PERCUTANEOUS TREATMENT OF FACET JOINT SYNOVIAL CYST

DEVELOPPED IN INTRA DUCTALS. KOUKI ,W. AMORRI, M. LANDOULSI , S.

BOUGUERRA , Y.AROUS , H. BOUJEMAA , N. BEN ABDALLAH

Military Hospital of Tunis

INTV3

OBJECTIVE:

To study the results of facet joint

intraarticular steroid injections in a

patient with symptomatic lumbar facet

joint synovial cysts developped in intra

ductal.

INTRODUCTIONFacet joint synovial cyst is an Expansion of the joint capsule and

synovium into the spinal canal

By definition it communicates with the adjacent joint

The average age when it occured is 60 years

It‘s a rare cause of radicular pain

Clinical signs are unilateral nerve root or radicular claudication bilateral

lower

Is easily diagnosed by new medical imaging modalities

Image-guided percutaneous steroid injections presents often an effective

alternative to surgery

CASE REPORT

The patient is a 59-years woman

Without individual medical history outside of an

overweight

complaining of low back sciatica type left L5,

associated with a left cruralgia, refractory to

medical treatment

EXPLORATION BY IMAGINGRadiographs of the lumbosacral spine : a degenerative spinal disco,

more advanced at L4-L5 segment, associated with a degenerative Low-

grade isthmic spondylolisthesis.

The CT scan : an intra ductal synovial cyst, next to the left posterior

facet joint L4-L5, measuring 2cm long axis, which causes a conflict

with the L5 root at its emergence, and L4 ipsilateral root.

THERAPEUTIC MANAGEMENT

A well conducted medical treatment with rest did

not lead to a favorable outcome.

A surgical treatment proposed refused by the

patient

She was entrusted to us for a percutaneous

treatment

PERCUTANEOUS TREATMENT UNDER SCANNER

1/ INSTALLATION OF THE PATIENT, AND TRACKING:

The patient is prone positioned.

The procedure is performed in the interventional scanner room

We conducted a helix centered on the lumbar spine to identify

the left facet joint L4-L5.

The CT features of the facet joint synovial cyst is a Rounded

picture of homogeneous fluid density intra ductal with hyper

dense fibrous shell.

2/ PROGRESS OF INTERVENTIONAL GESTURE:

After local anesthesia and surgical skin disinfection

Joint aspiration and injection of 1 ml of iodinated contrast

in facet joint, opacified both the joint and the cyst intra canal,

objectifying the communication between them.

fluid content was aspirated

Then we have inject a bulb of a prolonged action

corticosteroid (Altim®) combined with 1cc of Xylocaine®

under pressure until rupture of the cyst, as evidenced by a

loss of strength and opacification of the epidural space on the

acquisition of control.

FIG 1: AXIAL CT SCAN OF L4 IN BONE WINDOW SHOWING THE AVERAGE LOAD OF INTRA DUCTAL CYST WITH MASS EFFECT ON THE DURAL SHEATH

FIG 2: AXIAL CT SCAN OF L4 IN BONE WINDOW SHOWING THE COMPLETE FILLING OF THE CYST WITH EARLY EXTRA VASATION OF CONTRAST

FIG 3 : AXIAL CT SCAN OF L4 IN BONE WINDOW SHOWING THE COMPLETE FILLING OF THE CYST WITH CLEAR EXTRAVASATION OF CONTRAST MATERIAL BY CRACKING CYSTIC

FIG 4 : SAGITTAL RECONSTRUCTIONS SHOWING OPACIFICATION AND SIGNS OF INTRA DUCTAL CYST

3/ RESULT AND EVOLUTION:

Immediately, the patient describes an exaggeration of pain followed

by a relief

This is likely due to the effect of Xylocaine® and the reduction of

pressure in the cyst after its cracks.

This cracking is a cure of this cyst, it is evidenced by the

extravasation of contrast outside the cyst.

The decline in two years was marked by a favorable clinical course,

especially since the patient has lost weight and always wore a lumbar

corset.

DISCUSSION

1/ PATHOPHYSIOLOGY (1)(4):

It’s a manifestation of progressive posterior facet arthrosis : during

outbreaks of effusion, the normal joint recess become diverticula,

synovial recesses would enlarge with progressive fibrous thickening

and inflammation of their walls.

By definition, intraspinal synovial cysts communicate with the

adjacent facet joint.

They are characterized by the presence of synovial lining and clear

or xanthochromic content

Opposed to ganglion cysts that do not communicate with the facet

joint, have a fibrous wall, and contain gelatinous myxoid material

Both entities often are described as juxta-

articular or synovial cysts.

Synovial cysts would be a manifestation of facet

degeneration:

The L4-5 level is most commonly involved

because it corresponds to the level of maximal

mechanical stress and motion.

2/ IMAGING STUDY (1)(2)(3)(4):

CT-arthrography can identified synovial cysts communicating with the

adjacent facet joint with marked degeneration and a spondylolisthesis

Diagnosis at non contrast CT is based on the detection of a cystic

structure next to a degenerated facet joint, such as in our case. The cyst

may sometimes extend into the lateral recess.

The presence of bony erosions or remodeling suggest the possibility of

Tarlov cyst, arachnoid cyst, or cystic nerve sheath tumor, but these

changes have also been described in patients with synovial cysts.

