Synovial facet joint cysts after lumbar posterior decompression surgery

Yuichiro Morishita Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan

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Ryota Taniguchi Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan

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Osamu Kawano Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan

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Takeshi Maeda Department of Orthopedic Surgery, Spinal Injuries Center, Iizuka, Japan

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OBJECTIVE

Numerous studies have reported on synovial facet joint cysts of the spine as a primary lesion. The exact pathogenesis of those cysts is still controversial, but degeneration and destabilization seem to be underlying mechanisms. However, only a few reports have thus far investigated synovial cysts of the spine as postoperative complications of decompression surgery. In this retrospective clinical study, the authors focused on synovial cysts of the lumbar facet joints as complications after lumbar decompression surgery, with the aim of elucidating their pathophysiology.

METHODS

A total of 326 patients with 384 segments treated with posterior decompression surgery without fusion were included in the study. Of these segments, 107 were surgically decompressed unilaterally and 277 were decompressed bilaterally. After surgery, 18 of the 384 segments developed a complication of symptomatic facet synovial cyst. The anatomical and morphological evaluations of these segments were performed using functional plain radiographs, CT scans, and MR images.

RESULTS

All of the 18 segments with postoperative lumbar facet synovial cyst were treated with bilateral lumbar posterior decompression. There was no significant radiological lumbar spinal instability in any segments, although 17 of 18 segments demonstrated facet articular spondylotic changes. Moreover, 12 of 18 patients demonstrated lumbar retrolisthesis in the neutral position.

CONCLUSIONS

Based on the authors’ results, they propose that patients with lumbar degenerative disease who have a potential biomechanical lumbar instability such as disruption of the facet articular surface and hydrarthrosis or lumbar facet tropism might have a high risk for formation of lumbar facet synovial cyst after bilateral posterior decompression surgery.

OBJECTIVE

Numerous studies have reported on synovial facet joint cysts of the spine as a primary lesion. The exact pathogenesis of those cysts is still controversial, but degeneration and destabilization seem to be underlying mechanisms. However, only a few reports have thus far investigated synovial cysts of the spine as postoperative complications of decompression surgery. In this retrospective clinical study, the authors focused on synovial cysts of the lumbar facet joints as complications after lumbar decompression surgery, with the aim of elucidating their pathophysiology.

METHODS

A total of 326 patients with 384 segments treated with posterior decompression surgery without fusion were included in the study. Of these segments, 107 were surgically decompressed unilaterally and 277 were decompressed bilaterally. After surgery, 18 of the 384 segments developed a complication of symptomatic facet synovial cyst. The anatomical and morphological evaluations of these segments were performed using functional plain radiographs, CT scans, and MR images.

RESULTS

All of the 18 segments with postoperative lumbar facet synovial cyst were treated with bilateral lumbar posterior decompression. There was no significant radiological lumbar spinal instability in any segments, although 17 of 18 segments demonstrated facet articular spondylotic changes. Moreover, 12 of 18 patients demonstrated lumbar retrolisthesis in the neutral position.

CONCLUSIONS

Based on the authors’ results, they propose that patients with lumbar degenerative disease who have a potential biomechanical lumbar instability such as disruption of the facet articular surface and hydrarthrosis or lumbar facet tropism might have a high risk for formation of lumbar facet synovial cyst after bilateral posterior decompression surgery.

In Brief

The purpose of this study was to elucidate the pathophysiology of synovial facet joint cysts after lumbar decompression surgery. The patients with lumbar degenerative disease who had a potential biomechanical lumbar instability might have a high risk for formation of a lumbar facet synovial cyst after bilateral posterior decompression surgery. A better understanding of the underlying mechanisms that lead to the formation of postdecompression synovial cysts in facet joints may allow practitioners to avoid this postoperative complication.

