Treatment options for synovial cysts
There are three main treatment choices for synovial
cysts in the lumbar spine:
- Observation and activity modifications
- Injections
- Surgery
Observation and activity modification
If the synovial cyst is not creating a lot of dysfunction
or pain in the patient’s daily life, no medical
treatments may be necessary. Since the pain is
usually
caused by certain positions, changing positions is
a reasonable way to deal with the pain as long
as a patient
can still function adequately.
For exercise, it may be preferable for the patient
to try stationary biking instead of walking, because
in the seated position the patient should be fairly
comfortable.
Injections for synovial cysts
There are two types of injections that can be helpful
to alleviate the pain: facet injections or epidural
injections.
-
Facet injection. The facet joint can be entered
with a small needle and occasionally the cyst can
be drained by aspirating it through the joint. Afterwards,
the joint is then injected with steroid to decrease
inflammation.
-
Epidural steroid injection. The more common injection
technique is to inject around the cyst with steroid
in the epidural space (an epidural injection). It
does not reduce the cyst but can reduce the pain.
Although the mechanism of the pain reduction is
not well understood it is thought to be due to a
reduction in inflammation. It works well about 50%
of the time and not so well 50% of the time, and
unfortunately, the pain relief tends to be temporary.
Still, even though either injection is not all that
reliable in the long run it is reasonable to try since
the only other alternative is surgery. Generally, no
more than three injections within a year are recommended.
Sping surgery for synovial cysts
The most common kinds of spine surgery for synovial cysts can be either a decompression
alone or a decompression with a spine fusion.
Microdecompression spine surgery
If there is no associated instability with the cyst
(e.g. no degenerative spondylolisthesis as seen on
flexion/extension x-rays) then a microdecompression
of the nerve root with removal of the cyst is reasonable.
Basically, this is the same approach as would be used
for a microdiscectomy, and is a minimally invasive
surgery with a relatively quick recovery. (See also
Microdisectomy).
However, since the joint pathology (which caused
the original synovial cyst) is still present the cyst
can re-form at a later date.
Decompression with spine fusion surgery
The most reliable treatment method for a synovial
cyst is to remove the cyst and then fuse the joint.
Fusing the joint stops all the motion at that level,
and without any motion the cyst should not regenerate.
This is the most reliable treatment, but it is also
the most to go through. It changes the biomechanics
in the back because one of the joints will no longer
function. The L4-L5 level has the most motion, and
fusing it creates more stress on the other non-fused
levels of the lower spine. Also, the surgery is more
to go through since this is an open procedure, and
it takes about six to nine months or more for the
fusion to heal. (See also Decompression surgery
and Spine fusion surgery).
Decision-making factors for patients
When deciding which treatment to pursue, patients need
to base their decisions on three primary factors:
-
The amount of pain they are having
-
The length of time of their symptoms
-
The amount of dysfunction it causes in their life.
If the pain is relatively acute and tolerable, it is
probably reasonable for the patient to modify his or
her activities. If the pain is severe, then an injection
might be more reasonable. If the pain is severe and
has been going on for a while (e.g. years) or if the
injections have not worked then surgery is more reasonable.
For younger more active patients, a trial of a microdecompression
is probably a reasonable consideration (as long as there
is no gross instability of the joints), with the knowledge
that a fusion may be necessary in the future. For more
elderly or less active patients, it may be more reasonable
to jump to the definitive procedure of a fusion, since
the stress transfer the fusion creates to the other
joints is not as great in these patients and only one
procedure would then be necessary.
Conclusion on synovial cysts treatments
Synovial cysts are an uncommon cause of lumbar stenosis,
and the treatment is largely the same as for spinal
stenosis with the exception that there is often accompanying
spinal instability at the same joint that needs to be
considered if surgery becomes necessary.
Surgery is only necessary for those patients that would
like to do more activity with less pain. The surgery
is very effective for treatment of this condition. The
most successful surgery tends to be a decompression
with a fusion (approximately a 90-95% success rate should
be expected, which means a significant reduction in
pain, not necessarily pain free), but this is also the
treatment that is the hardest to go through and changes
the biomechanics of the spine. It should be considered
for people with moderate to severe activity limitations
that have joint instability along with the cyst, and
who have failed conservative treatments such as injections.
By:
Stephen H. Hochschuler, MD
September 9, 2002
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