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Symptomatic Lumbar Facet Joint Synovial Cysts: Clinical Assessment of Facet Joint Steroid Injection after 1 and 6 Months and Long-term Follow-up in 30 Patients

¹ Departments of Bone and Joint Radiology (C.P.C., M.W., J.D.L.)
² Orthopedic Surgery (R.N.), Hôpital Lariboisière, AP-HP, Assistance Publique des Hôpitaux de Paris, 2 rue Ambroise Paré, 75010 Paris, France
³ Department of Radiology, Hôpital la Timone, Marseille, France (P.C.)
⁴ Department of Radiology, Hôpital Saint-Antoine, Assistance Publique des Hôpitaux de Paris, France (P.L.H.).

	Abstract

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
PURPOSE: To study the results of facet joint intraarticular steroid injections in patients with symptomatic lumbar facet joint synovial cysts.

MATERIALS AND METHODS: Data from 30 patients (age range, 44–82 years; mean age, 67 years) with nerve root pain due to a lumbar facet joint synovial cyst and treated with facet joint steroid injection were retrospectively studied. On the basis of MacNab criteria, the clinical course of nerve root pain was evaluated after 1 (n = 30) and 6 (n = 28) months. Data from long-term follow-up (mean, 26 months) were also available in 14 nonsurgically treated patients.

RESULTS: After 1 month, the nerve root pain outcome was excellent or good in 20 patients (67%) and fair or poor in 10 (33%). After 6 months, 10 (50%) of these 20 patients still had excellent or good results, and 18 (60%) of the 30 patients had a fair or poor clinical status, 14 of whom underwent surgery; two patients (7%) were lost to follow-up. Excellent and good results were maintained at further follow-up (range, 9–50 months).

CONCLUSION: One-third of patients with symptomatic lumbar facet joint synovial cysts had long-lasting acceptable benefit from facet joint steroid injections in this study. Steroid injection should be indicated before surgery.

Index terms: Interventional procedures, 334.1269 • Spine, cysts, 334.3611 • Spine, facet joints, 334.3611 • Steroids, 334.1269

	Introduction

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Lumbar facet joint synovial cyst is a recognized cause of femoral and sciatic nerve root pain in the elderly (1–23). Facet joint synovial cysts are usually detected by using computed tomography (CT) (1–20,22,23) or magnetic resonance (MR) imaging (5,12,19,24,25). Although surgical excision is effective in symptomatic facet joint synovial cysts, many patients have a high surgical risk because they are elderly. In 1985, Casselman (9) suggested that facet joint steroid injections performed with radiologic guidance may be useful in compressive lumbar facet joint synovial cysts. Since then, findings of many studies have confirmed the short-term efficacy of facet joint steroid injections in facet joint synovial cysts (2–9,11,14,26–28). However, few studies have provided data on long-term clinical outcomes after steroid injection (2–9). To our knowledge, the two largest series of facet joint synovial cysts that included an evaluation of long-term clinical outcomes after steroid injection comprised seven (4) and eight (3) patients, with mean follow-up times of 19 and 15 months, respectively. We retrospectively studied clinical outcomes after 1-month, 6-month, and long-term follow-up in a series of 30 patients with symptomatic lumbar facet joint synovial cysts treated by means of facet joint steroid injection with radiologic guidance. We also sought to determine whether specific imaging characteristics of facet joint synovial cysts were of assistance in predicting outcomes after steroid injection.

	MATERIALS AND METHODS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Between December 1989 and April 1995, 36 consecutive patients with nerve root pain due to a lumbar facet joint synovial cyst were referred to the Department of Bone and Joint Radiology, Hôpital Lariboisière, Paris, France, for steroid injection into the facet joint with radiologic guidance. Thirty of these 36 patients were included in the study on the basis of the following selection criteria: (a) a facet joint synovial cyst was confirmed at lumbar facet joint arthrography, (b) the location of the facet joint synovial cyst was consistent with the clinical symptoms of nerve root impingement, (c) no other vertebral condition that might account for the nerve root pain was present (in particular, no disk herniation was found at CT or MR imaging, and no evidence of inflammatory spondylarthropathy was noted), (d) there was no history of surgery at the level of the facet joint synovial cyst, and (e) data on the clinical outcome could be evaluated 1 month after the injection. On the basis of these criteria, four patients were not included because their radiculopathy was possibly related to another vertebral lesion, and two other patients were not included because they were lost to follow-up immediately after the injection. Thus, 30 patients were in the study.