Posterior lumbar decompression surgery includes laminectomy, partial laminectomy (laminotomy), and discectomy as the most common surgical procedures for lumbar degenerative disease. Although the success rates are excellent, both minor and major complications are frequent. A resection of more than 50% of the bilateral facet joints may result in iatrogenic biomechanical instability.1 Postoperative lumbar instability may lead to various complications, such as herniated discs, spondylolisthesis, foraminal stenosis, bony restenosis, or facet synovial cysts.

Numerous studies have reported on synovial cysts of the spine as a primary lesion. The exact pathogenesis of those cysts is still a matter of discussion, but degeneration and destabilization seem to be underlying mechanisms.2–5 However, only a few reports have thus far described synovial cysts of the spine as postoperative complications of decompression surgery. Therefore, in this retrospective clinical study, we decided to focus on synovial cysts of the lumbar facet joints as complications after lumbar decompression surgery, with the aim of elucidating their pathophysiology. We believe that a better understanding of the underlying mechanisms that lead to the formation of postdecompression synovial cysts in facet joints may allow surgeons to avoid this postoperative complication.

Methods

Study Design

This was a retrospective clinical cohort study.

Study Population

Between January 2010 and December 2018, the senior author (Y.M.) surgically treated 490 patients with lumbar degenerative disease. Of these, a total of 326 patients, corresponding to 384 segments treated with posterior decompression surgery without fusion, were included in the study. The following were the criteria for exclusion from the study: spinal tumor, reoperation, or primary lumbar facet synovial cyst either on the preoperative diagnostic images or as an intraoperative finding. Surgeries were performed by the senior spine surgeon (Y.M.), and all of the decompression procedures were the same despite lumbar segments with less than 25% resection of facet joints. Among these, 107 patients (average age 42.5 years, range 16–84 years) with 107 segments (L1–2, 0; L2–3, 4; L3–4, 18; L4–5, 45; and L5–S1, 40) underwent unilateral (either microendoscopic discectomy or open surgery) and 219 patients (average age 69.4 years, range 21–91 years) with 277 segments (L1–2, 14; L2–3, 58; L3–4, 89; L4–5, 93; and L5–S1, 23) underwent bilateral decompression (open surgery).

After surgery, 15 patients with 18 decompressed segments of 326 patients with 384 segments (4.69%) developed symptomatic synovial facet joint cysts. All of these 18 segments had been treated with bilateral posterior decompression. No patient treated with unilateral posterior decompression developed a postoperative synovial lumbar facet joint cyst.

The average age of these 15 patients at the time of initial surgery was 68.4 years (range 34–82 years). Their radicular symptoms recurred after an average of 8.02 months (range 0.25–24 months). In 5 segments recurrence was bilateral, and in 13 segments it was unilateral. The segments concerned were 10 of 93 (10.75%) at L4–5; 6 of 89 (6.74%) at L3–4; 2 of 58 (3.45%) at L2–3; and 0 segments at L1–2 (0/14) and L5–S1 (0/23). Most of the patients responded to traditional conservative treatment, including selective nerve root block with dexamethasone sodium phosphate. However, 3 of 15 patients required subsequent surgery to resolve their radicular symptoms.

Institutional review board approval was granted and informed consent was obtained from all patients.

Evaluation of Lumbar Instability (functional radiographs)

Functional plain radiographs in flexion and extension with the patients standing were performed to evaluate lumbar instability preoperatively and at the time of recurrence of the synovial cyst.

Disc Angular Motion

The disc angle was measured in flexion and extension by using the Cobb technique, which calculates the angle between the inferior surface of the upper vertebra and the superior surface of the lower vertebra of the concerned segment. The sagittal angular motion was determined as the angle from lumbar flexion to extension (°).

Degree of Vertebral Slippage

The lumbar translational instability was evaluated in terms of the degree of the vertebral slippage (Fig. 1).6,7 The latter was calculated as the ratio between the sagittal length of the superior endplate of the lower vertebra (A) and the distance between the posteroinferior border of the upper vertebra and posterosuperior border of the lower vertebra (B): B/A * 100 (%). The measurement was performed during flexion, extension, and in a neutral position of the lumbar spine. A positive value was regarded as anterolisthesis and a negative value as retrolisthesis.

