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Background: Although lumbar zygapophyseal joint synovial cysts are fairly well recognized, they are an uncommon cause of lumbosacral radicular pain. Nonoperative treatments include percutaneous aspiration of the cysts under computed tomography or fluoroscopic guidance with a subsequent corticosteroid injection. However, there are mixed results in terms of long-term outcomes and cyst reoccurrence. This study prospectively evaluates percutaneous ruptures of zygapophyseal joint (Z-joint) synovial cysts for the treatment of lumbosacral radicular pain., Objectives: Primary: To determine whether percutaneous rupture of symptomatic Z-joint synovial cysts leads to sustained improvements in radicular pain and function. Secondary: To assess the rates of cyst recurrence and progression to surgical intervention following percutaneous rupture of symptomatic Z-joint synovial cysts., Design: Prospective cohort study., Setting: Outpatient academic spine practice., Participants: Adults with primary radicular pain due to a facet synovial cyst., Methods: Participants underwent fluoroscopically guided percutaneous Z-joint synovial cyst ruptures under standard-of-care practice. Data on pain, physical function, satisfaction, and progression to surgery were collected at 2 weeks, 6 weeks, 3 months, 6 months, and 1 year after rupture. An intention-to-treat analysis was used for assessment of patient-reported outcome measures., Main Outcome Measures: The Numerical Rating Scale, Oswestry Disability Index, and modified North American Spine Society questionnaires were used to measure pain, function, and satisfaction with the procedure, respectively., Results: Thirty-five participants were included in the study, and data were analyzed by an independent researcher. Statistically significant changes in Oswestry Disability Index were reported at 2 weeks, 3 months, and 1 year postintervention (P = .034, .040, and .039, respectively). A statistically and clinically significant relief of current pain was reported at 2 weeks (P = .025) and 6 weeks (P = .014) with respect to baseline. Patients showed significant improvements for best pain at 6 weeks with respect to baseline (P = .031). Patients' worst pain showed the greatest amount of improvement with clinically meaningful changes at all time points compared with baseline. Patient-reported satisfaction was found nearly 70% of the time at all time points. Forty percent (14/35) of participants required repeat cyst rupture, and 31% (11/35) required surgical interventions., Conclusions: There were statistically and clinically significant improvements in pain and function after percutaneous rupture of Z-joint synovial cysts. In addition, the outcomes support previous retrospective studies indicating that approximately 40% of patients will need surgery. This study provides further research to determine the utility of this procedure and to precisely define a subset of ideal candidates., Level of Evidence: Level II., (Copyright © 2018 American Academy of Physical Medicine and Rehabilitation. Published by Elsevier Inc. All rights reserved.)

Lumbar facet cysts are a rare but increasingly common cause of symptomatic nerve root compression and can lead to radiculopathy, neurogenic claudication, and cauda equina syndrome. The cysts arise from the zygapophyseal joints of the lumbar spine and commonly demonstrate synovial herniation with mucinous degeneration of the facet joint capsule. Lumbar facet cysts are most common at the L4-L5 level and often are associated with spondylosis and degenerative spondylolisthesis. Advanced imaging studies have increased diagnosis of the cysts; however, optimal treatment of the cysts remains controversial. First-line treatment is nonsurgical management consisting of oral NSAIDs, physical therapy, bracing, epidural steroid injections, and/or cyst aspiration. Given the high rate of recurrence and the relatively low satisfaction with nonsurgical management, surgical options, including hemilaminectomy or laminotomy to excise the cyst and decompress the neural elements, are typically performed. Recent studies suggest that segmental fusion of the involved levels may decrease the risks of cyst recurrence and radiculopathy.

We present a case of spontaneous resolution of a lumbar intraspinal synovial cyst. We discuss the management options, including conservative management.

Objective: This article presents a case in which synovial cysts appeared to cause compromise of the neural foramina and thecal sac with presenting neurological signs., Clinical Features: A 67-year-old female patient with a history of lumbar synovial cysts and synovectomy presented with recurrence of bilateral low back, leg pain, and apparent neurological compromise along with a recurrence of lumbar synovial cyst as evidenced on magnetic resonance images., Interventions and Outcome: Flexion distraction therapy, performance of Williams low back exercises and interferential therapy resulted in 50% relief. Frequency of care was progressively diminished as she improved. The patient experienced recurrence of severe episodes; multifidi strengthening exercises were provided to address a concomitant spondylolisthesis and instability, resulting in a cessation of these episodes and improvement in functional activities., Conclusion: Distraction therapy seemed to alleviate the constant pain without surgical intervention. In this case, the synovial cyst may have been an incidental finding versus a primary cause of the low back and leg pain. For similar patients, in the absence of correlative progressive neurological signs, surgical intervention may not be necessary.

