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Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy
The Spine Journal 5 (2005) 451–453
Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy Jason C. Eck, DO, MSa,*, Steven J. Triantafyllou, MDb a
Department of Orthopaedic Surgery, Memorial Hospital, 325 S, Belmont Avenue, York, PA 17403, USA b Department of Orthopaedic Surgery, York Hospital, 1001 S, George Street, York, PA 17405, USA Received 29 August 2004; accepted 4 January 2005
Abstract
BACKGROUND CONTEXT: Acute onset of radicular symptoms has been reported following hemorrhage into lumbar synovial cysts after trauma or in cases of spinal instability. No previous cases have been linked to anticoagulation therapy. PURPOSE: To present a case of symptomatic hemorrhagic lumbar synovial cyst occurring after anticoagulation therapy. STUDY DESIGN: A case report and review of the literature. METHODS: A patient presented with low back and radicular pain secondary to a large synovial facet cyst. Magnetic resonance imaging revealed a large facet cyst compressing the thecal sac and L3 exiting nerve root. RESULTS: The synovial cyst was excised during a lumbar decompression and fusion. Gross blood was present in the cyst. CONCLUSIONS: This is the first reported case of symptomatic hemorrhagic lumbar facet cyst associated with anticoagulation therapy. 쑖 2005 Elsevier Inc. All rights reserved.
Keywords:
Cyst; Stenosis; Lumbar spine; Coumadin; Hemorrhagic; Anticoagulation
Introduction Synovial cysts of the spine are relatively uncommon, with most occurring in the lumbar spine. The most common level affected is L4-5 [1]. The cysts typically project from the anterior portion of the facet joint leading to radicular or myelopathic symptoms. Symptoms can often be difficult to distinguish from a disc herniation. Synovial cysts are lined by synovial cells and typically contain a thin, straw-colored fluid [2–4]. Possible etiologies include herniation of synovium through the facet joint capsule secondary to either trauma or a degenerative process. Acute onset of radicular symptoms has been reported following hemorrhage into lumbar synovial cysts after trauma or in cases of spinal instability [5–8]. This report presents a case of a hemorrhagic synovial cyst secondary to anticoagulation therapy. There have been
FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this manuscript. * Corresponding author. Memorial Hospital, 325 S. Belmont St., Box 129, York, PA 17403. Tel.: (717) 843-8623; Fax: (717) 852-0022. E-mail address: [email protected] (J. Eck) 1529-9430/05/$ – see front matter doi:10.1016/j.spinee.2005.01.005
쑖 2005 Elsevier Inc. All rights reserved.
no previous reports of hemorrhagic lumbar synovial cysts occurring after anticoagulation therapy.
Case Report A 77-year-old male presented with a 2-week history of low back pain and right lower extremity radiculopathy. He complained of pain and numbness throughout the right anterior thigh. The patient had a history of multiple myeloma with involvement of the lumbosacral spine, polymyalgia rheumatica, hypertension, and depression. He also had a recent deep vein thrombosis for which he was taking warfarin for anticoagulation. The patient had undergone a recent intramedullary nail of the femur for an impending pathologic fracture. The patient denied any changes in bowel or bladder function or gait disturbances. He denied any recent history of trauma. Physical examination revealed no tenderness throughout the spine. There was full range of motion at the hips and low back with slightly increased pain during lumbar flexion. Straight leg raising tests were negative bilaterally. Reflexes of the upper extremities and left lower extremity
452
J.C. Eck et al. / The Spine Journal 5 (2005) 451–453
were 2⫹/4. Right patella reflex was 1⫹ and trace at the right ankle. Magnetic resonance imaging of the lumbar spine (Fig. 1) revealed abnormal signal intensity throughout the lumbosacral spine consistent with multiple myeloma but without
evidence of pathologic fracture, bony expansion, or infiltration. There was multiple level disc degeneration with mild anterolisthesis at the L3-4 level with advanced facet arthritis on the right side and severe central canal stenosis. A large synovial cyst was compressing the right L3 nerve root and thecal sac. After failing conservative care, the patient underwent L3-4 decompression with bilateral hemilaminectomies and facetectomies with excision of the synovial cyst. An L3-4 posterolateral fusion was performed with local morselized bone graft. During surgery the facet cyst was found to be filled with blood. Pathology identified the specimen as a synovial cyst with a synovial cell lining. The specimen was approximately 1.5 cm in diameter. The patient tolerated the procedure well without complications. The patient was discharged on postoperative day 1. The patient was retired at the time of surgery, but had returned to normal activities without limitation at 6 weeks postoperatively. At his 1-year follow-up, the patient denied any further symptoms related to his low back or right lower extremity. Discussion
Fig. 1. Axial (A) and sagittal (B) magnetic resonance imaging of the lumbar spine revealing abnormal signal intensity consistent with multiple myeloma but without pathologic fracture. A large facet cyst is visualized at L3-4 on the right with significant nerve root and thecal sac compression.
