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Spinal Stenosis, Spondylolisthesis and Percutaneous Treatment of Synovial Cysts of the Lumbar Facet Joint 2004

Solsberg, Murray, M.D.

Purpose:
Percutaneous techniques are effective in the conservative management of patients with radiculopathy and a synovial cyst of the facet joint. The purpose of this study was to compare the outcome of patients with and without spinal stenosis and/or spondylolisthesis treated with fluoroscopically guided synovial cyst rupture.

Methods and Materials:
38 patients with synovial cysts of the lumbar facet joints treated at our facility between 1999 and 2003 were contacted by telephone in November and December 2003. The patient's current pain level, limitations of daily activities and additional surgical and conservative treatments were recorded. Immediate pre and post procedure vis ual pain analog diagrams and scores were completed at the time of the procedure also. We also contacted each patient at 48 hours post procedure and noted the pain level. The demographics and pain responses were then analyzed. The chart, MRI and fluoroscopic images were also reviewed and the size and location of the facet cyst was noted. The spinal canal was measured on a workstation. Spinal stenosis was graded as: Normal (AP dimension >12mm cross sectional area > 100 mm2), Mild Relative (ap dimension>12 mm, cross sectional area >100, triangular shape of central canal, no thecal sac compression), Moderate Relative (thecal sac is effaced but cross sectional area > 100 mm2), and Absolute Severe (cross sectional area <100 mm2 and thecal sac compressed ap dimension less than 11 mm) spinal stenosis. Spondylisthesis was measured.

Results:
The average time of follow-up was 20 months (range 3-42). 20 patients had no residual back pain or radiculopathy. Only one patient in this group had severe spinal stenosis (Area = 75 mm2). Two patients in this group had spondylolisthesis >2 mm (2 and 7 mm respectively). In four other patients, the radiculopathy was resolved but they still had back pain. In this group one patient had severe stenosis (70 mm2 area) and no patient had spondylolisthesis over 2 mm. Six patients had no improvement post procedure and one patient had spinal stenosis (75 mm2) but none of the patients in this group underwent surgery. Eight patients had no improvement and had surgery. In the surgical group, four patients had spinal stenosis (50, 70, 75, 85 mm2 respectively) and three patients had spondylolisthesis (4, 6, 7 mm respectively). Probability of distribution for the surgical group versus the successfully treated radiculopathy group were significantly different (p <.05 (p=.00862)Fisher's exact test) for spinal stenosis but not for (p >.05 (p=.09)) spondylolisthesis.

Conclusions:
In our study, patients without spinal stenosis had better pain relief after percutaneous facet therapy. Patients with severe spinal stenosis and a synovial cyst frequently required surgery. There was no significant difference between the surgical and conservative therapy group in the incidence of spondylolisthesis but this patient group was small. Patients with spinal stenosis contemplating percutaneous therapy of a synovial cyst should be counseled about realistic expected outcomes.