====== Lumbar juxtafacet cyst ====== //J.Sales-Llopis// //Neurosurgery Service, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL - FISABIO Foundation), Alicante, Spain.// ===== General information ===== The term juxtafacet cyst (JFC) was originated by Kao et al ((Kao CC, Winkler SS, Turner JH. Synovial Cyst of Spinal Facet. Case Report. Journal of Neurosurgery. 1974; 41:372–376)) in [[1974]] and includes both [[synovial cyst]]s (those having a synovial lining membrane) and [[ganglion cyst]]s (those lacking synovial lining) adjacent to a spinal [[facet joint]] or arising from the [[ligamentum flavum]]. The distinction between these two may be difficult without [[histology]] and is clinically unimportant ((Freidberg SR, Fellows T, Thomas CB, et al. Experi- ence with Symptomatic Epidural Cysts. Neurosur- gery. 1994; 34:989–993)). JFC occur primarily in the [[lumbar spine]] (although cysts in the cervical ((Cartwright MJ, Nehls DG, Carrion CA, et al. Synovial Cyst of a Cervical Facet Joint: Case Report. Neuro- surgery. 1985; 16:850–852)) ((Onofrio BM, Mih AD. Synovial Cysts of the Spine. Neurosurgery. 1988; 22:642–647)) ((Goffin J, Wilms G, Plets C, et al. Synovial Cyst at the C1-C2 Junction. Neurosurgery. 1992; 30:914–916)) and thoracic ((Lopes NMM, Aesse FF, Lopes DK. Compression of Thoracic Nerve Root by a Facet Joint Synovial Cyst: Case Report. Surgical Neurology. 1992; 38:338–340)) spine has been described). ===== History ===== They were first reported in 1880 by von Gruker during an autopsy, ((Heary RF, Stellar S, Fobben ES. Preoperative Diagnosis of an Extradural Cyst Arising from a Spinal Facet Joint: Case Report. Neurosurgery. 1992; 30:415–418)) ((Pendleton B, Carl B, Pollay M. Spinal extradural benign synovial or ganglion cyst: case report and review of the literature. Neurosurgery. 1983 Sep;13(3):322-6. PubMed PMID: 6621847. )). and were first diagnosed clinically in 1968. Kao et al. later confirmed this in [[1974]] ((Kao CC, Winkler SS, Turner JH. Synovial cyst of spinal facet. Case report. J Neurosurg. 1974 Sep;41(3):372-6. PubMed PMID: 4416019. )). ===== Epidemiology ===== They are relatively rare, only 3 cases were identified in a series of 1500 spinal CT exams ((Mercader J, Muñoz Gomez J, Cardenal C. Intraspinal synovial cyst: diagnosis by CT. Follow-up and spontaneous remission. Neuroradiology. 1985;27(4):346-8. PubMed PMID: 4047392. )) but the frequency of diagnosis may be on the rise due to the widespread use of MRI and an increasing awareness of the condition. Eyster et al. reviewed approx. 1,800 MRIs and CTs over one and half year and found 11 (0.6% of) cases of lumbar synovial cysts of the spine ((Eyster EF, Scott WR. Lumbar synovial cysts: report of eleven cases. Neurosurgery. 1989 Jan;24(1):112-5. PubMed PMID: 2927587. )). However Doyle et al., ((Doyle AJ, Merrilees M. Synovial cysts of the lumbar facet joints in a symptomatic population: prevalence on magnetic resonance imaging. Spine (Phila Pa 1976). 2004 Apr 15;29(8):874-8. PubMed PMID: 15082987.)) found a prevalence of 2.3% anterior and 7.3% posterior spinal cyst in a review of 303 retrospective analyses of MRIs. Similarly Lemish et al. ((Lemish W, Apsimon T, Chakera T. Lumbar intraspinal synovial cysts. Recognition and CT diagnosis. Spine (Phila Pa 1976). 1989 Dec;14(12):1378-83. PubMed PMID: 2533404. )) identified 10 cysts in 2,000 reviews of CT lumbar spines. The average age was 63 years in Sabo et al. series ((Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg. 1996 Oct;85(4):560-5. PubMed PMID: 8814156. )) and 58 years in a review of 54 cases in the literature ((Liu SS, Williams KD, Drayer BP, Spetzler RF, Sonntag VK. Synovial cysts of the lumbosacral spine: diagnosis by MR imaging. AJNR Am J Neuroradiol. 