Synovial cysts are relatively uncommon in the spine but occur most frequently at the L4-5 level. The majority of these cysts are lined with synovial cells and contain a strawcolored fluid. There have been several previous reports of symptomatic hemorrhagic synovial cysts in the lumbar spine. It is believed they result from either trauma or spinal instability. Most cases are associated with facet joint osteoarthritis and degenerative spondylolisthesis, but there is no correlation with age, gender, or degree of disc degeneration [9]. As in this case, most patients present with progressive low back and lower extremity radicular symptoms resulting from compression of the thecal sac or nerve roots. Patients may complain of focal tenderness over the facet joints with exacerbation of pain during extension. Other common findings not present in the current case include motor and sensory deficits and positive straight leg raising tests [10]. The recommended treatment of symptomatic synovial cysts is excision through laminectomy. In this case, a wide decompression with facetectomy and fusion was required to facilitate removal of the cyst. Other reported treatment options include computed tomography–guided fine needle aspiration and percutaneous injection of hyaluronidase [5,8,11–13]. It is not possible to definitively correlate the presence of this patient’s hemorrhagic cyst with the anticoagulation therapy. However, the patient was known to have longstanding asymptomatic degenerative changes in the lumbosacral spine before initiation of anticoagulation. A magnetic resonance imaging scan taken the year before the symptoms began had no evidence of facet cyst. The patient began taking coumadin several weeks before the initiation of his symptoms.
J.C. Eck et al. / The Spine Journal 5 (2005) 451–453
Symptomatic lumbar facet cysts should be included in the differential diagnosis for patients presenting with progressive back pain and radicular symptoms. The symptoms are typically indistinguishable from disc herniation or spinal stenosis. Patients with significant facet degeneration and instability are predisposed to the development of facet cysts [9,14].
References [1] Sabo RA, Tracy PT, Weigner JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg 1996;85:560–5. [2] Finkelstein SD, Sayegh R, Watson P, Knuckey N. Juxta-Facet cysts. Report of two cases and review of clinicopathologic features. Spine 1993;18:779–82. [3] Franck JI, King RB, Petro GR, et al. A posttraumatic lumbar spinal synovial cyst. J Neurosurg 1987;66:293–6. [4] Jabre A, Shahbabian S, Keller JT. Synovial cyst of the cervical spine. Neurosurgery 1987;20:316–8.
Forty Years Ago in Spine
453
[5] Howling SJ, Kessel D. Acute radiculopathy due to a haemorrhagic lumbar synovial cyst. Clin Radiol 1997;52:73–4. [6] Kaneko K, Inoue Y. Haemorrhagic lumbar synovial cyst: a cause of acute radiculopathy. J Bone Joint Surg Br 2000;82-B:583–4. [7] Nishida K, Iguchi T, Kurihara A, et al. Symptomatic hematoma of lumbar facet joint: joint apoplexy of the spine? Spine 2003;28:E206–8. [8] Tatter SB, Cosgrove GR. Hemorrhage into a lumbar synovial cyst causing an acute cauda equina syndrome. J Neurosurg 1994;81: 449–52. [9] Doyle AJ, Merrilees M. Synovial cysts of the lumbar facet joints in a symptomatic population: prevalence on magnetic resonance imaging. Spine 2004;29:874–8. [10] Banning CS, Thorell WE, Leibrock LG. Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969–72. [11] Abrahams JJ, Wood GW, Eames FA, et al. CT-guided needle aspiration biopsy of an intraspinal synovial cyst (ganglion): case report and review of the literature. Am J Neuroradiol 1988;9:398–400. [12] Koenigsberg RA. Percutaneous aspiration of a lumbar synovial cyst: CT and MR considerations. Neuroradiology 1998;40:272–3. [13] Paul AS, Sochart DH. Improving the results of ganglion aspiration by the use of hyaluronidase. J Hand Surg [Br] 1997;22:219–21. [14] Howington JU, Connolly ES, Voorhies RM. Intraspinal synovial cysts: 10-year experience at the Ochsner Clinic. J Neurosurg Spine 1999; 91(2):193–9.
of chronic pain permitted assimilation of sensory, motivational, affective and behavioral factors and ushered in the current era of pain management.
Reference [1] Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965; 150:971–9.
