Lumbar Synovial Cysts—Should You Fuse or Not?

Abstract

BACKGROUND:Spinal synovial cysts are lesions that most commonly occur in the lumbar region. The need for an instrumented spinal fusion in addition to lumbar decompression with removal of the synovial cyst is unknown.OBJECTIVE:To test the hypothesis that select patients who underwent decompression with instrumented fusion for lumbar synovial cysts would be less likely to have subsequent surgery (SS) in a 2-year period than patients treated with laminectomy alone.METHODS:This retrospective cohort study was performed using IBM MarketScan Commercial Claims and Encounters Database. Patients who had a lumbar synovial cyst diagnosis and laminectomy surgery with or without fusion surgery were included in this study. Patients were tracked for SS 2 years after surgery. Laminectomy patients were propensity score–matched to laminectomy with fusion (LF) patients using a 2:1 ratio. The log-rank test and Cox regression were used to compare the cumulative incidence of SS between groups.RESULTS:There were 7664 and 1631 patients treated with laminectomy and LF before matching. After matching, there were 2212 laminectomy and 1631 LF patients and patient characteristics were balanced. The 2-year incidence of recurrent SS was 3.1% ([CI]: 2.2%, 4.0%) and 1.7% (95% CI: 0.9%, 2.5%) laminectomy and LF, respectively. Compared with laminectomy, LF had a statistically significant lower risk of recurrent SS (hazard ratio: 0.56 [95% CI: 0.32-0.97]; P-value: .04).CONCLUSION:All patients who had concomitant lumbar fusion showed decreased chance of having a cyst- or noncyst-related recurrence SS when compared with all patients undergoing laminectomy alone, regardless of diagnosis at the time of SS.

Perspective: Operate on lumbar synovial cysts and avoid ineffective percutaneous techniques

“…Five studies showed that patients with LSC/Stenosis undergoing primary decompressions/fusions resulted in lower LSC recurrence rates vs. for those having decompressions alone [Table 1]. [1,7,9,14,16] 1]. [4] Notably, preoperative LSC were located at the same level of DS (42.5%), and this correlated with facet arthropathy (89.3%), and degenerative disc disease (48.8%).…”

“…[1] When Gonzalez et al (2023) evaluated 1631 patients with LSC undergoing primary laminectomy/instrumented fusions vs. 2212 with LSC having initial laminectomies alone, they found the laminectomy/fusion group had a lower 1.7% incidence of postoperative LSC recurrences requiring additional surgery vs. a much higher 3.1% recurrence rate of LSC for those undergoing initial decompressiona alone [Table 1]. [9] Low Failure Rates for Incomplete Surgical Resection of Lumbar Synovial Cysts 1]. [15] Partial LSC resections were largely attributed to marked cyst/dural adhesions, where dissection was carried around the residual capsule to avoid/limit the risk of dural tears/cerebrospinal fluid fistulas.…”

“…Five studies showed that patients with LSC/Stenosis undergoing primary decompressions/fusions resulted in lower LSC recurrence rates vs. for those having decompressions alone [ Table 1 ]. [ 1 , 7 , 9 , 14 , 16 ] Utilizing 4 databases (i.e., 17 studies; 824 patients), Ramhmdani et al . (2019) found that patients with LSC/Stenosis/DS were; “...more likely to undergo spinal fusion surgery than laminectomy alone compared with patients with LSC and no preoperative DS” [ Table 1 ].…”

“…(2023) evaluated 1631 patients with LSC undergoing primary laminectomy/instrumented fusions vs. 2212 with LSC having initial laminectomies alone, they found the laminectomy/fusion group had a lower 1.7% incidence of postoperative LSC recurrences requiring additional surgery vs. a much higher 3.1% recurrence rate of LSC for those undergoing initial decompressiona alone [ Table 1 ]. [ 9 ]…”

“…Lumbar synovial cysts (LSC), best diagnosed on MR studies, may cause symptoms ranging from unilateral radiculopathy to cauda equina syndromes/compression [Table 1]. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16] Typically, attempts at percutaneous cyst aspiration, injection (i.e. with/without steroids/other), dilatation, and/or disruption typically fail.…”