Facet joint injection demonstrating communication of the facet joint with

the cyst is pathognomonic for the presence of a synovial cyst.

In the MRI signal is variable:

* HypoT1, hyperT2: type fluid

* HyperT1, hypoT2: type haem

* HypoT1, hypoT2: gas, calcification, hemosiderin

* HyperT1, hyperT2: blood, fat

The differential diagnosis includes ganglion cysts, posterior longitudinal

ligament cysts, and ligamentum flavum cysts; however, these cysts do not

communicate with the facet joint and are not lined with epithelium.

The cysts often are of fluid density, they rarely contain blood products,

calcium, or gas (gas in the facet joint).

The presence of increased wall density improves diagnosis and narrows the

differential diagnosis.

3/ Type of therapeutic management :

At the time of imaging, our patient had already undergone

medical management, combining rest and NSAIDs, with

support device.

The detection of a symptomatic synovial cyst may require

percutaneous steroid injection or surgery.

Surgery, performed initially, allows resection of the cyst and

treatment of other potential abnormalities: disk herniation,

spinal stenosis, narrowing of the lateral recess,

spondylolisthesis.

Long-term follow-up for surgical excision of symptomatic juxtafacet

cysts without spinal fusion revealed excellent to good results in 92%

of the patients, with a satisfaction rate of 80%, in the study of El

Shazly AA.(3).

Common surgical risks include spinal instability, dural tear,

neurologic injury, epidural hemorrhage and hematoma, seroma, and

cyst recurrence  

While surgery is the gold standard for the treatment for

symptomatic facet joint cysts, conservative options include bed rest,

physical therapy, acupuncture, oral analgesics and anti-

inflammatories, and percutaneous injection and aspiration

Arthrography-infiltration is a good alternative in case of cons-indication to

surgery or refusal

Percutaneous interventions are usually indicated in elderly or high-risk

patients (1)(2)(3). 

Under image-guided assistance, transforaminal or interlaminar epidural

corticosteroid and anesthetic injection can be performed pre-emptively or

concurrently to reduce the risk of procedure-related pain (1)(2)(3).

In long-term follow, C Parlier-Cuau(6), in his study of 30

Patients, found that One-third had long-lasting acceptable

benefit, and Bureau NJ(5) objective that among his 12 patients,

75% experienced complete resolution of their radiculopathy and

50% of patients, long-term follow-up imaging demonstrated

complete regression of the lumbar facet synovial cyst.

Although results are variable and the significant failure rate, this

gesture can usually pass a course of acute pain. In most cases, the

improvement made possible the resumption of professional

activity or at least allows to establish the normal posture (1)(4).

In our case, CT-guided percutaneous infiltration, has enabled us to

confirm the diagnosis, and treat the cyst, which allowed an immediate

relief of pain without recurrence after a decline of three years.

J.F.Martha et al.(1) Have a large series of 101 injections with rupture

of the cyst showed an immediate analgesic effect in 80% of cases and

stressed that the infiltration allowed to postpone surgery in half of

cases and follow up to 3 years showed an analgesic effect the same on

both therapeutic.

Complications of facet infiltrations in the lumbar spine are rare,

shared with corticosteroid infiltrations to other sites such as risks of

infection or local hematoma(1)(4).

In the study by Allen et al.(2) Another alternative of treatment is the

under fluoroscopics percutaneous contrast distention, and rupture

of the lumbar Z-joint cyst, it can expect about a 70% chance of a

successful long-term outcome. Recurrence rate is high (37.5%) and

usually occurs in the first 3 months. However, patients still have a

45% chance of a successful outcome after the second cyst rupture.

The advantage of CT over fluoroscopy is the direct treatment of

synovial cysts as well as ganglion, posterior longitudinal ligament,

and ligamentum flavum cysts that do not communicate with the

facet joint, therefore allowing direct, safe, and reliable puncture of

the cyst without dural violation

CONCLUSION

Arthrography of the facet joint, supplemented by

intra-articular injection of corticosteroids, is the last

step of medical management, it’s simple to perform,

useful to confirm the diagnosis, may provides

complete or significant regression of radicular

symptoms, and may be an alternative to surgical

excision of the cyst.

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lumbar synovial cysts: a case series of 101 patients. Spine J 2009;9:899-904.

2. Allen TL, Tatli Y, Lutz GE. Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a

clinical outcome study. Spine J 2009;9:387-95.

3. El Shazly AA, Khattab MF. Surgical excision of a Juxtafacet cyst in the lumbar spine: A report of

thirteen cases with long-term follow up. Asian J Neurosurg 2011;6:78-82

4. Anthony Chang. Percutaneous CT-Guided Treatment of Lumbar Facet Joint Synovial Cysts. HSS

Journal 5:2, 165-168.

5. Bureau NJ, Kaplan PA, Dussault RG. Lumbar Facet Joint Synovial Cyst: Percutaneous Treatment with

Steroid Injections and Distention-Clinical and Imaging Follow-up in 12 Patients. Radiology

2001;221:179-185.

6. C Parlier-Cuau; M Wybier; R Nizard; P Champsaur; P Le Hir; J D Laredo. Symptomatic lumbar facet

joint synovial cysts: clinical assessment of facet joint steroid injection after 1 and 6 months and long-

term follow-up in 30 patients. Radiology 1999;210(2):509-13.

THANX