Improved outcomes with direct percutaneous CT guided lumbar synovial cyst treatment: advanced approaches and techniques.

PURPOSE: To determine if lumbar synovial cyst rupture in symptomatic patients results in improved clinical outcome when using direct tandem and/or coaxial percutaneous CT guided techniques.

MATERIALS AND

METHODS

20 patients with unilateral lower extremity radiculopathy and/or low back pain underwent CT guided percutaneous treatment for their symptomatic lumbar synovial cysts. Cysts were identified with the use of a low osmolar non-ionic contrast agent via facet joint injection or through direct injection. Cyst rupture, using a direct tandem and/or coaxial technique, was attempted in all patients using an 18 gauge guide needle and a 22 gauge insert needle. Following attempted cyst aspiration, cyst rupture was performed using 1-3 mL of a mixture of methylprednisolone (2 mL, 80 mg) and bupivacaine (3 mL, 0.5%). All patients were followed-up in clinic for a minimum of 6 months after their procedures and up to a maximum of 24 months.

RESULTS

11 patients were male and nine were female, with an average age of 65.6 years. 17 patients presented with severe unilateral lower extremity radiculopathy and three patients were experiencing low back pain. One of the patients had two synovial cysts, and therefore a total of 21 lumbar synovial cysts were treated in this group of patients. Direct cyst puncture was achieved using a tandem technique in nine patients, a coaxial interlaminar approach in seven patients, a coaxial transforaminal approach in two patients, and a coaxial trans-facet approach in three patients. Cyst rupture was documented in all cases, as evidenced by CT confirmation of cyst decompression and contrast agent extravasation into the epidural space. The mean surveillance period in these patients was 18 months. Six patients experienced their usual radicular pain within 2 months of their treatment. Four of these patients were re-treated for recurrent smaller cysts. These patients have not had a recurrence at 24 months of follow up. Two of these six patients elected to undergo open surgical decompression without symptomatic improvement. No treatment related complications were observed in this group of patients.

CONCLUSIONS

Direct tandem and/or coaxial percutaneous CT guided techniques for rupture and treatment of symptomatic lumbar synovial cysts reduces recurrence rates and therefore helps avoid more invasive open surgical procedures in this group of patients.