FIG. 1.
FIG. 1.

Illustration of the measurement of the degree of vertebral slippage as the ratio between the sagittal length of the superior surface of the lower vertebra (A) and the distance between the posteroinferior border of the upper vertebra and the posterosuperior border of the lower vertebra (B) (formula: B/A * 100).

Anatomical Evaluation of Lumbar Facet Joints on CT and MRI

Facet Joint Angle

The facet angle (°) was defined as the angle between a midsagittal line and a tangent of the articular surface. The measurement was performed bilaterally by using preoperative axial CT images (Fig. 2).

FIG. 2.
FIG. 2.

Facet joint angle. Illustration of the angle between a midsagittal line (solid line) and a tangent of the articular surface (dotted lines).

Spondylotic Changes of the Facet Joint

Based on Pathria et al.’s criteria,8 lumbar facet joints with grade 3 (sclerosis or moderate osteophyte) and grade 4 (marked osteophyte) changes on preoperative axial CT images were defined as having significant spondylotic changes of the facet joint. Moreover, the presence of hydrarthrosis was evaluated using T2-weighted axial MR images (Fig. 3).

FIG. 3.
FIG. 3.

CT (left) and T2-weighted MR (right) axial images of spondylotic changes in the lumbar facet joints. Disruption of the articular surface of the facet joints and hydrarthrosis were observed (arrows).

Statistical Analysis

Continuous variables are presented as the mean ± SD. The Wilcoxon signed-rank test was used for all statistical analyses. A p value of less than 0.05 was considered statistically significant.

Results

In 3 of the 18 patients the disease was resistant to conservative treatment, and these individuals were subsequently treated surgically with facetectomy and transforaminal lumbar interbody fusion. After the resection of the inferior articular process of the upper vertebra in these 3 patients, there was no persistence of the ligamentum flavum in the surgical field. In 1 patient the synovial cyst was concealed by the superior articular process of the L5 vertebra consecutive from the articular surface (Fig. 4). The histopathological diagnosis described that the “cystic wall shows fibrous tissue focally lined by histiocytes with hemosiderin deposits, calcification, and multinucleated giant cells.”

FIG. 4.
FIG. 4.

Axial MR image (left) and intraoperative photograph (right) obtained in a patient with a postoperative synovial cyst. The cyst was concealed under the superior articular process consecutive from the articular surface.

Evaluation of Lumbar Instability

The values of sagittal angular motion from lumbar flexion to extension are shown in Table 1. No significant difference was seen between preoperative values and those at the time of recurrence.

TABLE 1.

Sagittal angular motion from lumbar flexion to extension in 18 patients with lumbar degenerative disease

Case No.Angular Motion (°)
PreopPostop
1612
241
335
4104
51314
6412
799
868
91310
10813
11106
1248
1348
141515
151213
1665
17109
1863
Average ± SD7.94 ± 3.78.61 ± 4.05

Postop designates the time of recurrence of synovial cyst.

The values of degree of vertebral slippage in each posture at preoperative evaluation and at the time of recurrence are shown in Table 2. There were no significant differences in the degrees of vertebral slippage in each posture between assessments performed preoperatively and at the time of recurrence. All of the average degrees of vertebral slippage showed negative values. In the neutral position, 12 of 18 segments demonstrated negative values preoperatively.

TABLE 2.

