====== Lumbar juxtafacet cyst surgery ======
Different procedures have been used for the treatment of lumbar juxtafacet cysts (JFCs). Recently, full-endoscopic cyst excision has been suggested as a reasonable alternative
((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.))


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The cyst may be adherent to the [[dura]]. The cyst may also collapse during the surgical approach and may be missed. A JFC may serve as a marker for possible instability and should prompt an evaluation for the same. Some argue for performing a fusion since JFC may arise from instability; however, it appears that fusion is not required for a good result in many cases
((Kurz LT, Garfin SR, Unger AS, et al. Intraspinal Synovial Cyst Causing Sciatica. J Bone Joint Surg. 1985; 67A:865–871)).
Therefore it is suggested that consideration for fusion be made on the basis of any instability and not merely on the basis of the presence of a JFC.
Minimally invasive spine surgery (MISS) has also been used for removal
((Sehati N, Khoo LT, Holly LT. Treatment of lumbar synovial cysts using minimally invasive surgical techniques. Neurosurg Focus. 2006; 20:E2–E6)).
Long-term follow-up is lacking. A 15 mm entry incision is made 1.5 cm lateral to midline.
Following surgical treatment, symptomatic JFCs may recur or may develop on the contralateral side
((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)).
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[[Lumbar juxtafacet cyst]] (JFC) surgery is largely recommended in all cases of intractable [[pain]] or [[neurological deficit]]
((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.))
((Hemminghytt S, Daniels DL, Williams AL, Haughton VM. Intraspinal synovial
cysts: natural history and diagnosis by CT. Radiology. 1982 Nov;145(2):375-6.
PubMed PMID: 7134440.
))
((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;93(1 Suppl):53–7.))
((Yarde WL, Arnold PM, Kepes JJ, O’Boynick PL, Wilkinson SB, Batnitzky S. Synovial cysts of the lumbar spine: Diagnosis, surgical management, and pathogenesis. Report of eight cases. SurgNeurol. 1995;43:459–64.))
((Hsu KY, Zucherman JF, Shea WJ, Jeffrey RA. Lumbar intraspinal synovial and ganglion cysts (facet cysts).Ten-year experience in evaluation and treatment. Spine (Phila Pa 1976) 1995;20:80–9.)).

If symptoms persist with [[conservative treatment]], some authors recommend cyst aspiration or [[facet joint injection]] with [[steroid]]s, while most surgeons prefer surgical excision of the cyst
((Kurz LT, Garfin SR, Unger AS, Thorne RP, Rothman RH. Intraspinal synovial cyst
causing sciatica. J Bone Joint Surg Am. 1985 Jul;67(6):865-71. PubMed PMID:
4019534.)).

The cyst may be adherent to the dura. The cyst may also collapse during the surgical approach and may be missed.

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A JFC may indicate possible instability, which must be evaluated. Some recommend primary [[spinal fusion]] in conjunction with surgical excision of the JFC. However, it appears that in many cases fusion is not required for a good result
((Kurz LT, Garfin SR, Unger AS, Thorne RP, Rothman RH. Intraspinal synovial cyst
causing sciatica. J Bone Joint Surg Am. 1985 Jul;67(6):865-71. PubMed PMID:
4019534.)).

Therefore it is suggested that consideration for fusion be made on the basis of any instability and not merely on the basis of the presence of a JFC.

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Few reports have described the long-term follow-up of the surgical excision of JFC.

The treatment was surgical excision of the cyst, as well as complete laminectomy if there was concomitant spinal stenosis. Follow-up, ranging from eighteen to twenty-five months, revealed complete resolution of the sciatica in all patients
((Kurz LT, Garfin SR, Unger AS, Thorne RP, Rothman RH. Intraspinal synovial cyst
causing sciatica. J Bone Joint Surg Am. 1985 Jul;67(6):865-71. PubMed PMID:
4019534.)).

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Many authors reported that no difference in surgical outcome was found between patients having fusion and those who did not have it
((Boviatsis EJ, Stavrinou LC, Kouyialis AT, Gavra MM, Stavrinou PC, Themistokleous M, et al. Spinal synovial cysts: Pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review. Eur Spine J. 2008;17:831–7.))
((Pirotte B, Gabrovsky N, Massager N, Levivier M, David P, Brotchi J. Synovial cysts of the lumbar spine: Surgery-related results and outcome. J Neurosurg. 2003;99(1 Suppl):14–9.)).

While others concluded that, a concomitant fusion procedure may be performed in selected cases
((Métellus P, Fuentes S, Adetchessi T, Levrier O, Flores-Parra I, Talianu D,
Dufour H, Bouvier C, Manera L, Grisoli F. Retrospective study of 77 patients
harbouring lumbar synovial cysts: functional and neurological outcome. Acta
Neurochir (Wien). 2006 Jan;148(1):47-54; discussion 54. Epub 2005 Oct 31. PubMed 
PMID: 16258839.
))
((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;93(1 Suppl):53–7.)).

