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Case 2

History: 65 year old man with chronic back pain

Synovial Cyst

Synovial cyst formed from degenerative facet joint

Location

Posterior lateral to thecal sac

Adjacent to facet

Lumbar spine (90%)

70-80% @ L4-L5

Synovial Cyst

MRI findings

T1

Hypointense – similar to CSF

Hyperintense less common but due to proteinaceous fluid or hemorrhage

T2

Hyperintense – direct communication with facet

Hypointense – if there is hemorrhage

Low intensity rim

T1 + C

Enhancing wall

STIR

Hyperintense

Synovial Cyst

Top DDX

Ganglion Cyst

Likely from Ligamentum Flavum

Contains myxoid material

Difficult to distinguish by imaging (Pathologically different)

Extruded Disc Fragment

Not Contiguous with facet joint

Usually anterior epidural location

Not as hyperintense on T2

Nerve Sheath Tumor

Intense post contrast enhancement

Usually Intradural-Extramedullay location

Synovial Cyst

Etiology

Facet osteoarthropathy

Stress loading on lumbar spine

Facet instability and hypermobility

Synovial proliferation

Demographics

Age > 60 yo

M > F

No racial predilection

Synovial Cyst

Presentation

Chronic lower back pain

Acute pain from hemorrhage

Radicular Sx

Cauda Equina Sx

Natural History

May regress spontaneously

High post-surgical success in symptomatic patients

Synovial Cyst

Treatment

Conservative

Bed Rest

Analgesics

Epidural and Facet/Cyst Injection

Bracing

Laminectomy and cyst excision

In setting of intractable pain

Nerve compression