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Spontaneous Resolution of Lumbar Facet Joint Cyst
Accepted Manuscript Spontaneous resolution of a lumbar juxtafacet cyst – case report Elena Downs, Laurence AG. Marshman PII:
S1878-8750(18)30917-3
DOI:
10.1016/j.wneu.2018.04.197
Reference:
WNEU 8033
To appear in:
World Neurosurgery
Received Date: 10 January 2018 Revised Date:
25 April 2018
Accepted Date: 26 April 2018
Please cite this article as: Downs E, Marshman LA, Spontaneous resolution of a lumbar juxtafacet cyst – case report, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.04.197. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Spontaneous Resolution of a Lumbar Facet Joint Cyst – Case report
Authors: Elena Downs1, Laurence AG Marshman1,2 1
Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville 4810,
School of Medicine and Dentistry, James Cook University, Douglas, Townsville 4810,
Queensland, Australia
Highlights: •
SC
2
RI PT
Queensland, Australia
Juxtafacet cysts are uncommon spinal lesions that can cause neural compression and are typically managed surgically Rarely juxtafacet cysts can spontaneously resolve
•
We present the case of a spontaneous resolving right L4/5 juxtafacet cyst in a 60 year
M AN U
•
old female patient with MRI images •
Only 6 previous cases of spontaneously resolving lumbar juxtafacet cysts, with imaging, have been documented in the literature
TE D
The case supports that juxtafacet cysts, without neurological deficit, may be safely
EP
managed conservatively; pending possible spontaneous resolution
AC C
•
ACCEPTED MANUSCRIPT Spontaneous resolution of a lumbar juxtafacet cyst – case report Introduction Juxtafacet cysts (JFC) are uncommon spinal lesions that can cause neural compression and are typically managed surgically. Rarely, JFCs can spontaneously resolve. We present the case of a
RI PT
spontaneously resolving right L4/5 JFC and literature review.
Case Description
A fit and well 60 year old female presented with progressive chronic low back pain (CLBP) and
intermittent right sciatica. On examination she had a reduced range of movement in her lumbar
SC
spine and no neurological deficit. MRI demonstrated disc degeneration and facet hypertrophy with a right L4/5 JFC. Our patient was very keen on avoiding surgical intervention unless all other
M AN U
treatments had been exhausted, or her symptoms had progressed. She therefore received a sacral epidural and right L4/5 trans-foramenal steroid injection which effected some improvement in her right sciatica: however, CLBP continued. She then underwent bilateral L4/5 facet joint radiofrequency neurotomies (RFN), and participated in the PAGPROS study¹. Approximately 19 months after her initial presentation, her sciatica had completely resolved, and her CLBP had significantly
Discussion
TE D
improved. Repeat MRI demonstrated complete JFC resolution.
Spinal synovial facet joint cysts causing neural compression have been recognized since the 1950s². ‘JFC’ was first used to describe synovial and ganglion cysts of spinal facet joints by Kao etc al in
EP
1968³. While synovial and ganglion cysts are histologically distinct entities, treatment and prognosis in both is felt to be identical, hence the collective term ‘JFC’⁴ʼ⁵͗. However, radiologically, each can
AC C
sometimes be distinguished using MRI, since synovial cysts are attached to the facet synovium, whilst ganglion cysts remain distinct.
JFCs can be incidental or present with acutely or insidiously with symptoms and signs of radiculopathy, neurogenic claudication, myelopathy and even cauda equina syndrome⁵. Intracystic or epidural haemorrhage from JFCs can occur, and result in acute exacerbations of symptoms⁴.
JFCs are typically found in the lumbar spine with a propensity to arise at the L4/5 level, the most mobile segment in the lumbar spine⁶. However, they can occur at any level from the cervical to lumbosacral junction⁶. JFC aetiology is felt to be related to spinal or, more specifically, facet joint
ACCEPTED MANUSCRIPT instability, as they are predominantly found together with degenerative facet disease and/or spondylolithesis⁷. JFC are typically unilateral lesions, but can occur bilaterally⁷.