Sophisticated and newer imaging capabilities have resulted in increased reporting and treatment options of spinal lumbar synovial cysts (LSS). Most of the patients with lumbar cysts tend to be in their sixth decade of life with a slight female predominance. The incidence of LSS is thought to be less than 0.5% of the general symptomatic population. They may be asymptomatic and found incidentally or the epidural growth of cysts into the spinal canal can cause compression of neural structures and hence associated clinical symptoms. Most of the symptomatic LSS patients present with radicular pain and neurological deficits. Spinal synovial cysts are commonly found at L4-5 level, the site of maximum mobility. They may be unilateral or bilateral and at one or multilevel. MRI is considered the tool of choice for its diagnosis. The etiology of LSS is still unclear, but underlying spinal instability, facet joint arthropathy and degenerative spondylolisthesis has a strong association for worsening symptoms and formation of spinal cysts. Synovial cysts resistant to conservative therapy should be treated surgically. Resection and decompression with or without fusion and instrumentation remains an appropriate option. Synovial cysts may recur following surgery. The optimal approach for patients with juxtafacet LSS remains unclear. The best surgical treatment option for each particular individual should be tailored depending upon the symptoms, radiological findings and other co morbidities.

Objective: To evaluate the success of fluoroscopically guided, contrast-enhanced lumbar zygapophyseal joint (Z-joint) aspiration and steroid injection combined with transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar Z-joint cyst-induced radicular pain., Design: Retrospective case series with independent follow-up., Setting: Institutional, referral center., Participants: Twenty-three patients referred to a single provider for procedure-based management of radicular pain believed secondary to lumbar Z-joint cyst. Inclusion criteria consisted of lumbar radicular pain that was consistent with the level and side of the Z-joint cyst as a causative lesion., Interventions: Eighteen patients were treated with a fluoroscopically guided, contrast-enhanced Z-joint aspiration and steroid injection at the level of the causative cyst coupled with a fluoroscopically guided, contrast-enhanced TFESI over the level of the presumably irritated spinal nerve., Main Outcome Measures: Patient satisfaction, and whether or not surgery was performed., Results: Fifty percent of patients treated with the procedure had significant long-term benefit and avoided surgical intervention at an average follow-up of 9.9 months., Conclusions: Fluoroscopically guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar Z-joint cyst-induced radicular pain.

Objective: To present the treatment of low back and radicular pain due to synovial cysts of the lumbar spine including chiropractic distraction manipulation and physiological therapeutic care., Clinical Features: Two patients (71-year-old man and 59-year-old woman) with magnetic resonance imaging (MRI)-diagnosed large synovial cysts at the L3 through L4 and L4 through L5 vertebral levels, respectively, had lower extremity pain, numbness, and tingling of the respective L4 and L5 dermatomes., Intervention and Outcome: Chiropractic distraction manipulation was performed at the level of the synovial cyst. The manipulation was performed daily until 50% pain relief was attained, followed by diminished frequency of care. Physiotherapy included positive galvanism, iontophoresis, tetanizing electrical stimulation, stabilization exercises, and home cryotherapy. The male patient's pain was reduced by 50% in 14 days and 100% at 60 days. Range of motion of the thoracolumbar spine increased, walking distance increased from 1 to 2 blocks to 1 mile without pain, and repeat MRI showed reduced size of the cyst. The female patient, under the same treatment regimen, was pain free in 6 weeks., Conclusion: Chiropractic distraction manipulation and physiological therapeutic care relieved 2 patients with low back and radicular pain attributed to MRI-confirmed synovial cysts of the lumbar spine. This treatment may be an initial conservative treatment option for synovial cysts with careful patient monitoring for progressive neurologic deficit which would necessitate surgery. Distraction manipulation may be a safe and effective conservative treatment of synovial cyst causing radicular pain; further data collection of clinical outcomes is warranted.

Intraspinal synovial cyst primarily occurs in the lumbar spine and may cause back pain and compression nerve disturbance. Percutaneous aspiration has been recommended as an alternative to surgery in three cases. We report on two patients who improved after aspiration of gelatinous material and steroid injection but whose cyst recurred within a short period of time. There are reportedly two types of synovial cyst: One contains serosanguineous fluid and the other gelatinous fluid. These two types are indistinguishable on computed tomography or magnetic resonance imaging. The results of all patients whose aspirated material was gelatinous were unsuccessful, including our cases. Thus, the outcome may depend on the pathology of the cyst.