There were 21 women and nine men (sex ratio, 0.48), with a mean age of 67 years (age range, 44–82 years). All patients had typical sciatic or femoral nerve root pain of at least 6 months duration that was unresponsive to conservative treatment, including the administration of nonsteroidal antiinflammatory drugs and rest. Some patients had received epidural steroid injections performed by a rheumatologist, also with no substantial pain relief. A lumbar facet joint synovial cyst was demonstrated at CT in 27 patients (Fig 1) and at MR imaging in three (Fig 2). In all patients, the facet joint synovial cyst was confirmed at lumbar facet joint arthrography (Fig 3a, 3c), which was performed as the first step of the radiologically guided injection of steroids. The procedure was as follows. The patient was in the prone position. With fluoroscopic control, a 20-gauge, 9-cm spinal needle was inserted vertically and parallel to the x-ray beam toward the inferior recess of the joint until the bone was reached (29). Lidocaine (1%) was first injected. Return of fluid confirmed the correct intraarticular position of the needle. The injection of 1 mL of iopamidol 200 (Iopamiron; Schering-France, Lys-Lez-Lannoy, France) immediately opacified the superior recess, confirming correct intraarticular needle position, and filled the facet joint synovial cyst. No contrast material was withdrawn during arthrography. The steroid was then injected (3.75 mg of cortivazol [Altim; Roussel, Paris, France] or 100 mg of prednisolone acetate [Hydrocortancyl; Roussel]) without additional anesthetics.

View larger version (131K): [in this window] [in a new window]   Figure 1a. (a) Facet joint synovial cyst on a CT scan in a 63-year-old man. The cyst (arrow) is seen as a mass within the epidural space that displaces the overlying yellow ligament. (b) Facet joint synovial cyst on a CT scan in an 81-year-old woman. Note calcification within the cyst wall. 1 = cyst. Circular cursor (113 HU) indicates the site of measurement of x-ray attenuation, and this measure was consistent with calcific deposits.

View larger version (140K): [in this window] [in a new window]   Figure 1b. (a) Facet joint synovial cyst on a CT scan in a 63-year-old man. The cyst (arrow) is seen as a mass within the epidural space that displaces the overlying yellow ligament. (b) Facet joint synovial cyst on a CT scan in an 81-year-old woman. Note calcification within the cyst wall. 1 = cyst. Circular cursor (113 HU) indicates the site of measurement of x-ray attenuation, and this measure was consistent with calcific deposits.

View larger version (151K): [in this window] [in a new window]   Figure 2. Fast spin-echo T2-weighted MR image (6,000/128 [repetition time msec/echo time msec]) of a facet joint synovial cyst in a 54-year-old man. The cyst (arrow) appears as a smooth, extradural, well-circumscribed mass adjacent to a facet joint. The signal intensity is predominantly high. The central area of low signal intensity is thought to be related to the presence of fibrous or hemosiderin deposits.

View larger version (166K): [in this window] [in a new window]   Figure 3a. (a) Facet joint arthrogram obtained in a 78-year-old woman after contrast material was injected into the right L5-S1 facet joint shows that the injection penetrated a facet joint synovial cyst (arrow), filling it completely. (b) CT scan obtained in the same patient as in a after opacification of the cyst (straight arrow) through the right L5-S1 facet joint. Note the severe degenerative changes of the facet joints, including marked joint space narrowing (arrowheads) and major osteophytosis (curved arrows). (c) Facet joint arthrogram obtained in an 82-year-old man shows an incompletely filled facet joint synovial cyst (arrow) at the L4-5 level.

View larger version (143K): [in this window] [in a new window]   Figure 3b. (a) Facet joint arthrogram obtained in a 78-year-old woman after contrast material was injected into the right L5-S1 facet joint shows that the injection penetrated a facet joint synovial cyst (arrow), filling it completely. (b) CT scan obtained in the same patient as in a after opacification of the cyst (straight arrow) through the right L5-S1 facet joint. Note the severe degenerative changes of the facet joints, including marked joint space narrowing (arrowheads) and major osteophytosis (curved arrows). (c) Facet joint arthrogram obtained in an 82-year-old man shows an incompletely filled facet joint synovial cyst (arrow) at the L4-5 level.

View larger version (142K): [in this window] [in a new window]   Figure 3c. (a) Facet joint arthrogram obtained in a 78-year-old woman after contrast material was injected into the right L5-S1 facet joint shows that the injection penetrated a facet joint synovial cyst (arrow), filling it completely. (b) CT scan obtained in the same patient as in a after opacification of the cyst (straight arrow) through the right L5-S1 facet joint. Note the severe degenerative changes of the facet joints, including marked joint space narrowing (arrowheads) and major osteophytosis (curved arrows). (c) Facet joint arthrogram obtained in an 82-year-old man shows an incompletely filled facet joint synovial cyst (arrow) at the L4-5 level.

