- Professor of Clinical Neurosurgery, School of Medicine, University of State of New York at Stony Brook, Mineola, New York, USA
- Chief of Neurosurgical Spine/Education, NYU Winthrop Hospital, Mineola, New York, USA
Nancy E. Epstein
Professor of Clinical Neurosurgery, School of Medicine, University of State of New York at Stony Brook, Mineola, New York, USA
Chief of Neurosurgical Spine/Education, NYU Winthrop Hospital, Mineola, New York, USA
DOI:10.4103/sni.sni_27_18Copyright: © 2018 Surgical Neurology International This is an open access article distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as the author is credited and the new creations are licensed under the identical terms.
How to cite this article: Nancy E. Epstein. Spinal case of the month with short perspective: How would you treat this L3-L4 synovial cyst?. 07-Mar-2018;9:56
How to cite this URL: Nancy E. Epstein. Spinal case of the month with short perspective: How would you treat this L3-L4 synovial cyst?. 07-Mar-2018;9:56. Available from: http://surgicalneurologyint.com/surgicalint-articles/spinal-case-of-the-month-with-short-perspective-how-would-you-treat-this-l3%e2%80%91l4-synovial-cyst/
Background:In this new section, Case of the Month with Short Perspective from Surgical Neurology International, we want to see how various spine surgeons would approach different spinal pathologies. In this first case, an elderly male presented with 3 years of lower back pain and progressive neurogenic claudication with bilateral radiculopathy that had exacerbated over the prior 6 months. An outside physician performed a magnetic resonance (MR) study of the lumbar spine that showed a massive synovial cyst filling the spinal canal (e.g., large bilateral cysts) at the L3-L4 level with grade I spondylolisthesis. The MR and CT studies also both demonstrated moderate L2-L3, and severe L3-L4 stenosis.
Methods:Despite the massive synovial cyst filling the spinal canal at the L3-L4 level, pain management (anesthesia training) spent 3 months performing three successive epidural steroid injections accompanied by attempts at percutaneous synovial cyst aspiration/rupture.
Results:By the time the patient presented to neurosurgery, he had developed severe neurogenic claudication, radiculopathy, myelopathy, and a cauda equina syndrome. Dynamic X-rays revealed a mild grade I degenerative spondylolisthesis at the L3-L4 level without active motion, while both computed tomography (CT) and MR studies confirmed moderate stenosis stenosis/ossification of the yellow ligament at the L2-L3 level, severe stenosis at L3-L4 level with spondylolisthesis, and massive bilateral synovial cysts at the L3-L4 level filling the spinal canal.
Conclusions:Following an L2-L4 decompressive laminectomy without fusion (note the absence of motion intraoperatively at the L3-L4 level), the patient's symptoms resolved, and he regained normal function. How would you have managed this patient?
Keywords: Decompression, fusion, lumbar case study, perspective, synovial cyst
In the new Case of the Month with Short Perspective section from Surgical Neurology International, we ask how various spine surgeons would approach different spinal pathologies. In this first case study, an elderly male presented with 3 years of lower back pain and 6 months of progressive neurogenic claudication with myelopathy and bilateral radiculopathy. An outside physician performed a magnetic resonance (MR) study of the lumbar spine that showed moderate stenosis/ossification of the yellow ligament (OYL) at the L2-L3 level with severe stenosis/OYL at the L3-L4 level accompanied by massive bilateral synovial cysts filling the spinal canal and grade I L3-L4 spondylolisthesis. How would you have managed this patient?
An elderly male presented with 3 years of lower back pain accompanied by 6 months of progressive neurogenic claudication, myelopathy, and bilateral radiculopathy. An outside physician ordered a lumbar MR scan that demonstrated moderate stenosis/OYL at the L2-L3 level, and marked stenosis/OYL with degenerative spondylolisthesis and massive bilateral synovial cysts filling the canal at the L3-L4 level (note the synovial cysts extended all the way to the L2-L3 level). Despite the marked thecal sac/cauda equina compression, over the next 3 months, anesthesia/pain management performed three epidural steroid injections with attempted cyst aspirations/ruptures. When the patient's symptoms worsened, characterized now by a severe cauda equina syndrome, he was finally seen by neurosurgery; the straight leg raising examination (SLR) was limited bilaterally to 30 degrees, iliopsoas/quadriceps/extensor hallucis longus/dorsiflexors weakness was present bilaterally at the 3/5 level, Patellar and Achilles reflexes were absent, and there was a marked decrease in pin appreciation in the L3, L4, and L5 distributions. Dynamic X-rays showed a mild grade I degenerative spondylolisthesis t the L3-L4 level without active motion. The CT and the new MR scans confirmed moderate L2-L3 and severe L3-L4 stenosis/OYL with massive bilateral L3-L4 synovial cysts filling the spinal canal and the previously noted grade I l3-L4 spondylolistheiss [Figures
Short perspective reviewing lumbar synovial cyst diagnosis and treatment
Symptoms and signs of synovial cysts
Patients with synovial cysts typically present in their mid 60s with a 2:1 or 1:1 male: female ratio.[
Reported failure rates of percutaneous radiographically-directed cyst rupture/aspiration
Synovial cysts typically have tough, firm, thick, and often ossified/calcified capsules containing gelatinous/crank case fluid or fibrous material (e.g. rather thn fluid) that can be readily aspirated.[
Success of decompressive surgery for lumbar synovial cysts
Synovial cysts, whether unilateral or bilateral, include foraminal and cephalad components that impinge not only on the thecal sac and the inferiorly exiting nerve root, but also compress the superior, foraminal, and far laterally exiting root.[
Low secondary reoperation/fusion rates after decompressions for lumbar synovial cysts
With surgical decompression, the reoperation rates for synovial cysts is low. In a study by Bruder et al. out of 141 synovial cysts, 70% underwent initial decompression (typically hemilaminectomies).[
Invitation for comments
This is the first in a series of monthly case studies with Short Perspectives for Surgical Neurology International. We invite your responses. Would you have originally ordered epidural injections in this patient? What surgical approach would you have performed – a laminectomy and/or other decompression alone, and/or decompression with a fusion?
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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