In 1965, Melzack and Wall published their classic theory of pain [1]. Their gate control model
Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy Jason C. Eck, DO, MSa,*, Steven J. Triantafyllou, MDb a
Department of Orthopaedic Surgery, Memorial Hospital, 325 S, Belmont Avenue, York, PA 17403, USA b Department of Orthopaedic Surgery, York Hospital, 1001 S, George Street, York, PA 17405, USA Received 29 August 2004; accepted 4 January 2005
Abstract
BACKGROUND CONTEXT: Acute onset of radicular symptoms has been reported following hemorrhage into lumbar synovial cysts after trauma or in cases of spinal instability. No previous cases have been linked to anticoagulation therapy. PURPOSE: To present a case of symptomatic hemorrhagic lumbar synovial cyst occurring after anticoagulation therapy. STUDY DESIGN: A case report and review of the literature. METHODS: A patient presented with low back and radicular pain secondary to a large synovial facet cyst. Magnetic resonance imaging revealed a large facet cyst compressing the thecal sac and L3 exiting nerve root. RESULTS: The synovial cyst was excised during a lumbar decompression and fusion. Gross blood was present in the cyst. CONCLUSIONS: This is the first reported case of symptomatic hemorrhagic lumbar facet cyst associated with anticoagulation therapy. 쑖 2005 Elsevier Inc. All rights reserved.
Keywords:
Cyst; Stenosis; Lumbar spine; Coumadin; Hemorrhagic; Anticoagulation
Introduction Synovial cysts of the spine are relatively uncommon, with most occurring in the lumbar spine. The most common level affected is L4-5 [1]. The cysts typically project from the anterior portion of the facet joint leading to radicular or myelopathic symptoms. Symptoms can often be difficult to distinguish from a disc herniation. Synovial cysts are lined by synovial cells and typically contain a thin, straw-colored fluid [2–4]. Possible etiologies include herniation of synovium through the facet joint capsule secondary to either trauma or a degenerative process. Acute onset of radicular symptoms has been reported following hemorrhage into lumbar synovial cysts after trauma or in cases of spinal instability [5–8]. This report presents a case of a hemorrhagic synovial cyst secondary to anticoagulation therapy. There have been
FDA device/drug status: not applicable. Nothing of value received from a commercial entity related to this manuscript. * Corresponding author. Memorial Hospital, 325 S. Belmont St., Box 129, York, PA 17403. Tel.: (717) 843-8623; Fax: (717) 852-0022. E-mail address: [email protected] (J. Eck) 1529-9430/05/$ – see front matter doi:10.1016/j.spinee.2005.01.005
쑖 2005 Elsevier Inc. All rights reserved.
no previous reports of hemorrhagic lumbar synovial cysts occurring after anticoagulation therapy.
Case Report A 77-year-old male presented with a 2-week history of low back pain and right lower extremity radiculopathy. He complained of pain and numbness throughout the right anterior thigh. The patient had a history of multiple myeloma with involvement of the lumbosacral spine, polymyalgia rheumatica, hypertension, and depression. He also had a recent deep vein thrombosis for which he was taking warfarin for anticoagulation. The patient had undergone a recent intramedullary nail of the femur for an impending pathologic fracture. The patient denied any changes in bowel or bladder function or gait disturbances. He denied any recent history of trauma. Physical examination revealed no tenderness throughout the spine. There was full range of motion at the hips and low back with slightly increased pain during lumbar flexion. Straight leg raising tests were negative bilaterally. Reflexes of the upper extremities and left lower extremity
452
J.C. Eck et al. / The Spine Journal 5 (2005) 451–453
were 2⫹/4. Right patella reflex was 1⫹ and trace at the right ankle. Magnetic resonance imaging of the lumbar spine (Fig. 1) revealed abnormal signal intensity throughout the lumbosacral spine consistent with multiple myeloma but without
evidence of pathologic fracture, bony expansion, or infiltration. There was multiple level disc degeneration with mild anterolisthesis at the L3-4 level with advanced facet arthritis on the right side and severe central canal stenosis. A large synovial cyst was compressing the right L3 nerve root and thecal sac. After failing conservative care, the patient underwent L3-4 decompression with bilateral hemilaminectomies and facetectomies with excision of the synovial cyst. An L3-4 posterolateral fusion was performed with local morselized bone graft. During surgery the facet cyst was found to be filled with blood. Pathology identified the specimen as a synovial cyst with a synovial cell lining. The specimen was approximately 1.5 cm in diameter. The patient tolerated the procedure well without complications. The patient was discharged on postoperative day 1. The patient was retired at the time of surgery, but had returned to normal activities without limitation at 6 weeks postoperatively. At his 1-year follow-up, the patient denied any further symptoms related to his low back or right lower extremity. Discussion
Fig. 1. Axial (A) and sagittal (B) magnetic resonance imaging of the lumbar spine revealing abnormal signal intensity consistent with multiple myeloma but without pathologic fracture. A large facet cyst is visualized at L3-4 on the right with significant nerve root and thecal sac compression.