Clinical data from patients were collected by an independent observer. All patients were sent a standardized questionnaire based on the criteria developed by MacNab et al (30) (Table 1). In 21 patients, a medical record was also available. Ten patients did not return the questionnaire. Eight of them were contacted by telephone and answered the questionnaire. Among the two remaining patients, one had died of an unrelated disease and the other one was lost to follow-up at 4 months. However, for these two patients, a medical record was available that allowed an assessment of their clinical status at 1-month follow-up.

	RESULTS

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

 
Clinical and Imaging Features
The level of the facet joint synovial cyst was L2-3 in one patient (3%), L3-4 in three patients (10%), L4-5 in 25 patients (83%), and L5-S1 in one patient (3%). Degenerative spondylolisthesis at the level of the facet joint synovial cysts was seen on plain radiographs in 18 patients (60%), all of whom had their facet joint synovial cyst at the L4-5 level. Two other patients had a facet joint synovial cyst at the L3-4 level and degenerative spondylolisthesis at the L4-5 level. Facet joint synovial cyst wall calcifications were seen on CT scans in seven patients (27%). Degenerative changes in the facet joints at the level of the facet joint synovial cyst were seen at CT or MR imaging in all patients (100%). Facet joint synovial cyst contrast material filling during facet joint arthrography was complete in 16 patients (53%) and partial in 14 (47%).

Follow-up Data
After 1 month, the clinical result was excellent in six (20%) of the 30 patients, good in 14 (47%), fair in six (20%), and poor in four (13%).

After 6 months, 28 patients were examined. Of the 20 patients who had an excellent or good result after 1 month, one was lost to follow-up, 10 still had an excellent (n = 5) or good (n = 5) result, and nine reported the recurrence of pain after a mean of 3 months (range, 1.5–5.5 months). Each of these nine patients received an additional radiologically guided steroid injection into the facet joint synovial cyst, with a fair (n = 4) or poor (n = 5) result. Of these nine patients, seven subsequently underwent surgery for persistent pain, one died of an unrelated disease, and one had a final poor outcome but was not treated surgically. Of the six patients with a fair result after 1 month, three underwent surgery and three still had a fair result after 6 months. None of these six patients received additional steroid injections. All four patients with a poor result after 1 month underwent surgery before the 6-month evaluation.

In total, of the 28 patients examined after 6 months, 10 (36%) had an excellent or good result and 18 (64%) had a fair or poor result, which led to surgical treatment in 14 patients. The clinical outcome was good after surgery (mean follow-up, 28 months; range, 6–60 months) in every case.

Long-term follow-up data were available in the 14 nonsurgically treated patients. The mean duration of follow-up was 26 months (range, 8–50 months). The 10 patients with an excellent (n = 5) or good (n = 5) result after 6 months still had an excellent or good result at the last follow-up examination (mean, 35 months; range, 9–50 months). Seven of these 10 patients did not receive any additional steroid injections during the mean follow-up of 30 months (range, 9–50 months), whereas three required additional steroid injections for recurrent pain. Of these three patients, one required a second steroid injection after 48 months and still had a good result 12 months later. In the two others, a second steroid injection was performed after 6 and 7 months. This second injection provided relief for 6 and 12 months. These two patients received a third steroid injection for recurrent pain, with a good result at the last follow-up examination at 24 and 50 months. The four patients with a fair result after 6 months still had a fair result at the last follow-up examination (mean, 16 months; range, 8–36 months), although they received additional facet joint injections.

Predictive Factors
There were no significant differences between patients with an excellent or good result and those with a fair or poor result with respect to age, sex, duration of symptoms, distribution of pain, level of the cyst, or radiologic findings studied. In particular, the clinical outcome after steroid injection was not influenced by the presence of degenerative spondylolisthesis, facet joint synovial cyst wall calcifications, or the degree of facet joint synovial cyst contrast material filling during facet joint arthrography (Table 2).