1989 Nov-Dec;10(6):1239-42. PubMed PMID: 2512789. )). Most of the patients with lumbar cysts tend to be in their sixth decade of life with a range that is varied from as early as 28 years to as late as 94 years ((Lyons MK, Atkinson JL, Wharen RE, Deen HG, Zimmerman RS, Lemens SM. Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience. J Neurosurg. 2000 Jul;93(1 Suppl):53-7. PubMed PMID: 10879758. )). A female bias has been reported often ((Lyons MK, Atkinson JL, Wharen RE, Deen HG, Zimmerman RS, Lemens SM. Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience. J Neurosurg. 2000 Jul;93(1 Suppl):53-7. PubMed PMID: 10879758. )) , but others refute that. They are extremely rare in adolescence and young adulthood, only two pediatric cases have been reported in the literature, but they could be considered in the differential diagnosis in adolescent patients with low back pain and radiculopathy. Surgical removal of LSC could be considered as a treatment option to provide immediate and safe symptomatic relief ((Kalevski SK, Haritonov DG, Peev NA. Lumbar intraforaminal synovial cyst in young adulthood: case report and review of the literature. Global Spine J. 2014 Aug;4(3):191-6. doi: 10.1055/s-0034-1370694. Epub 2014 Feb 21. PubMed PMID: 25083362; PubMed Central PMCID: PMC4111946.)). They may be bilateral. It is typically a process that only happens in the lumbar spine, and it almost always develops at the L4-L5 level ((Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg. 1996 Oct;85(4):560-5. PubMed PMID: 8814156. )) ((Gorey MT, Hyman RA, Black KS, Scuderi DM, Cinnamon J, Kim KS. Lumbar synovial cysts eroding bone. AJNR Am J Neuroradiol. 1992 Jan-Feb;13(1):161-3. PubMed PMID: 1595435.)) (rarely at L3-L4). ===== Classification ===== {{::lumbar_juxtafacet_cyst_classification.jpg?600|}} https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5605355/figure/F4/ ===== Etiology ===== The etiology is unknown (possibilities include: synovial fluid extrusion from the joint capsule, latent growth of a developmental rest, myxoid degeneration and cyst formation in collagenous connective tissue...), increased motion seems to have a role in many cysts, and the role of trauma in the pathogenesis is debated ((Onofrio BM, Mih AD. Synovial Cysts of the Spine. Neurosurgery. 1988; 22:642–647)) ((Franck JI, King RB, Petro GR, et al. A Posttraumatic Lumbar Spinal Synovial Cyst. Case Report. J Neurosurg. 1987; 66:293–296)) but probably plays a role in a small number (≈ 14%) ((Sabo RA, Tracy PT, Weinger JM. A Series of 60 Juxtafacet Cysts: Clinical Presentation, the Role of Spinal Instability, and Treatment. J Neurosurg. 1996; 85:560–565)). ---- Most occur in patients with severe spondylosis and facet joint degeneration ((Silbergleit R, Gebarski SS, Brunberg JA, McGillicudy J, Blaivas M. Lumbar synovial cysts: correlation of myelographic, CT, MR, and pathologic findings. AJNR Am J Neuroradiol. 1990 Jul-Aug;11(4):777-9. PubMed PMID: 2136366. )) 25 % had degenerative spondylolisthesis ((Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg. 1996 Oct;85(4):560-5. PubMed PMID: 8814156. )) Unknown, increased motion seems to have a role in many cysts and the role of trauma in the [[pathogenesis]] is debated ((Onofrio BM, Mih AD. Synovial cysts of the spine. Neurosurgery. 1988 Apr;22(4):642-7. PubMed PMID: 3374775. )) ((Franck JI, King RB, Petro GR, Kanzer MD. A posttraumatic lumbar spinal synovial cyst. Case report. J Neurosurg. 