Degree of vertebral slippage in 18 patients who underwent lumbar posterior decompression for degenerative disease

Case No.Degree of Vertebral Slippage (%)
PreopPostop
NeutralFlexionExtensionNeutralFlexionExtension
1−15.29−7.69−12.93−15.19−7.79−18.65
2−4.4−5.12−5.11−2.13−4.40−5.44
3−5.75−3.59−6.42−13.32−8.65−11.41
4−17.85−10.89−20.43−18.79−17.90−18.27
5−14.68−5.21−9.68−10.58−11.74−10.52
6−4.83−0.77−3.17−4.160.00−4.30
701.76−2.340.002.550.00
81814.2317.0717.7227.1818.77
9−11.53−5.7−12.16−6.16−2.69−9.98
1003.240.002.218.761.88
11−15.2−5.81−14.31−13.00−14.75−20.87
1200−5.97−3.740.00−7.29
13−7.36−10.43−7.24−5.40−2.72−9.21
14−5.726.22−6.77−5.726.22−6.77
15−6.063−4.83−1.379.06−3.52
16−11−11.17−13.31−8.89−16.74−17.24
171.637.14−0.464.967.652.40
189.9114.414.265.0817.3811.91
Average ± SD−5.01 ± 9.16−0.91 ± 7.86−5.21 ± 9.25−4.36 ± 8.7−0.48 ± 11.94−6.03 ± 10.43

Postop designates the time of recurrence of synovial cyst.

Anatomical Evaluation of Lumbar Facet Joints

The values of facet joint angles and facet tropism are shown in Table 3. A significant difference was seen between right and left facet angles (p < 0.01).

TABLE 3.

Facet angle and facet tropism in 18 patients who underwent lumbar posterior decompression for degenerative disease

Case No.Facet Angle (°)Facet Tropism (°)
RtLt
129323
212164
329334
428235
522297
6405717
7275
8154227
933407
1029254
1120277
12462620
1352457
1413112
15425513
1642519
1723241
18273912
Average ± SD33.5 ± 9.9432.33 ± 17.318.56 ± 6.87

Spondylotic changes of the facet joints on preoperative axial CT images were seen in 17 of 18 segments (94.4%). Moreover, 13 of 18 segments (72.2%) had hydrarthrosis on preoperative axial T2-weighted MR images.

Discussion

Several etiologies of synovial cysts of the spine have been suggested, including inflammation, congenital conditions, myxoid degeneration of collagen tissue, developmental arrest of synovial tissue, metaplasia of pluripotent mesenchymal cells, and proliferation of fibroblasts with increased hyaluronic acid production.9–11 Because most synovial cysts of the spine arise from the L4–5 level as the most mobile spine segment, some authors have advocated that degeneration and segmental instability may play key roles in their formation.2–4,12–14 In the present study, the L4–5 segment showed the most frequent occurrence of the postoperative facet cyst being the same as the primary cyst.

The prevalence of synovial lumbar facet joint cysts is unknown. However, they are increasingly identified nowadays with advances in MRI capacity. Doyle and Merrilees15 reported their frequency to be 2.3% in patients with low-back pain or radiculopathy. Although a number of authors describe primary synovial facet joint cysts of the spine, there are only a few reports on the pathophysiology of secondary synovial facet joint cysts following posterior decompression of the lumbar spine.16,17 In their clinical study, Ikuta et al.16 found an incidence of postoperative intraspinal facet joint cysts of 8.6% after microendoscopic posterior decompression of lumbar spinal stenosis. They hypothesized that the pathogenesis of postoperative intraspinal facet joint cysts is similar to that of the primary cysts.

Spinal degeneration is thought to cause protrusion of the synovial membrane through defects in the joint capsule, creating a paraarticular cavity that may be filled with synovial fluid or air.9,18 After decompression surgery, the joint capsule of the facet joint of the treated site may easily protrude into the spinal canal because the medial portion of the facet joint has become weak after the removal of the ligamentum flavum. Mechanical stress, such as segmental instability of the involved spinal segment, may further aggravate the protrusion of the facet capsule. Evidence for the validity of this hypothesis can be derived from the fact that postoperative facet joint cysts develop within the early postoperative period. However, previous investigators did not describe the pathogenesis and morphology of secondary synovial facet joint cysts after posterior decompression of the lumbar spine. In the present study, 4.69% of the posteriorly decompressed segments developed symptomatic synovial facet joint cysts postoperatively. The average recrudescence of the radicular symptoms 8 months after the operation was relatively early, which is in accordance with the hypothesis of Ikuta et al.16

