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Int J Surg Case Rep
Int J Surg Case Rep
International Journal of Surgery Case Reports
2210-2612
Elsevier

S2210-2612(24)00931-3
10.1016/j.ijscr.2024.110150
110150
Case Report
A challenge diagnosis of lumbar synovial facet cyst. A case report
Filali Zayed filalizayed10@yahoo.fr
ac⁎
Briki Amine ac
Ferjani Souad bc
Aloui Yassine ac
Moulahi Oubaidallah ac
Haddad Naoufel d
a Department of Orthopedic Surgery and Traumatology, Hospital Habib Bourguiba, BP 4100 Medenine, Tunisia
b Department of Radiology, Hospital Habib Bourguiba, BP 4100 Medenine, Tunisia
c University of Sfax Medical School, Tunisia
d University Tunis El Manar Medical School, Tunisia
⁎ Corresponding author at: Department of Orthopedic Surgery and Traumatology, Hospital Habib Bourguiba, BP 4100 Medenine, Tunisia. filalizayed10@yahoo.fr
10 8 2024
10 2024
10 8 2024
123 11015011 6 2024
5 8 2024
8 8 2024
© 2024 The Authors
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction and importance

Synovial cysts occur more frequently in the lumbar spine, especially at L4–5 level. Traditional open surgical management with posterolateral arthrodesis is the currently recommended treatment.

Case presentation

This is a 64-year-old woman with no prior pathological history. Initial clinical and radiological assessment concluded that there was advanced right coxarthrosis with a degenerative lumbar spine.

The patient therefore had a total hip arthroplasty secondarily presented an intermittent neurogenic claudication without sphincter disorders.

The MRI concluded at a compressive synovial facet cyst at the L4-L5 level.

The patient underwent surgical treatment. At two years postoperatively, the walking distance was significantly improved while maintaining moderate lower back pain.

Clinical discussion

The diagnosis of synovial facet cysts of spine is a challenge that depends heavily on history, physical examination, and MRI.

MRI will demonstrate not only the nature of the cystic lesion, but also its relationship to the root, the cord or the thecal sac.

The L4-L5 level of the lumbar spine is the most common location of the synovial cyst of the facet joints. As in our case, surgical treatment combining posterolateral arthrodesis is currently recommended for these types of lesions.

Surgical treatment, as in our case, is sometimes delayed when this pathology is associated with advanced osteoarthritis of the hips.

Conclusion

Improved imaging capabilities such as magnetic resonance imaging (MRI) have resulted in increased reporting, diagnostic yield and treatment of spinal synovial cysts.

Surgical treatment combining posterolateral arthrodesis is the treatment for this lesion.

Highlights

• Synovial cysts occur more frequently in the lumbar spine, especially at L4–5 level.

• Improved imaging capabilities such as magnetic resonance imaging (MRI) have resulted in increase reporting, diagnostic yield and treatment of spinal synovial cysts.

• Lumbar synovial facet cysts are a potential cause of radiculopathy, back pain and neurogenic claudication.

• Traditional open surgical management with posterolateral arthrodesis is recommended treatment.

Keywords

Lumbar synovial cyst
Lumbar spinal stenosis
Laminectomy
Spinal instability
Facet joint arthropathy
Case report
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pmc1 Introduction

Synovial cysts of the spine, firstly described by Baker in 1885, are cystic dilatations of the synovial sheaths and may occur in any of the spinal areas: cervical, dorsal or lumbo-sacral region thoracic [1] (Fig. 1, Fig. 2, Fig. 3, Fig. 4).Fig. 1 Pelvis radiographs.

A: Anteroposterior view showing advanced coxarthrosis of the right hip.

B: Anteroposterior view showing total right hip arthroplasty.

Fig. 1

Fig. 2 Lumbar spine radiographs.

A: Anteroposterior view showing stepped disc pinching without degenerative scoliosis.

B: Lateral oblique view showing stepped disc pinching more marked at the L4-L5 level.

Fig. 2

Fig. 3 Lumbar spine magnetic resonance imaging.

A: T2- sagittal plane showing a right synovial facet cyst at level L4-L5.

B: T2- axial plane showing a right synovial facet cyst at level L4-L5, compressing the right L5 root and repressing the dural sheath.

Fig. 3

Fig. 4 Lumbar spine post-operative radiographs.

A: Anteroposterior view showing Instrumented posterolateral arthrodesis of the L4-L5 level.

B: Lateral oblique view showing Instrumented posterolateral arthrodesis of the L4-L5 level.

Fig. 4

Synovial cysts occur more frequently in the lumbar spine, especially at L4–5 level, it is the most mobile level with more sagittal articular facets, than in the cervical or thoracic regions [2].

Lumbar spinal synovial cysts are a potential cause of radiculopathy, back pain and neurogenic claudication. These cysts arise from the facet joint and are often associated with spondylosis, traumatic injury or spinal instability [3].

Improved imaging capabilities such as computed tomography (CT) and magnetic resonance imaging (MRI) have resulted in increased reporting, diagnostic yield and treatment options of spinal synovial cysts [4].