Because, in the majority of series, surgical resection has been recommended, the natural history of JFCs is unclear. However, in 6 previous cases, spontaneous resolution has been observed
RI PT
radiologically⁸⁻¹¹. Four of these were female of mean age 60±5 years. One patient was an outlier at 15 years of age. All JFCs were unilateral, with 5/6 having occurred at L4/5.
Non-operative options to provide symptom relief include rest, analgesia, bracing and physiotherapy. Steroidal Injections into the epidural, trans-foramenal and facet regions, along with RFNs, have all
SC
been described: however, with variable, but generally poor, efficacy⁶΄⁹. Cyst aspiration can also be undertaken, but is associated with frequent recurrence⁶. It is felt unlikely that the RFN received by
M AN U
our patient contributed to JFC resolution, given that the JFC was intra- canalicular whilst RFN is extra-canalicular.
Possible causes for JFC resolution include cyst rupture, as seen in other regions in the body¹², or a reduction in the local intra-articular forces that contributed to synovial herniation through the facet joint capsule¹³. Progression of facet disease with hypertrophy (as seen in our case), together with
TE D
spinal disc space collapse, may reduce intra-articular pressures, and so result in cyst shrinkage and sclerosis⁶. Notwithstanding, ganglion cysts elsewhere (e.g. the wrist) spontaneously resolved in 40%
Conclusion
EP
of patients within 6 years¹⁴.
Surgery to remove a JFC +/- spinal stabilisation remains the mainstay and definitive treatment for
AC C
symptomatic JFCs as the incidence of reported spontaneous resolution is low and conservative measures generally have disappointing outcomes. Despite this, our case supports that JFCs, without neurological deficit, may be safely managed conservatively; pending possible spontaneous resolution. Patients should be advised of this when discussing management options as it is possible that spontaneous resolution has a higher incidence than previously acknowledged. Indeed, spontaneous resolution may in fact reflect the natural history of the condition.
ACCEPTED MANUSCRIPT Figure Legend A 60 year old female presented with chronic low back pain (CLBP) and right sciatica. Clinical examination revealed restricted lumbar spine movement and right sciatica. MRI revealed degenerative disc and facet joint disease especially at L4/5. On the right, there was a juxtafacet cyst (JFC) (fig 1). A right L4/5 trans-foramenal steroid injection effected some improvement in her right
RI PT
sciatica: however, CLBP continued, and was managed conservatively. At 19 months review, right sciatica remained in remission. MRI at this juncture revealed complete spontaneous resolution of the previous right JFC and slight progression of the facet hypertrophy (fig 2). This is the 6th case reported. Where MRI demonstrates a joint communication, a ‘synovial cyst’ can be assumed:
however, when this absent, as with our case, a ‘ganglion cyst’ (GC) is designated. The distinction
AC C
EP
TE D
M AN U
SC
may be considered academic.
ACCEPTED MANUSCRIPT References 1. Robertson K, Marshman L, Hennessy M, Harriss L, Plummer D. Pregabalin versus gabapentin in the treatment of sciatica: study protocol for a randomised, double-blind, cross-over trial (PAGPROS). Trials 2018;19.
2. Vosschulte K, Börger G. Anatomische und funktionelle untersuchungen uber den bandscheibenprolaps. Langenbecks Arch Chir. 1950;265:329-355
3. Kao CC, Uihlein A, Bickel WH, et al. Lumbar intraspinal extradural ganglion cyst. J Neurosurg. 1968;29:168– 172.
4. Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg. 1966;85:560-565.
RI PT
5. Efstathios J, Staurinou LC, Kouyialis AT, Gavra MM, Stavrinou PC, Themistokleous M, et al. Spinal synovial
9. 10. 11. 12. 13.
Zachariae L, Vibe Hansen H. Ganglia: Recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chir Scand. 1973;139:625–628.
AC C
EP
TE D
14.
SC
8.