Not all of our patients demonstrated segmental angular or translational instability on radiological studies obtained both pre- and postoperatively. However, spondylotic changes of the facet joints or hydrarthrosis were seen in 94.4%. The facet joint fluid visible on MR images seemed to be closely associated with radiographic spinal instability.19,20 There might be a potential biomechanical instability that exerts excessive mechanical stresses on the facet joints without significant clinical instability. In this study, all of the vertebral slippage measurements in flexion, extension, and in a neutral position demonstrated retrolisthesis. Moreover, 12 of 18 segments demonstrated retrolisthesis in the neutral position. Retrolisthesis of the lumbar vertebrae might spread the articular cavity and might lead to fluid inside the joint.

Facet tropism is defined as an asymmetry between the left and right facet joint orientation of more than 8°.14,21–24 In our patients with a postoperative synovial cyst, there was a significant difference in the facet angle between right and left, with a mean facet tropism of 8.56° ± 6.87°. The facet joints play a critical role in maintaining the stability of the lumbar spine by distributing the load evenly on both sides during compression and extension. Facet tropism and increased sagittal orientation of the facet joints are thought to be risk factors for the development of lumbar spondylosis.

Merter et al.25 reported in their biomechanical study that the contributions of the lumbar interspinous ligament and ligamentum flavum to counteracting compression forces in the lumbar spine were 25.4% and 27.8%, respectively. In our study, none of the postoperative lumbar facet synovial cysts occurred after unilateral posterior decompression. Unilateral posterior decompression might lead to less instability due to avoidance of bilateral medial facetectomy and resection of the lumbar interspinous ligament and bilateral ligamentum flavum when compared with bilateral decompression. Bilateral medial facetectomy and resection of interspinous ligament and bilateral ligamentum flavum seem to be important causal factors of postoperative lumbar facet synovial cysts. Bilateral decompression of a lumbar segment creates a space for protrusion of the capsule of the facet joint, thereby potentially facilitating the formation of a synovial cyst.

These results have to be assessed in light of the limitations of the study. Potentially, there might have been asymptomatic synovial cysts postoperatively that were not considered, resulting in a higher actual incidence of postoperative synovial cysts. Furthermore, we did not provide an anatomical comparative investigation between the patients with and without postoperative synovial cysts. The exact method of surgical management and the decision on whether fusion is required in lumbar degenerative disease in patients who have a potential biomechanical lumbar instability is still a matter of discussion. Therefore, based on the current investigation, further research in a larger patient population is needed to clarify the pathophysiology of synovial facet joint cysts after lumbar decompression surgery in detail.

Conclusions

Based on our results, unilateral posterior decompression might lead to less instability due to avoidance of bilateral medial facetectomy and resection of the lumbar interspinous ligament and ligamentum flavum. Bilateral posterior decompression surgery in patients who have a potential biomechanical lumbar instability, such as articular spondylotic changes and hydrarthrosis or facet tropism might present a risk for postoperative synovial facet joint cysts.

Disclosures

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author Contributions

Conception and design: Morishita, Taniguchi. Acquisition of data: Morishita, Taniguchi. Analysis and interpretation of data: Morishita. Drafting the article: Morishita. Critically revising the article: Morishita. Reviewed submitted version of manuscript: Morishita, Kawano, Maeda. Approved the final version of the manuscript on behalf of all authors: Morishita. Statistical analysis: Morishita. Administrative/technical/material support: Morishita. Study supervision: Morishita, Kawano, Maeda.

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Images and illustration from Akinduro et al. (pp 834–843). Copyright Tito Vivas-Buitrago. Published with permission.
  • FIG. 1.

    Illustration of the measurement of the degree of vertebral slippage as the ratio between the sagittal length of the superior surface of the lower vertebra (A) and the distance between the posteroinferior border of the upper vertebra and the posterosuperior border of the lower vertebra (B) (formula: B/A * 100).

