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Various Surgeries for Synovial Cysts Have Similar Outcomes

A painful condition involving synovial or ganglion cysts can interfere with everyday activities. Synovial cysts are small fluid-filled masses on the synovium, the lining of the joint. Ganglion cysts are cysts found on the tendons. Both types of cysts are most often found in the wrist, knee, ankle, and foot, although they can appear elsewhere, such as the spine. Most often, spinal cysts are associated with degeneration of the spine from diseases such as osteoarthritis (the so-called wear-and-tear arthritis), spinal stenosis (narrowing of the spinal canal), and scoliosis (curvature of the spine).

The spinal cysts were first identified in 1950 and have since been treated with nonsurgical methods, but with very limited success. Most patients end up having surgery, which has many approaches, depending on the location of the cysts and the surgeon's preferences. The authors of this article reviewed the outcomes of patients who had surgery to remove the cysts, and their outcome, with the benefits and drawbacks, if any.

The authors reviewed 167 patients who had a total of 195 synovial cysts that were causing pain or disability. Symptoms included lower back pain (82.5 percent of the patients), radiculopathy (nerve irritation) of the legs and/or feet (97.5 percent), weakness (39.9 percent), neurogenic claudication (limping from pain in the calf) (20 percent), changes in sensation (33.3 percent), and bowel and bladder incontinence (3.2 percent), to name a few. The researchers noted if the patients were also diagnosed with illnesses such as diabetes (13.5 percent), coronary artery disease (hardening of the arteries) (14.7 percent), osteoporosis (thinning of the bones) (7.6 percent), obesity (7.0 percent), and/or high blood pressure (43.6 percent), and if they smoked (8.3 percent) or had previous back surgery (34 percent).

While reviewing the surgery notes, the researchers noted where the cysts were and classified the surgeries into one of four:

1- unilateral hemilaminectomy, removing one side of bone layer;
2- bilateral laminectomy, removal of both sides of a part of the bone on the vertebrae;
3- facetectomy with in situ fusion removal of part of the bone to keep it from pressing on the nerve root; or
4- , fusing of part of the bone to keep it from pressing on the nerve root.

After the classifications were noted, three cases were removed from the study because they could not be identified.

The researchers found that patients who underwent surgery number one alone "were less likely to have motor weakness, sensory deficits, or neurogenic claudication compared to" patients who had one of the other three surgeries. Patients who underwent surgery numbers three and four "had the highest rates of preoperative neurogenic claudication and sensory deficits; all patients with preoperative bladder and/or bowel dysfunction underwent fusion."

When looking at the location of the cysts, eight were found in the cervical/cervicothoracic levels, the neck down to upper mid-back. Three were in the thoracic/thoracolumbar spine, the mid-back down to just where the lower back begins, and 184 were found in the lumbar/lumbosacral spine, the lower back down to above the "tailbone."

Surgery for all patients kept them in the hospital for an average of 4.2 days, while those who had surgery four stayed the longest (up to 7.4 days). These patients also lost the most blood and had the highest number of complications during surgery. Among all the patients in the study, this group four were the only ones who experienced cerebral spinal fluid leakage (leaking of the fluid that surrounds the spinal cord), deep vein thrombosis, or DVT (blood clots in the legs), pulmonary embolism (clots to the lung), post-surgery infections, and wound dehiscence (incision opening up after surgery).

Follow-up for the patients was an average of 16.5 months (plus or minus 9.2 months). Although there were patients who needed repeat surgeries for disc herniations (bulging or slipped discs), collapse of some vertebrae, movement of the bone where it didn't heal properly, or return of symptoms, there was no difference between the number of patients between the surgery groups. Of all patients, 21.6 percent reported recurrent back pain after surgery and 11.8 percent reported recurrent leg pain. Those who were in group two had the highest reports of recurrent back pain. Group four patients had the lowest rate of recurrent back pain. Cysts did reoccur in five patients (3 percent of all patients) at the original spinal level: three among those in group two and two among those in group one.

The authors concluded initial and immediate improvement occurred in patients, regardless of the type of surgery performed, however within two years of undergoing a hemilaminectomy or laminectomy alone, patients did complain of recurrent back pain.


Risheng Xu, AM, et al. Factors Associated with Recurrent Back Pain and Cyst Recurrence After Surgical Resection of One Hundred Ninety-Five Spinal Synovial Cysts. Analysis of One Hundred Sixty-Seven Consecutive Cases. In Spine. May 1, 2010. Vol. 35, No. 10. Pp. 1044-1053.

05/27/2010

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