M AN U
6. 7.
cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review. Eur Spine J. 2008;17:831-837. Choudhri HF, Perling LH. Diagnosis and management of juxtafacet cysts. Neurosurg Focus. 2006;20:E1. Bruder M, Cattani A, Gessler F, Droste C, Setzer M, Seifert V, et al. Synovial cysts of the spine: long-term followup after surgical treatment of 141 cases in a single-centre series and comprehensive literature review of 2900 degenerative spinal cysts. J Neurosurg Spine. 2017;27:256-267. Swartz PG, Murtagh FR. Spontaneous resolution of an intraspinal synovial cyst. Am J Neuroradiol. 2003;24:12611263. Houten JK, Sanderson SP, Cooper PR. Spontaneous regression of symptomatic lumbar synovial cysts. J Neurosurg (Spine 2). 2003;99:235-238. Maezawa Y, Baba H, Uchida K, Furusawa N, Kubota C, Yoshizawa K. Spontaneous remission of a solitary intraspinal synovial cyst of the lumbar spine. Eur Spine J. 2000;9:85-87. Mercader J, Muñoz Gomez J, Cardenal C. Intraspinal synovial cyst: diagnosis by CT. Follow up and spontaneous remission. Neuroradiology. 1985;27:346-348. Macfarlane D, Bacon P. Popliteal cyst rupture in normal knee joints. British Medical Journal. 1980; 281:1203– 1204. Resnick D, Niwayama G. Soft Tissues, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia: WB Saunders, 1995;4491–4622.
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig 2
EP
TE D
M AN U
SC
Fig 1.
ACCEPTED MANUSCRIPT
Spontaneous Resolution of a Lumbar Facet Joint Cyst – Case report
Authors: Elena Downs1, Laurence AG Marshman1,2 1
Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville 4810,
2
RI PT
Queensland, Australia School of Medicine and Dentistry, James Cook University, Douglas, Townsville 4810,
Queensland, Australia
SC
Abbreviations: JFC – Juxtafacet cyst
•
L – Lumbar
•
MRI – Magnetic Resonance Image
•
RFN – Radio frequency neurotomy
•
PAGPROS – Pregabalin verses gabapentin in the treatment of sciatica
•
N – Number
•
CLBP – Chronic lower back pain
•
GC – Ganglion cyst
AC C
EP
TE D
M AN U
•
S1878-8750(18)30917-3
DOI:
10.1016/j.wneu.2018.04.197
Reference:
WNEU 8033
To appear in:
World Neurosurgery
Received Date: 10 January 2018 Revised Date:
25 April 2018
Accepted Date: 26 April 2018
Please cite this article as: Downs E, Marshman LA, Spontaneous resolution of a lumbar juxtafacet cyst – case report, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.04.197. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Spontaneous Resolution of a Lumbar Facet Joint Cyst – Case report
Authors: Elena Downs1, Laurence AG Marshman1,2 1
Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville 4810,
School of Medicine and Dentistry, James Cook University, Douglas, Townsville 4810,
Queensland, Australia
Highlights: •
SC
2
RI PT
Queensland, Australia
Juxtafacet cysts are uncommon spinal lesions that can cause neural compression and are typically managed surgically Rarely juxtafacet cysts can spontaneously resolve
•
We present the case of a spontaneous resolving right L4/5 juxtafacet cyst in a 60 year
M AN U
•
old female patient with MRI images •
Only 6 previous cases of spontaneously resolving lumbar juxtafacet cysts, with imaging, have been documented in the literature
TE D
The case supports that juxtafacet cysts, without neurological deficit, may be safely
EP
managed conservatively; pending possible spontaneous resolution
AC C
•
ACCEPTED MANUSCRIPT Spontaneous resolution of a lumbar juxtafacet cyst – case report Introduction Juxtafacet cysts (JFC) are uncommon spinal lesions that can cause neural compression and are typically managed surgically. Rarely, JFCs can spontaneously resolve. We present the case of a
RI PT
spontaneously resolving right L4/5 JFC and literature review.
Case Description
A fit and well 60 year old female presented with progressive chronic low back pain (CLBP) and
intermittent right sciatica. On examination she had a reduced range of movement in her lumbar
SC
spine and no neurological deficit. MRI demonstrated disc degeneration and facet hypertrophy with a right L4/5 JFC. Our patient was very keen on avoiding surgical intervention unless all other
M AN U
treatments had been exhausted, or her symptoms had progressed. She therefore received a sacral epidural and right L4/5 trans-foramenal steroid injection which effected some improvement in her right sciatica: however, CLBP continued. She then underwent bilateral L4/5 facet joint radiofrequency neurotomies (RFN), and participated in the PAGPROS study¹. Approximately 19 months after her initial presentation, her sciatica had completely resolved, and her CLBP had significantly
Discussion
TE D
improved. Repeat MRI demonstrated complete JFC resolution.