Synovial cysts are relatively uncommon in the spine but occur most frequently at the L4-5 level. The majority of these cysts are lined with synovial cells and contain a strawcolored fluid. There have been several previous reports of symptomatic hemorrhagic synovial cysts in the lumbar spine. It is believed they result from either trauma or spinal instability. Most cases are associated with facet joint osteoarthritis and degenerative spondylolisthesis, but there is no correlation with age, gender, or degree of disc degeneration [9]. As in this case, most patients present with progressive low back and lower extremity radicular symptoms resulting from compression of the thecal sac or nerve roots. Patients may complain of focal tenderness over the facet joints with exacerbation of pain during extension. Other common findings not present in the current case include motor and sensory deficits and positive straight leg raising tests [10]. The recommended treatment of symptomatic synovial cysts is excision through laminectomy. In this case, a wide decompression with facetectomy and fusion was required to facilitate removal of the cyst. Other reported treatment options include computed tomography–guided fine needle aspiration and percutaneous injection of hyaluronidase [5,8,11–13]. It is not possible to definitively correlate the presence of this patient’s hemorrhagic cyst with the anticoagulation therapy. However, the patient was known to have longstanding asymptomatic degenerative changes in the lumbosacral spine before initiation of anticoagulation. A magnetic resonance imaging scan taken the year before the symptoms began had no evidence of facet cyst. The patient began taking coumadin several weeks before the initiation of his symptoms.
J.C. Eck et al. / The Spine Journal 5 (2005) 451–453
Symptomatic lumbar facet cysts should be included in the differential diagnosis for patients presenting with progressive back pain and radicular symptoms. The symptoms are typically indistinguishable from disc herniation or spinal stenosis. Patients with significant facet degeneration and instability are predisposed to the development of facet cysts [9,14].
References [1] Sabo RA, Tracy PT, Weigner JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg 1996;85:560–5. [2] Finkelstein SD, Sayegh R, Watson P, Knuckey N. Juxta-Facet cysts. Report of two cases and review of clinicopathologic features. Spine 1993;18:779–82. [3] Franck JI, King RB, Petro GR, et al. A posttraumatic lumbar spinal synovial cyst. J Neurosurg 1987;66:293–6. [4] Jabre A, Shahbabian S, Keller JT. Synovial cyst of the cervical spine. Neurosurgery 1987;20:316–8.
Forty Years Ago in Spine
453
[5] Howling SJ, Kessel D. Acute radiculopathy due to a haemorrhagic lumbar synovial cyst. Clin Radiol 1997;52:73–4. [6] Kaneko K, Inoue Y. Haemorrhagic lumbar synovial cyst: a cause of acute radiculopathy. J Bone Joint Surg Br 2000;82-B:583–4. [7] Nishida K, Iguchi T, Kurihara A, et al. Symptomatic hematoma of lumbar facet joint: joint apoplexy of the spine? Spine 2003;28:E206–8. [8] Tatter SB, Cosgrove GR. Hemorrhage into a lumbar synovial cyst causing an acute cauda equina syndrome. J Neurosurg 1994;81: 449–52. [9] Doyle AJ, Merrilees M. Synovial cysts of the lumbar facet joints in a symptomatic population: prevalence on magnetic resonance imaging. Spine 2004;29:874–8. [10] Banning CS, Thorell WE, Leibrock LG. Patient outcome after resection of lumbar juxtafacet cysts. Spine 2001;26:969–72. [11] Abrahams JJ, Wood GW, Eames FA, et al. CT-guided needle aspiration biopsy of an intraspinal synovial cyst (ganglion): case report and review of the literature. Am J Neuroradiol 1988;9:398–400. [12] Koenigsberg RA. Percutaneous aspiration of a lumbar synovial cyst: CT and MR considerations. Neuroradiology 1998;40:272–3. [13] Paul AS, Sochart DH. Improving the results of ganglion aspiration by the use of hyaluronidase. J Hand Surg [Br] 1997;22:219–21. [14] Howington JU, Connolly ES, Voorhies RM. Intraspinal synovial cysts: 10-year experience at the Ochsner Clinic. J Neurosurg Spine 1999; 91(2):193–9.
of chronic pain permitted assimilation of sensory, motivational, affective and behavioral factors and ushered in the current era of pain management.
Reference [1] Melzack R, Wall P. Pain mechanisms: a new theory. Science 1965; 150:971–9.
In 1965, Melzack and Wall published their classic theory of pain [1]. Their gate control model