Synovial cysts of the spine are cystic formations connected to the facet joint and containing synovial fluid lined by a cuboid or pseudostratified columnar epithelium. They may result in lumbar radiculopathy in a significant number of cases.
They may be asymptomatic and found incidentally. However, larger cyst can result in stenosis of the spinal canal and cause compression of neural structures resulting in associated clinical symptoms.
Uncomplicated cysts are internally lined with cuboid or pseudostratified columnar epithelium and filled with clear or straw colored fluid.
They are typically associated with adjacent facet joint arthropathy.
They typically occur in the spine.
- synovial cysts in the spine occur predominantly in the lumbar region as compared to thoracic and cervical regions 2
- in the lumbar spine, there may be a predilection towards the L4-5 level 3,4
Typically seen as a calcified cystic lesion adjacent to a facet joint 3. CT may also show adjacent facet joint arthropathy +/- the presence of gas.
This entity cannot be reliably distinguished from ganglion cyst on standard MRI. However, communication with the joint space after intra-articular injection with contrast reliably differentiates the two.
- gas within the cyst is pathognomonic for a synovial cyst
- facet joint cysts may contain complex fluid as a result of internal debris or hemorrhage
- neural based cysts can usually be differentiated by imaging as these cysts show intimate relation with the adjacent nerve, rather than with the adjacent joint space
Calcification within cyst wall appears low signal intensity on both T1 and T2 weighted images whereas hemorrhagic cysts display increase intensity compared to CSF likely due to T1 shortening from methemoglobin.
The cysts do not always possess the signal characteristics of a simple cyst, so contrast administration may be needed in some cases. It is important to remember that they are a cause of peripherally enhancing masses in the extrathecal space anywhere along the spinal canal.
Treatment and prognosis
Cysts can be operated upon or accessed percutaneously.
The patient is positioned prone, followed by CT guided access into the inferior articular recess using a spinal needle. Once an intra-articular location is confirmed with contrast, and communication with the synovial cyst is demonstrated, rupture of the cyst is attempted using a steroid and anesthetic mixture 7,8.
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- 3. Liu SS, Williams KD, Drayer BP et-al. Synovial cysts of the lumbosacral spine: diagnosis by MR imaging. AJR Am J Roentgenol. 1990;154 (1): 163-6. doi:10.2214/ajr.154.1.2104702 - Pubmed citation
- 4. 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 (1): 179-85. doi:10.1148/radiol.2211010213 - Pubmed citation
- 5. Boviatsis EJ, Stavrinou LC, Kouyialis AT et-al. Spinal synovial cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review. Eur Spine J. 2008;17 (6): 831-7. doi:10.1007/s00586-007-0563-z - Free text at pubmed - Pubmed citation
- 6. Venkatanarasimha N, Suresh SP. AJR teaching file: An uncommon cause of spinal canal stenosis. AJR Am J Roentgenol. 2009;193 (3_supplement): S56-8. doi:10.2214/AJR.07.7110 - Pubmed citation
- 7. Chang A. Percutaneous CT-guided treatment of lumbar facet joint synovial cysts. (2009) HSS journal : the musculoskeletal journal of Hospital for Special Surgery. 5 (2): 165-8. doi:10.1007/s11420-009-9124-9 - Pubmed
- 8. Kursumovic A, Bostelmann R, Gollwitzer M, Rath S, Steiger HJ, Petridis AK. Intraspinal Lumbar Juxtaarticular Cyst Treatment Through CT-Guided Percutaneus Induced Rupture Results in a Favorable Patient Outcome. (2016) Clinics and practice. 6 (4): 866. doi:10.4081/cp.2016.866 - Pubmed