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70 yo female with radicular pain

Synovial Cyst

Location: posterolateral extradural lesion adjacent to facet joint

90% Lumbar spine

-70-80% at L4-L5

Associations: disc space loss, vacuum disc, endplate sclerosis, facet arthropathy, scoliosis

Imaging

CT – difficult to see due to fluid density. May see if cyst has mural calcifications, intracystic gas or increased density from hemorrhage.

MR

T1 hypointense to CSF or hyperintense if contains protein or blood

T2 hyperintense with direct connection to joint or hypointense if contains hemorrhage

STIR Hyperintense

T1+c Enhancing wall well circumscribed

Differential Diagnosis

Extruded Disc Fragment

Not contiguous with facet joint

Typically anterior epidural (posterolateral uncommon)

Not as hyperintense on T2

Ganglion Cyst

Likely from ligamentum flavum

A lined fibrous connective tissue capsule filled with myxoid material

Difficult to distinguish from synovial cyst

Nerve Sheath Tumor

Intadural extramedullary, classic dumbell shape

Avid homogeneous enhancement

Assymetric ligamentum flavum hypertrophy

Hypointense T2 with more broad based contour with accompanying diffuse ligamentum flavum thickening

Pathology

Thickened connective tissue and synovium

Encapsulated lesion containing serous or mucinous material +/- hemorrhage

Microscopic findings of fibrous connective tissue, inflammatory cell infiltration, calcium deposits and hypervascular synovial lining

Presentation

Typically in Females>Males age >/= to 60

Present with chronic low back pain

Acute pain from hemorrhage

Radicular symptoms or neurogenic claudication.

Treatment

Conservative –bed rest, spinal epidural or facet injections, analgesics

Surgical- laminectomy with cyst excision

Percutaneous- Ct or fluoroscopic guided cyst aspiration/maceration and steroid injection.

-1/2 to 2/3 patients have symptomatic relief after six months.