Symptomatic lumbar synovial cysts can be treated by several modalities. Traditional open surgical management, which consists of laminectomy, medial facetectomy and excision of the cyst generally and posterolateral instrumented arthrodesis provides superior outcomes than more conservative approaches such as intraarticular corticosteroid injections or percutaneous cyst aspiration or resection [3].

The aim of this case is to clarify our delayed management of a symptomatic lumbar synovial facet cyst because it was associated with a more symptomatic ipsilateral coxarthrosis.

The work has been reported in line with the SCARE criteria and the revised 2023 SCARE guidelines [5].

2 Case presentation

This is a 64-year-old woman with no prior pathological history who consulted for chronic low back pain with painful, disabling stiffness of the right hip.

Initial clinical and radiological assessment concluded that there was advanced right coxarthrosis with a degenerative lumbar spine, especially since the neurological examination at rest was without any particular anomalies (Fig. 1, Fig. 2).

The patient therefore had a total hip arthroplasty with simple consequences (Fig. 1).

After freedom of the hip, the patient secondarily presented an intermittent neurogenic claudication with a limited walking distance without sphincter disorders.

The clinical examination concluded that there was pain in the bilateral L5 and S1 roots. The MRI concluded that there was a narrow degenerative lumbar canal aggravated by compression at the L4-L5 level by an extradural cystic formation continuing with the right posterior L4-L5 joint in favor of a synovial facet cyst (Fig. 3).

The patient underwent L4-L5 posterior laminectomy with right L4-L5 partial arthrectomy, resection of the cyst formation and instrumented L4-L5 posterolateral arthrodesis (Fig. 4). The postoperative course was simple.

At two years postoperatively, the walking distance was significantly improved while maintaining moderate lower back pain.

3 Clinical discussion

Synovial cysts of the facet joints of the spine have become more and more frequent with the evolution of radiological explorations, especially magnetic resonance imaging (MRI) [6].

The diagnosis of synovial cysts of spine is a challenge that depends heavily on history, physical examination, and MRI, with a sensitivity rate of 90 % in comparison to CT scans [[7], [8]]. Synovial cysts of spine may be asymptomatic and found incidentally. The clinical presentation of a cyst depends on it volume, site and its relationship to the surrounding bony and neural structures. Most of the symptomatic patients present with radicular pain as in our case, or neurological deficits. Other sign and symptoms including cauda equina syndrome and spinal stenosis syndromes have also been reported. MRI will demonstrate not only the nature of the cystic lesion, but also its relationship to the root, the cord or the thecal sac. On MR imaging, synovial cysts appear as well circumscribed, smooth, extra-dural in location and adjacent to facet joints [4].

The differential diagnosis based on imaging data can discuss the cyst of the ligamentum flavum, the ganglion cyst (which is a synovial cyst which has lost its communication with the joint), the cyst of the posterior common vertebral ligament and cystic tumors [[8], [9], [10]].

The L4-L5 level of the lumbar spine is the most common location of the synovial cyst of the facet joints. This stage is the most mobile favored by the sagittal orientation of the articular facets. The predilection for cysts to occur adjacent to this facet joint level has been attributed to the amount of degenerative spondylosis and spinal instability [[7], [8], [9], [10], [11], [12]].

Symptomatic lumbar synovial cysts can be treated by several modalities. Traditional open surgical management, which consists of laminectomy, medial facetectomy and excision of the cyst generally and posterolateral instrumented arthrodesis provides superior outcomes than more conservative approaches such as bed rest, oral analgesics, physical therapy, orthopedic corsets, CT-guided needle aspiration and intra-articular injection of corticosteroid drugs [3].

As in our case, surgical treatment combining posterolateral arthrodesis is currently recommended for these types of lesions. It definitively resolves the problem of segmental instability of the spine and therefore the risks of recurrence of cysts [12].

Surgical treatment, as in our case, is sometimes delayed by a few months or even years when this pathology is associated with advanced osteoarthritis of the hips. The surgeon first treats the hip in the face of the patient's functional complaints and subsequently we discover that all the symptoms of the lower limbs are of spinal cord origin. We must remain classic and always examine the spine in the presence of hip pathology and request an MRI if the clinical symptoms are truncated [10].

4 Conclusion

Synovial cysts occur more frequently in the lumbar spine, especially at L4–5 level, it is the most mobile level with more sagittal articular facets. Improved imaging capabilities such as magnetic resonance imaging (MRI) have resulted in increased reporting, diagnostic yield and treatment of spinal synovial cysts.

In our case, surgical treatment combining posterolateral arthrodesis is the treatment for this lesion. It definitively resolves the problem of segmental instability of the spine and therefore the risks of recurrence of cysts.

Ethical approval

Ethics approval is not required for case reports in our institution (Ethics Committee of University of Sfax Medical School, Tunisia) as they are deemed not to be research.

Funding

This research did not receive any specific grant form funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Zayed Filali: Conceptualization, Original draft writing.

Amine Briki, Souad Ferjani and Nawfel Haddad: Data collection and processing.

Yassine Aloui and Oubaidallah Moulahi: Assist with data analysis.

Guarantor

Zayed Filali.

Consent

Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Conflict of interest statement

None.
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