1987 Feb;66(2):293-6. PubMed PMID: 3806212. )) but probably plays a role in a small number (= 14 %) ((Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg. 1996 Oct;85(4):560-5. PubMed PMID: 8814156. )). ---- There has been a general understanding that Cystic Formations of the Mobile Spine (CYFMOS) are associated with degenerative spine changes. More recent articles however have suggested that identifying detailed imaging characteristics can assist in determining outcomes when CYFMOS are treated with interventional percutaneous methods or surgical decompression with or without concomitant fusion. CYFMOS although uncommon are not a rare finding seen in the spine when there is a background of degenerative spine changes. These cystic lesions are generally symptomatic by exhibiting mass effect on adjacent structure. Most treatments are aimed at decompression by interventional percutaneous or surgical means. Various imaging characteristics of these CYFMOS including their signal intensity, presence of spinal instability, particular patterns of adjacent degenerative changes, and imaging changes following interventional treatments can help guide physicians when managing these cases ((Anand A, Pfiffner TJ, Mechtler L. The Role of Imaging in the Management of Cystic Formations of the Mobile Spine (CYFMOS). Curr Pain Headache Rep. 2018 Aug 25;22(10):70. doi: 10.1007/s11916-018-0723-3. Review. PubMed PMID: 30145776. )). ===== Pathology ===== see [[Juxtafacet cyst pathology]] ===== Clinical Features ===== [[Lumbar juxtafacet cyst clinical]]. ===== Diagnosis ===== [[Lumbar juxtafacet cyst diagnosis]]. ===== Differential diagnosis ===== [[Lumbar juxtafacet cyst differential diagnosis]]. ===== Treatment ===== [[Lumbar juxtafacet cyst treatment]]. ===== Systematic Review and Meta-Analysis ===== Giordan et al. performed a [[meta-analysis]] to assess the overall rates of favorable [[outcome]]s and [[adverse event]]s for each available [[treatment]] and determine the [[outcome]] and [[complication]] rates concerning spine [[stability]]. Multiple [[database]]s were searched for English-language studies involving adult patients with lumbar JFCs who had been followed for more than 6 months. Outcomes included the proportion of patients with a satisfactory outcome. Adverse events included recurrence and revision rates as well as intraoperative complications. They further stratified the analysis based on the spine's condition ([[lumbar degenerative spondylolisthesis]] vs without degenerative listhesis). A total of 43 studies, including 2226 patients, were identified. Over 80% of patients experienced satisfactory improvement after surgical excision but only 66.2% after percutaneous cyst rupture and aspiration. Overall, recurrence and revision rates were almost double in patients with preoperative degenerative listhesis at the cyst level, especially in the minimally invasive group (2.1% vs 31.3% and 6.8% vs 13.1%, respectively). The rate of full-endoscopic satisfactory outcomes was approximately 90%, with low rates of adverse events (<2%). They analyzed the outcome and [[adverse event]] rates for each kind of available treatment for JFC. Full endoscopy has outcomes and rates of adverse events that overlap with open and minimally invasive approaches ((Giordan E, Gallinaro P, Stafa A, Canova G, Zanata R, Marton E, Verme JD. A Systematic Review and Meta-Analysis of Outcomes and Adverse Events for Juxtafacet Cysts Treatment. Int J Spine Surg. 2022 Feb 25:8181. doi: 10.14444/8181. Epub ahead of print. PMID: 35217587.)) ===== Case series ===== [[Lumbar juxtafacet cyst case series]]. ===== Case reports ===== [[Lumbar juxtafacet cyst case reports]]. ===== References =====