Spinal synovial facet joint cysts causing neural compression have been recognized since the 1950s². ‘JFC’ was first used to describe synovial and ganglion cysts of spinal facet joints by Kao etc al in
EP
1968³. While synovial and ganglion cysts are histologically distinct entities, treatment and prognosis in both is felt to be identical, hence the collective term ‘JFC’⁴ʼ⁵͗. However, radiologically, each can
AC C
sometimes be distinguished using MRI, since synovial cysts are attached to the facet synovium, whilst ganglion cysts remain distinct.
JFCs can be incidental or present with acutely or insidiously with symptoms and signs of radiculopathy, neurogenic claudication, myelopathy and even cauda equina syndrome⁵. Intracystic or epidural haemorrhage from JFCs can occur, and result in acute exacerbations of symptoms⁴.
JFCs are typically found in the lumbar spine with a propensity to arise at the L4/5 level, the most mobile segment in the lumbar spine⁶. However, they can occur at any level from the cervical to lumbosacral junction⁶. JFC aetiology is felt to be related to spinal or, more specifically, facet joint
ACCEPTED MANUSCRIPT instability, as they are predominantly found together with degenerative facet disease and/or spondylolithesis⁷. JFC are typically unilateral lesions, but can occur bilaterally⁷.
Because, in the majority of series, surgical resection has been recommended, the natural history of JFCs is unclear. However, in 6 previous cases, spontaneous resolution has been observed
RI PT
radiologically⁸⁻¹¹. Four of these were female of mean age 60±5 years. One patient was an outlier at 15 years of age. All JFCs were unilateral, with 5/6 having occurred at L4/5.
Non-operative options to provide symptom relief include rest, analgesia, bracing and physiotherapy. Steroidal Injections into the epidural, trans-foramenal and facet regions, along with RFNs, have all
SC
been described: however, with variable, but generally poor, efficacy⁶΄⁹. Cyst aspiration can also be undertaken, but is associated with frequent recurrence⁶. It is felt unlikely that the RFN received by
M AN U
our patient contributed to JFC resolution, given that the JFC was intra- canalicular whilst RFN is extra-canalicular.
Possible causes for JFC resolution include cyst rupture, as seen in other regions in the body¹², or a reduction in the local intra-articular forces that contributed to synovial herniation through the facet joint capsule¹³. Progression of facet disease with hypertrophy (as seen in our case), together with
TE D
spinal disc space collapse, may reduce intra-articular pressures, and so result in cyst shrinkage and sclerosis⁶. Notwithstanding, ganglion cysts elsewhere (e.g. the wrist) spontaneously resolved in 40%
Conclusion
EP
of patients within 6 years¹⁴.
Surgery to remove a JFC +/- spinal stabilisation remains the mainstay and definitive treatment for
AC C
symptomatic JFCs as the incidence of reported spontaneous resolution is low and conservative measures generally have disappointing outcomes. Despite this, our case supports that JFCs, without neurological deficit, may be safely managed conservatively; pending possible spontaneous resolution. Patients should be advised of this when discussing management options as it is possible that spontaneous resolution has a higher incidence than previously acknowledged. Indeed, spontaneous resolution may in fact reflect the natural history of the condition.
ACCEPTED MANUSCRIPT Figure Legend A 60 year old female presented with chronic low back pain (CLBP) and right sciatica. Clinical examination revealed restricted lumbar spine movement and right sciatica. MRI revealed degenerative disc and facet joint disease especially at L4/5. On the right, there was a juxtafacet cyst (JFC) (fig 1). A right L4/5 trans-foramenal steroid injection effected some improvement in her right
RI PT
sciatica: however, CLBP continued, and was managed conservatively. At 19 months review, right sciatica remained in remission. MRI at this juncture revealed complete spontaneous resolution of the previous right JFC and slight progression of the facet hypertrophy (fig 2). This is the 6th case reported. Where MRI demonstrates a joint communication, a ‘synovial cyst’ can be assumed:
however, when this absent, as with our case, a ‘ganglion cyst’ (GC) is designated. The distinction
AC C
EP
TE D
M AN U
SC
may be considered academic.
