Institutional members access full text with Ovid®

Share this article on:

The Prevalence and Pathogenesis of Synovial Cysts Within the Ligamentum Flavum in Patients With Lumbar Spinal Stenosis and Radiculopathy

Wilby, Martin J. MA, MB, BChir, PhD, FRCS*; Fraser, Robert D. AM, MD, FRACS*; Vernon-Roberts, Barrie AO, MD, PhD, FRCPath, FRCPA*†; Moore, Robert J. MAppSc, PhD*†

doi: 10.1097/BRS.0b013e3181b22bd0
Clinical Case Series

Study Design. A clinicopathologic study of synovial cysts in the ligamentum flavum (LF) in patients with spinal stenosis.

Objective. To investigate the pathogenesis of lumbar juxtafacet cysts.

Summary of Background Data. Contradictions in the terminology applied to lumbar juxtafacet cysts arise from the frequent sparsity of synovial lining cells, which has led to synovial cysts often being called “ganglion cysts” despite lacking confirmatory pathology.

Methods. A total of 27 consecutive patients with radiologically confirmed stenosis underwent laminectomy. LF/facet joint (FJ) relationships were retained by en bloc excision of the LF and the medial inferior FJ. Controls were LF/FJ specimens from 47 cadaver lumbar spines.

Results. The 27 patients yielded 51 LF/FJ specimens containing 28 synovial cysts, 12 of which were unilateral and 8 were bilateral. Fragments of articular cartilage and bone were embedded in the walls of 89% of cysts and in the walls of a bursa-like channel originating from the medial aspect of the FJ capsule and extending into the LF. Communication with the FJ via this channel was observed in 21 (75%) of the 28 synovial cysts. Extending up to 12 mm in length, the channel was present in nearly all control spines at the L4–L5 level but in only about half at the T12–L1 level.

Conclusion. Cysts having an extensive or meagre synovial cell lining are common in the LF of patients with symptomatic lateral or central stenosis. The cysts communicate with the FJ by a bursa-type channel within the LF. Advanced osteoarthritis of the FJ causes the liberation of fragments of cartilage and bone into the synovial fluid of the joint space. This enables some fragments to escape from the joint into the channel and become lodged within its wall where they provoke granulation tissue and scar formation. The tissue response to articular debris may block the synovial-lined channel to cause synovial cyst formation.

En bloc excision of the ligamentum flavum and medial inferior facet joint in 20 patients yielded 12 unilateral and 8 bilateral synovial cysts. Cyst formation follows the blockage of a pre-existing bursa-like intraligamentous channel in continuity with the joint space by scar tissue formed in response to osteoarthritic joint debris.

From the *The Adelaide Centre for Spinal Research and Hanson Institute, Institute of Medical and Veterinary Science, Adelaide, South Australia; and †Discipline of Pathology, University of Adelaide, Adelaide, South Australia.

Acknowledgment date: October 30, 2008. First revision date: March 5, 2009. Acceptance date: April 6, 2009.

The manuscript submitted does not contain information about medical device(s)/drug(s).

Institutional funds were received in support of this work. No benefits in any form have been or will be received from a commercial party related directly or indirectly to the subject of this manuscript.

This work was awarded a prize for an outstanding paper at the ISSLS Annual Scientific Meeting in Geneva, Switzerland, May 2008.

Address correspondence and reprint requests to Barrie Vernon-Roberts, AO, MD, PhD, FRCPath, FRCPA, The Adelaide Centre for Spinal Research, Institute of Medical and Veterinary Science, PO Box 14 Rundle Mall, Adelaide, South Australia 5000; E-mail:

© 2009 Lippincott Williams & Wilkins, Inc.