absence of randomization and lack of control was apparently due to a small cohort and rarity of symptomatic disease, but also partially induced by selection bias and single-out treatment option. The evidence is based on case-series reviews coupled with a hint of authoritative statement, but on the other hand, is compensated by an objective review of the literature. The authors should be commended on their meticulous follow-up documentation and outcome results. We concur with the authors that the mainstay in this microsurgical intervention is to limit the arthrectomy and maintain the integrity of 2/3 of the medial facet joint to avoid instability. As a final note, physicians involved in the management of such disease entities should be aware of recent molecular biology research and development and the role of proteinases, collagenases, cadherin-1, and lubrican as potential substrates for future medical treatment option.
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Landi, A., Marotta, N., Tarantino, R. et al. Microsurgical excision without fusion as a safe option for resection of synovial cyst of the lumbar spine: long-term follow-up in mono-institutional experience. Neurosurg Rev 35, 245–253 (2012). https://doi.org/10.1007/s10143-011-0356-z
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DOI: https://doi.org/10.1007/s10143-011-0356-z