Evidence that atypical juxtafacet cysts are joint derived

Clinical article

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Object

Juxtafacet cysts (JFCs) in usual locations have recently been shown to have joint connections. The pathogenesis of JFCs in unusual locations has remained obscure. The authors hypothesize that all JFCs, including atypical ones, are joint derived.

Methods

In this study the authors sought to explain the occurrence and formation of clinical outliers of spinal JFCs. In Part I, they performed an extensive literature search to identify case reports of spinal intraneural cysts that have been unappreciated despite the fact that they should occur. In Part II, they studied far-lateral (extraforaminal) cysts treated at their institution and reported in the literature. The presence of a joint connection was specifically looked for since this finding has not been widely appreciated.

Results

In Part I, 3 isolated case reports of spinal intraneural JFCs without reported joint connections were identified: 2 involving L-5 and 1, C-8. In Part II, 6 cases involving patients with far-lateral JFCs treated at the authors' institution were reviewed and all 6 had joint connections. Two of these cases had been previously published, although their joint connections were not appreciated. In 2 of the newly reported cases, arthrography confirmed a communication between the facet and the cyst. Only 1 of 5 cases in the literature had a recognized joint connection.

Conclusions

The authors believe that all JFCs are joint derived. This explanation for intraneural and extraneural JFCs in typical locations would be consistent with the unified articular (synovial) theory and the pathogenesis for intraneural and extraneural ganglion cyst formation in the limbs. Facet joints appear no different from other synovial joints occurring elsewhere. Understanding the pathogenesis of these cysts will help target treatment to the joint, improve surgical outcomes, and decrease recurrences.

Abbreviations used in this paper:FSE = fast spin echo; JFC = juxtafacet cyst.

Article Information

Address correspondence to: Robert J. Spinner, M.D., Department of Neurologic Surgery, Mayo Clinic, Gonda 8S-214, Rochester, Minnesota 55905. email: spinner.robert@mayo.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    An L-5 intraneural JFC, Case 1. A: A CT scan of the lumbar spine at the L-5 level showing asymmetrical scalloping of the posterior vertebral body on right side (arrows) with smooth cortical margins occupied by a soft-tissue density. B: Anteroposterior view of the lumbar myelography. Elongated right ventral lateral extradural defect at L-5 level (arrows). C: Postmyelography CT. There is a ventral lateral extradural defect at L-5 level with compression of dural sac. Lesion does not fill with contrast material. Reproduced with permission from Hemmati M et al.: Symptomatic intraspinal ganglion cyst of the nerve root sheath. AJNR Am J Neuroradiol 10 (5 Suppl):S100, 1989, © by American Society of Neuroradiology.

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    An L-5 intraneural JFC, Case 2. Left: Axial T2-weighted MR image showing an abnormal signal with double contour (arrow) along the margin of the L-5 pedicle in close apposition to the dural sac. Right: Sketch created by the surgeon, illustrating the nuances of the surgical anatomy. Reprinted from Spine J 6(2), Choi JY et al.: Faces of spine care: from surgical pathology. Where a nerve root mass has arthritic origin, pp 212–216, © 2006 with permission from Elsevier, Inc.

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    Far-lateral (extraneural) JFC, Case 1. A: Axial T2-weighted FSE image demonstrating a far-lateral complex cyst (asterisk) arising from the facet joint (arrow) and causing mass effect on the right L-5 nerve root. There is a second synovial cyst (plus sign) arising from the posterior aspect of the facet joint (arrowhead) extending medially. B: Sagittal T2-weighted FSE image of the lumbar spine showing the far-lateral anterior cyst (asterisk) and the neck of the cyst (arrow) representing the connection to the joint at the anterior L5–S1 facet joint. C: Sagittal T2-weighted FSE image just medial to B showing the multilobular posterior cyst (plus sign) and the cyst connection (arrowhead) originating from the posterior facet joint at the same level.

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    Far-lateral (extraneural) JFC, Case 2. A: Axial T2-weighted FSE image of the lumbar spine at L5–S1 showing a farlateral cyst (asterisk) arising from the anterior facet joint. The joint connection is not included on this image. Note also a posterior, multilobular cyst (plus sign) arising from the posterior facet joint, with the narrow neck of the joint connection visible (arrowhead). B: Sagittal T2-weighted FSE image with fat suppression demonstrating the cyst (asterisk) arising from the anterior facet joint with the joint connection visible (arrow). C: Sagittal T2-weighted FSE image with fat suppression slightly medial to B showing the posterior cyst (plus sign) and its joint connection (arrowhead). D: Frontal digital radiograph obtained during an epidural steroid injection. With the needle in the posterior S-1 foramen, contrast filled a posterior synovial cyst, the facet joint (arrows), and subsequently the lateral cyst (arrowhead). The needle was then advanced further into epidural space and injection performed.

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    Far-lateral (extraneural) JFC, Case 3. Left: Axial T2-weighted FSE image with fat suppression at the level of L-5 showing a hyperintense cyst (arrow) at the lateral aspect of the foramen. Right: Sagittal T2-weighted FSE image of the lumbar spine showing fluid extending from the facet (curved arrow) to the cyst (arrow), including the joint connection (arrowhead) at the anterior facet joint.

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    Artistic rendition depicting the mechanisms for propagation of intraneural and extraneural JFCs.

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