ACCEPTED MANUSCRIPT References 1. Robertson K, Marshman L, Hennessy M, Harriss L, Plummer D. Pregabalin versus gabapentin in the treatment of sciatica: study protocol for a randomised, double-blind, cross-over trial (PAGPROS). Trials 2018;19.
2. Vosschulte K, Börger G. Anatomische und funktionelle untersuchungen uber den bandscheibenprolaps. Langenbecks Arch Chir. 1950;265:329-355
3. Kao CC, Uihlein A, Bickel WH, et al. Lumbar intraspinal extradural ganglion cyst. J Neurosurg. 1968;29:168– 172.
4. Sabo RA, Tracy PT, Weinger JM. A series of 60 juxtafacet cysts: clinical presentation, the role of spinal instability, and treatment. J Neurosurg. 1966;85:560-565.
RI PT
5. Efstathios J, Staurinou LC, Kouyialis AT, Gavra MM, Stavrinou PC, Themistokleous M, et al. Spinal synovial
9. 10. 11. 12. 13.
Zachariae L, Vibe Hansen H. Ganglia: Recurrence rate elucidated by a follow-up of 347 operated cases. Acta Chir Scand. 1973;139:625–628.
AC C
EP
TE D
14.
SC
8.
M AN U
6. 7.
cysts: pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review. Eur Spine J. 2008;17:831-837. Choudhri HF, Perling LH. Diagnosis and management of juxtafacet cysts. Neurosurg Focus. 2006;20:E1. Bruder M, Cattani A, Gessler F, Droste C, Setzer M, Seifert V, et al. Synovial cysts of the spine: long-term followup after surgical treatment of 141 cases in a single-centre series and comprehensive literature review of 2900 degenerative spinal cysts. J Neurosurg Spine. 2017;27:256-267. Swartz PG, Murtagh FR. Spontaneous resolution of an intraspinal synovial cyst. Am J Neuroradiol. 2003;24:12611263. Houten JK, Sanderson SP, Cooper PR. Spontaneous regression of symptomatic lumbar synovial cysts. J Neurosurg (Spine 2). 2003;99:235-238. Maezawa Y, Baba H, Uchida K, Furusawa N, Kubota C, Yoshizawa K. Spontaneous remission of a solitary intraspinal synovial cyst of the lumbar spine. Eur Spine J. 2000;9:85-87. Mercader J, Muñoz Gomez J, Cardenal C. Intraspinal synovial cyst: diagnosis by CT. Follow up and spontaneous remission. Neuroradiology. 1985;27:346-348. Macfarlane D, Bacon P. Popliteal cyst rupture in normal knee joints. British Medical Journal. 1980; 281:1203– 1204. Resnick D, Niwayama G. Soft Tissues, in Resnick D (ed): Diagnosis of Bone and Joint Disorders, ed 3. Philadelphia: WB Saunders, 1995;4491–4622.
RI PT
ACCEPTED MANUSCRIPT
AC C
Fig 2
EP
TE D
M AN U
SC
Fig 1.
ACCEPTED MANUSCRIPT
Spontaneous Resolution of a Lumbar Facet Joint Cyst – Case report
Authors: Elena Downs1, Laurence AG Marshman1,2 1
Department of Neurosurgery, The Townsville Hospital, Douglas, Townsville 4810,
2
RI PT
Queensland, Australia School of Medicine and Dentistry, James Cook University, Douglas, Townsville 4810,
Queensland, Australia
SC
Abbreviations: JFC – Juxtafacet cyst
•
L – Lumbar
•
MRI – Magnetic Resonance Image
•
RFN – Radio frequency neurotomy
•
PAGPROS – Pregabalin verses gabapentin in the treatment of sciatica
•
N – Number
•
CLBP – Chronic lower back pain
•
GC – Ganglion cyst
AC C
EP
TE D
M AN U
•