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Progressive Enlargement of a Lumbar Zygapophyseal Cyst

LaBan, Myron M. MD, MMSc; Wang, Ay-Ming MD

American Journal of Physical Medicine & Rehabilitation: October 2005 - Volume 84 - Issue 10 - p 821
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From the Departments of Physical Medicine and Rehabilitation (MML) and Radiology, Subsection of Neuroradiology (A-MM), William Beaumont Hospital, Royal Oak, Michigan.

All correspondence and requests for reprints should be addressed to Myron M. LaBan, MD, MMSc, William Beaumont Hospital, Rehabilitation, 3601 West 13 Mile Road, Royal Oak, MI 48073-6769

The signs and symptoms of a lumbar zygapophyseal joint cyst (LZJC) often replicate more common intrathecal mass lesions (i.e., disk herniations or tumors). However, they can readily be distinguished one from another by magnetic resonance imaging. Characteristically, they seem as round or ovoid cystic accumulations of fluid projecting beyond the peripheral margins of the vertebral facet joint. Two types of juxta-articular cysts have been described: ganglion or synovial cysts. In the initial case, the cyst may not communicate with the facet joint and often contains a gelatinous material. In the latter case, there is a synovial lining and the enclosed fluid is clear or xanthochromic and communicates directly with the joint cavity.1 LZJCs have a 2.3% prevalence rate, occurring most often at the L4–L5 vertebral level, with 60% associated with spondylolisthesis.2

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A 78-yr-old woman presented with symptoms of lumbar pain associated with complaints of numbness and tingling in the lower limbs and with “leg tiredness.” She had a history of anemia, arthritis, hypertension, and cardiac bypass surgery. A neuromusculoskeletal and electroneuromyographic examination were both normal. A magnetic resonance image of the lumbar spine demonstrated hypertrophy of the vertebral facet joints and ligamentum flavum (Fig. 1) at L4–L5, with a mild spinal stenosis and a small right-sided LZJC at this level. The patient’s symptoms were relieved with physical therapy, including thermotherapy, intermittent split-table pelvic traction, and progressive William’s flexion exercises. She returned 3 yrs later with complaints of night-time lumbosacral pain and restless leg syndrome arousing her from sleep. Suspecting a “typical” lumbar spinal stenosis, instead, repeated magnetic resonance imaging demonstrated (Fig. 2) a large 1.3 × 1.4 cm right-sided LZJC compressing the thecal sac and cauda equina. Repeated electroneuromyography revealed chronic bilateral multiple-level polyradiculopathy. In this instance, the symptoms of “Vesper’s Curse” (i.e., night pain and restless leg syndrome in association with cardiopulmonary dysfunction and lumbar spinal stenosis3) was related to the fortuitous presence of an enlarged LZJC inciting the symptoms of ischemic radiculopathy.

LZJCs are invariably associated with facet joint arthritis and joint instability, as demonstrated in this patient with an anterolisthesis at L4–L5. As in this patient, surgical excision of a symptomatic LZJC has remained the standard treatment. However, percutaneous computed tomographically guided drainage with steroid injection has been demonstrated to be an effective initial alternative.4

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1.Kjerulf TD, Terry DW, Boubelick RJ Lumbar synovial or ganglion cysts. Neurosurgery 1986;19:415–20
2.Doyle AJ, Merrilees M Synovial cysts of the lumbar facet joints in a symptomatic population. Spine 2004;29:874–8
3.LaBan MM “Vesper’s Curse” night pain: The bane of Hypnos. Arch Phys Med Rehabil 1984;65:501–4
4.Lim AKP, Higgins SJ, Saifuddin A, et al: Symptomatic lumbar synovial cyst: Management and direct CT-guided puncture and steroid injection. Clin Radiol 2001;56:990–3
© 2005 Lippincott Williams & Wilkins, Inc.