  • FIG. 2.

    Facet joint angle. Illustration of the angle between a midsagittal line (solid line) and a tangent of the articular surface (dotted lines).

  • FIG. 3.

    CT (left) and T2-weighted MR (right) axial images of spondylotic changes in the lumbar facet joints. Disruption of the articular surface of the facet joints and hydrarthrosis were observed (arrows).

  • FIG. 4.

    Axial MR image (left) and intraoperative photograph (right) obtained in a patient with a postoperative synovial cyst. The cyst was concealed under the superior articular process consecutive from the articular surface.

  • 1

    Gupta MC, Khan SN. Lumbar diskectomy and stenosis surgery. In: Rao RD, ed.Complications in Orthopaedics: Spine Surgery. AAOS; 2006:5564.

  • 2

    Epstein NE. Lumbar synovial cysts: a review of diagnosis, surgical management, and outcome assessment. J Spinal Disord Tech. 2004;17(4):321325.

  • 3

    Howington JU, Connolly ES, Voorhies RM. Intraspinal synovial cysts: 10-year experience at the Ochsner Clinic. J Neurosurg. 1999;91(2)(suppl):193199.

  • 4

    Kjerulf TD, Terry DW Jr, Boubelik RJ. Lumbar synovial or ganglion cysts. Neurosurgery. 1986;19(3):415420.

  • 5

    Vosschulte K, Borger G. The inflammatory processes in sciatica due to intervertebral disk hernia. Article in German. Med Monatsschr. 1950;4(5):371375.

  • 6

    Kanayama M, Hashimoto T, Shigenobu K, et al. Intraoperative biomechanical assessment of lumbar spinal instability: validation of radiographic parameters indicating anterior column support in lumbar spinal fusion. Spine (Phila Pa 1976).2003;28(20):23682372.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Taillard W. Spondylolisthesis in children and adolescents. Article in French. Acta Orthop Scand. 1954;24(2):115144.

  • 8

    Pathria M, Sartoris DJ, Resnick D. Osteoarthritis of the facet joints: accuracy of oblique radiographic assessment. Radiology. 1987;164(1):227230.

  • 9

    Arantes M, Silva RS, Romão H, et al. Spontaneous hemorrhage in a lumbar ganglion cyst. Spine (Phila Pa 1976).2008;33(15):E521E524.

  • 10

    Banning CS, Thorell WE, Leibrock LG. Patient outcome after resection of lumbar juxtafacet cysts. Spine (Phila Pa 1976).2001;26(8):969972.

  • 11

    Chimento GF, Ricciardi JE, Whitecloud TS III. Intraspinal extradural ganglion cyst. J Spinal Disord. 1995;8(1):8285.

  • 12

    Eck JC, Triantafyllou SJ. Hemorrhagic lumbar synovial facet cyst secondary to anticoagulation therapy. Spine J. 2005;5(4):451453.

  • 13

    Epstein NE. Lumbar laminectomy for the resection of synovial cysts and coexisting lumbar spinal stenosis or degenerative spondylolisthesis: an outcome study. Spine(Phila Pa 1976).2004;29(9):10491056.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 14

    Van Schaik JP, Verbiest H, Van Schaik FD. The orientation of laminae and facet joints in the lower lumbar spine. Spine (Phila Pa 1976).1985;10(1):5963.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Doyle AJ, Merrilees M. Synovial cysts of the lumbar facet joints in a symptomatic population: prevalence on magnetic resonance imaging. Spine (Phila Pa 1976).2004;29(8):874878.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16

    Ikuta K, Tono O, Oga M. Prevalence and clinical features of intraspinal facet cysts after decompression surgery for lumbar spinal stenosis. J Neurosurg Spine. 2009;10(6):617622.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Seo JH, Park G, Ju CI, et al. Radiological analysis of symptomatic complications after bilateral laminotomy for lumbar spinal stenosis. Korean J Spine. 2012;9(1):1823.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

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