	DISCUSSION

TOP Abstract Introduction MATERIALS AND METHODS RESULTS DISCUSSION References

Steroid injection into the facet joint with radiologic guidance has been used to treat low back pain related to degenerative facet joint disease (26–28,32–36). To our knowledge, the first report of facet joint steroid injection in a symptomatic facet joint synovial cyst was written by Casselman in 1985 (9). Since then, this method has been the focus of many studies (2–9,11,14,26–28), although to our knowledge none included an evaluation of clinical outcomes in large numbers of patients. Of the 112 cases that we identified in the literature (1–23), 24 (2–9) were treated by means of steroid injection into the facet joint synovial cyst under radiologic guidance and had data on clinical outcomes after 1 (n = 24) and 6 months or longer (n = 22) that could be retrospectively studied and compared with those in our 30 patients. Results of facet joint injection in these 24 cases were roughly rated as good (complete or substantial nerve root pain relief) or poor (moderate, minimal, or absent nerve root pain relief). After 1 month, the result was excellent or good in 67% of our 30 patients and in 75% of the 24 patients from the literature. After 6 months, results were still excellent or good in 36% of our 28 patients and in 50% of the 22 patients from the literature. Of the patients with an excellent or good result after 1 month, 50% (10 of 20) in our study and 66% (12 of 18) in the literature still had an excellent or good result after 6 months. In our study, all the patients with an excellent or good result after 6 months still had an excellent or good result at the last follow-up examination at a mean of 35 months (range, 9–50 months), although in some of these cases additional steroid injections into the facet joint were required. Conversely, no benefit was obtained from repeating the steroid injections into the facet joint synovial cyst in those of our patients who had an excellent or good result after 1 month but experienced early (mean, 3 months) pain recurrence. Among patients with a poor result after 1 month, none in our series and only one from the literature (4) had a good result after 6 months. Some of these patients received additional steroid injections 1–6 months after the first injection, with no benefit.

In our series, all the patients who were treated surgically had a good postoperative clinical outcome after a mean follow-up of 28 months. Others have also reported efficacy of surgical excision of lumbar facet joint synovial cysts (5,10,15,30).

We found no correlation between clinical outcome and presence of facet joint synovial cyst wall calcifications, degree of facet joint synovial cyst contrast material filling during facet joint arthrography, or presence of degenerative spondylolisthesis at the level of the facet joint synovial cyst. To our knowledge, potential relationships between these findings and the clinical outcome after steroid injection with radiologic guidance were not investigated in previous studies.

The main methodologic limitation of our study is its retrospective design. The patients were referred to Hôpital Lariboisière by several physicians who used a variety of criteria for deciding to perform steroid injection into the facet joint synovial cyst with radiologic guidance. However, all our patients had nerve root pain and met our selection criteria. Another cause of bias is that the steroid injections were not performed by a single physician. Although the procedure was defined in a standard protocol (29), we cannot exclude that the variable experience of the treating physicians in injecting lumbar facet joints may have been a source of variability in the clinical outcomes. In addition, the effectiveness of steroids could not be tested because of the lack of a control group. Actually, a control group receiving a placebo injection of isotonic saline (36) would have improved the validity of the therapeutic evaluation. Use of a visual analog scale to evaluate pain before the procedure and at each evaluation would have improved the reliability of our assessments. Since our patients were referred to us by many different physicians, we used a global measure of improvement based on MacNab criteria (30), which are frequently used in retrospective studies. Patient answers to the same standardized questionnaire was the only criterion taken into account for the evaluation of the treatment result, with no evaluation by an independent observer.

Another possible bias derives from the time elapsed between the steroid injection and this retrospective investigation. Some patients had to retrospectively evaluate several months or years later the intensity of their radicular pain at 1 month and 6 months after the injection. The value of a retrospective evaluation of pain, even if it is a long-lasting incapacitating leg pain such as in the present cases, is questionable. However, a medical file was also available in 21 of the 30 patients and was used to confirm the information collected from the questionnaire. In the nine remaining patients, pain status was unchanged from 1 month after injection to the final evaluation. Of these nine patients, four experienced pain relief throughout the whole follow-up period, while five already had a poor result at the 1-month evaluation and underwent surgery before the 6-month evaluation. Therefore, it was assumed that they were able to grossly evaluate their pain status retrospectively.

In conclusion, all 36% of patients with radicular pain due to a lumbar facet joint synovial cyst had an excellent or good clinical outcome at long-term follow-up (mean, 35 months), although one-third required additional steroid injections. In patients with a fair or poor result after 1 month, as well as in those with an excellent or good result after 1 month but with pain recurrence during the next 5 months, repeated steroid injections were ineffective and surgery was finally required. Presence of degenerative spondylolisthesis, facet joint synovial cyst wall calcifications, and degree of facet joint synovial cyst contrast material filling during facet joint arthrography were not helpful in predicting which patients would experience long-term pain relief after the steroid injection.

	Footnotes

 
Address reprint requests to C.P.C.

From the 1996 RSNA scientific assembly.

Author contributions: Guarantor of integrity of entire study, J.D.L.; study concepts, M.W.; study design, C.P.C.; literature research, C.P.C., R.N.; clinical studies, M.W.; data acquisition, C.P.C., M.W.; data analysis, M.W., P.C.; statistical analysis, P.L.H., C.P.C.; manuscript preparation, C.P.C.; manuscript editing, M.W.; manuscript review, J.D.L.

Received December 23, 1997; revision requested March 23, 1998; revision received July 7, 1998; accepted September 8, 1998.

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