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Hamdi G. Sukkarieh, Patrick W. Hitchon, Olatilewa Awe and Jennifer Noeller

OBJECT

The authors sought to determine patient-related outcomes after minimally invasive surgical (MIS) lumbar intraspinal synovial cyst excision via a tubular working channel and a contralateral facet-sparing approach.

METHODS

All the patients with a symptomatic lumbar intraspinal synovial cyst who underwent surgery at the University of Iowa Hospitals and Clinics with an MIS excision via a contralateral approach were treated between July 2010 and August 2014. There was a total of 13 cases. Each patient was evaluated with preoperative neurological examinations, lumbar spine radiography, MRI, and visual analog scale (VAS) scores. The patients were evaluated postoperatively with neurological examinations and VAS and Macnab scores. The primary outcomes were improvement in VAS and Macnab scores. Secondary outcomes were average blood loss, hospital stay duration, and operative times.

RESULTS

There were 5 males and 8 females. The mean age was 66 years, and the mean body mass index was 28.5 kg/m2. Sixty-nine percent (9 of 13) of the cysts were at L4–5. Most patients had low-back pain and radicular pain, and one-third of them had Grade 1 spondylolisthesis. The mean (± SD) follow-up duration was 20.8 ± 16.9 months. The mean Macnab score was 3.4 ± 1.0, and the VAS score decreased from 7.8 preoperatively to 2.9 postoperatively. The mean operative time was 123 ± 30 minutes, with a mean estimated blood loss of 44 ± 29 ml. Hospital stay averaged 1.5 ± 0.7 days. There were no complications noted in this series.

CONCLUSIONS

The MIS excision of lumbar intraspinal synovial cysts via a contralateral approach offers excellent exposure to the cyst and spares the facet joint at the involved level, thus minimizing risk of instability, blood loss, operative time, and hospital stay. Prospective randomized trials with longer follow-up times and larger cohorts are needed to conclusively determine the superiority of the contralateral MIS approach over others, including open or ipsilateral minimally invasive surgery.

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Maged D. Fam, Royce W. Woodroffe, Logan Helland, Jennifer Noeller, Nader S. Dahdaleh, Arnold H. Menezes and Patrick W. Hitchon

OBJECTIVE

Adult spinal arachnoid cysts (SACs) are rare entities of indistinct etiology that present with pain or myelopathy. Diagnosis is made on imaging studies with varying degrees of specificity. In symptomatic cases, the standard treatment involves surgical exploration and relief of neural tissue compression. The aim of this study was to illustrate features of SACs in adults, surgical management, and outcomes.

METHODS

The authors searched medical records for all SACs in adults in the 10-year period ending in December 2016. Radiology and pathology reports were reviewed to exclude other spine cystic disorders. Recurrent or previously treated patients were excluded. Demographic variables (age, sex) and clinical presentation (symptoms, duration, history of infection or trauma, and examination findings) were extracted. Radiological features were collected from radiology reports and direct interpretation of imaging studies. Operative reports and media were reviewed to accurately describe the surgical technique. Finally, patient-reported outcomes were collected at every clinic visit using the SF-36.

RESULTS

The authors’ search identified 22 patients with SACs (mean age at presentation 53.5 years). Seventeen patients were women, representing an almost 3:1 sex distribution. Symptoms comprised back pain (n = 16, 73%), weakness (n = 10, 45%), gait ataxia (n = 11, 50%), and sphincter dysfunction (n = 4, 18%). The mean duration of symptoms was 15 months. Seven patients (32%) exhibited signs of myelopathy. All patients underwent preoperative MRI; in addition, 6 underwent CT myelography. SACs were located in the thoracic spine (n = 17, 77%), and less commonly in the lumbar spine (n = 3, 14%) and cervical/cervicothoracolumbar region (n = 2, 9%). Based on imaging findings, the cysts were interpreted as intradural SACs (n = 11, 50%), extradural SACs (n = 6, 27%), or ventral spinal cord herniation (n = 2, 9%); findings in 3 patients (14%) were inconclusive. Nineteen patients underwent surgical treatment consisting of laminoplasty in addition to cyst resection (n = 13, 68%), ligation of the connecting pedicle (n = 4, 21%), or fenestration/marsupialization (n = 2, 11%). Postoperatively, patients were followed up for an average of 8.2 months (range 2–30 months). Postoperative MRI showed complete resolution of the SAC in 14 of 16 patients. Patient-reported outcomes showed improvement in SF-36 parameters. One patient suffered a delayed wound infection.

CONCLUSIONS

In symptomatic patients with imaging findings suggestive of spinal arachnoid cyst, surgical exploration and complete resection is the treatment of choice. Treatment is usually well tolerated, carries low risks, and provides the best chances for optimal recovery.