Métellus et al.
((Métellus P, Fuentes S, Adetchessi T, Levrier O, Flores-Parra I, Talianu D,
Dufour H, Bouvier C, Manera L, Grisoli F. Retrospective study of 77 patients
harbouring lumbar synovial cysts: functional and neurological outcome. Acta
Neurochir (Wien). 2006 Jan;148(1):47-54; discussion 54. Epub 2005 Oct 31. PubMed 
PMID: 16258839.
))
has concluded that there is no reliable criterion that allows the development of a symptomatic spinal instability to be predicted in patients with preoperative spondylolisthesis, and therefore, fusion as a first line procedure is still debatable. Others have mentioned an association between spinal cysts and spondylolisthesis/instability and better surgical outcomes in patients having fusion than in those who did not have it
((Khan AM, Synnot K, Cammisa FP, Girardi FP. Lumbar synovial cysts of the spine:
an evaluation of surgical outcome. J Spinal Disord Tech. 2005 Apr;18(2):127-31.
PubMed PMID: 15800428.
))
((Pirotte B, Gabrovsky N, Massager N, Levivier M, David P, Brotchi J. Synovial cysts of the lumbar spine: Surgery-related results and outcome. J Neurosurg. 2003;99(1 Suppl):14–9.))
((Bydon A, Xu R, Parker SL, McGirt MJ, Bydon M, Gokaslan ZL, et al. Recurrent back and leg pain and cyst reformation after surgical resection of spinal synovial cysts: Systematic review of reported postoperative outcomes. Spine J. 2010;10:820–6.))
((Tillich M, Trummer M, Lindbichler F, Flaschka G. Symptomatic intraspinal synovial cysts of the lumbar spine: Correlation of MR and surgical findings. Neuroradiology. 2001;43:1070–5.)).
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Due to concerns about progressive instability, laminectomy with lumbar fusion has been advocated as the best treatment option for synovial cysts with spondylolithesis
((Bydon M, Papadimitriou K, Witham T, Wolinsky JP, Sciubba D, Gokaslan Z, Bydon 
A. Treatment of spinal synovial cysts. World Neurosurg. 2013 Feb;79(2):375-80.
doi: 10.1016/j.wneu.2012.08.016. Epub 2012 Sep 25. Review. PubMed PMID: 23022636.
))
((Bydon A, Xu R, Parker SL, McGirt MJ, Bydon M, Gokaslan ZL, Witham TF.
Recurrent back and leg pain and cyst reformation after surgical resection of
spinal synovial cysts: systematic review of reported postoperative outcomes.
Spine J. 2010 Sep;10(9):820-6. doi: 10.1016/j.spinee.2010.04.010. Epub 2010 May
20. Review. PubMed PMID: 20488765.
)).
However lumbar fusion procedures involve increased operative time and blood loss as well as the risk of developing adjacent segment disease
((Saavedra-Pozo FM, Deusdara RA, Benzel EC. Adjacent segment disease perspective
and review of the literature. Ochsner J. 2014 Spring;14(1):78-83. Review. PubMed 
PMID: 24688337; PubMed Central PMCID: PMC3963057.
)).

===== Minimally invasive spine surgery =====


Studies using minimally invasive techniques with tubular retractors for decompression and resection of synovial cysts have showed promising results in a limited number of patients
((James A, Laufer I, Parikh K, Nagineni VV, Saleh TO, Hartl R. Lumbar juxtafacet cyst resection: the facet sparing contralateral minimally invasive surgical approach. J Spinal Disord Tech. 2012;25(2):E13–7.))
((Sandhu FA, Santiago P, Fessler RG, Palmer S. Minimally invasive surgical treatment of lumbar synovial cysts. Neurosurgery. 2004;54(1):107–11. discussion 11-2.))
((Sehati N, Khoo LT, Holly LT. Treatment of lumbar synovial cysts using minimally invasive surgical techniques. Neurosurg Focus. 2006;20(3):E2.))
((Sukkarieh HG, Hitchon PW, Awe O, Noeller J. Minimally invasive resection of lumbar intraspinal synovial cysts via a contralateral approach: review of 13 cases. J Neurosurg Spine. 2015;23(4):444–50.)).


This type of approach decreases damage to surroundings muscular, bony and ligamentous structures and could potentially minimize segmental instability, particularly in the presence of preexisting spondylolisthesis
((Sandhu FA, Santiago P, Fessler RG, Palmer S. Minimally invasive surgical treatment of lumbar synovial cysts. Neurosurgery. 2004;54(1):107–11. discussion 11-2.))
((Armin SS, Holly LT, Khoo LT. Minimally invasive decompression for lumbar
stenosis and disc herniation. Neurosurg Focus. 2008;25(2):E11. doi:
10.3171/FOC/2008/25/8/E11. Review. PubMed PMID: 18673040.
))
However there is no published study on minimally invasive resection of lumbar synovial cysts that compares outcomes between patients with and without spondylolisthesis.

A 15 mm entry incision is made 1,5 cm lateral to midline.

Following surgical treatment, symptomatic JFCs may recur or may develop on the contralateral side
((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.)).

===== 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.))

===== References =====