Synovial Spinal Cyst
Synovial cyst of the spine is an interesting topic. Basically, you need to recognize that it is a synovial cyst, and you need to recognize the treatment is probably removal by some sort of decompression and you may need fusion if there is instability. It occurs due to arthritis of the facets. It occurs mostly in patients 60 years or older. It usually affects the level of L4-L5. This is one of the most active levels. There will be bulging of the lining of the covering of the facet joint. The synovial cyst is a cyst or a fluid filled cavity. When the fluid escapes from the arthritic facet joint, because it is under pressure, it dilates the capsule of the facet joint and creates a cyst. The connection between the synovial cyst and the facet joint becomes obvious. The synovial cyst is walled off from the spinal canal. The synovial cyst causes pressure on the nerve root as it tries to exit the foramen. Compare both sides. The synovial cyst acts like a herniated disc. The patient will have low back pain, numbness, and radiation of the pain down the leg. The synovial cyst is best diagnosed by an MRI. The MRI can also diagnose the compression on the nerve root by the cyst. The synovial cyst is bright in T2 MRI because it is a fluid filled mass (it’s not like an intervertebral disc) and the cyst is contiguous with the hypertrophied facet joint, which also has a high signal intensity. The synovial cyst indicates a facet pathology. The patient will be initially treated conservatively. There is a high recurrence rate with nonsurgical treatment, and if there is no improvement, then you will need to do surgery. If the patient has radiculopathy alone, do decompression. If the patient has significant low back pain due to spinal instability, you will do decompression and fusion. To check for instability, look at the MRI or the x-rays. Get flexion/extension x-rays before you decide on surgical intervention. Basically, because you have the synovial cyst and when you go in and remove the cyst, you have hypertrophy of the facets and the ligamentum flavum, so you will do a hemilaminotomy and partial facetectomy with direct decompression of the neural elements. Do fusion if there is instability.
Common Knee Problems
A common knee problem could be patellar chondromalacia. This chronic pain is due to softening of the cartilage beneath the knee cap. Pain is from mild to complete erosion of the cartilage in the back of the knee cap. It causes pain in the front of the knee. It occurs more in young people. It becomes worse from climbing up and down stairs. Treatment for patellar chondromalacia usually includes therapy and NSAIDS. Another common knee problem could be Patellar Bursitis. This is characterized by pain and inflammation over the front of the kneecap. This occurs when the bursa becomes inflamed and fills with fluid at the top of the knee. It causes pain, swelling, tenderness, and a lump in the area on top of the kneecap. Lateral Collateral Ligament Rupture usually occurs as a result of sports activities. Medial Collateral Ligament Rupture is an injury to the ligament on the inner part of the knee. It is the most commonly injured knee ligament. Anterior Cruciate Ligament Tear involves valgus stress to the knee. Usually the patient will have swelling and hematoma. It can be diagnosed by MRI or a positive Lachman’s test. Patellar Tendonitis is characterized by inflammation and pain located inferior to the knee cap area. The meniscus is a cusion that protects the cartilage of the knee. A meniscal injury will cause pain of the medial or lateral side of the knee. The outer 30% of the meniscus has blood supply. Meniscal tears can be diagnosed by MRI or a positive McMurrays test. Patient with meniscal tears typically have a history of locking, swelling, and instability of the knee. Arthritis of the Knee Joint is characterized by progressive wearing away of the cartilage of the joint. The knee is a common part of the body that is most affected by arthritis. Knee arthritis causes decreased joint space. A Baker’s Cyst causes swelling in the back of the knee filled with synovial fluid. The cyst is between the semimembranous and medial gastrochnemius muscles. Gout is a type of arthritis or joint inflammation caused by an excessive level of uric acid in the blood. It can affect any joint especially the big toe. The gout crystals look like needles and have a negative birefringence.
A ganglion cyst is a mass or lump that forms below the surface of the skin. It is a benign cyst that is filled with a jelly-like fluid. The term ganglion means “knot”. It is not a malignant tumor, but a soft tissue benign mass. Ganglion cysts can occur anywhere; however, they usually occur at the wrist area and may occur at the foot (usually on top). This mass can change in size, vary in size, and may grow slowly.
The mass is usually asymptomatic and typically, the patient will find the mass at the top of the foot. The patient may have a burning sensation due to nerve irritation or compression of the nerve. Sometimes, a ganglion cyst mass occurs in the tarsal tunnel area, causing tarsal tunnel syndrome. If this is the case and the pain and burning sensation is not resolved with conservative treatment, excision of the mass is probably the best option. The patient may have skin irritation, as well as difficulty in walking and wearing shoes. If the ganglion is pushing on a nerve and causing irritation, something surgical needs to be done, such as aspiration or removal. Usually, the patient’s symptoms become better after these treatments.
The physician will need to differentiate a ganglion cyst from plantar fibromatosis. Remember, ganglion cysts tend to occur at the top of the foot. Plantar fibromatosis occurs at the bottom of the foot. A ganglion cyst will transilluminate, while plantar fibromatosis will not.
Treatment typically consists of observation, shoe modification, and aspiration/injection of steroids. Surgery is performed as the last resort.
Ganglion of the wrist is the number one soft tissue hand mass. If a mass is present in the wrist, there is a 70% probability that it is a ganglion.
The bump or the cyst is filled with gelatinous material that can change in size and is close to a tendon sheath or the wrist joint. The causes of cysts are unknown. It may be caused by trauma or degeneration and weakness of the capsule.
Ganglion cysts of the wrist can be either dorsal or volar. A ganglion cyst that grows on the top of the wrist is called a dorsal ganglion. Dorsal ganglion is common (70%) and arises from the scapholunate ligament. A ganglion cyst that grows on the bottom of the wrist is called a volar ganglion. These are less common (20%), but are most common between the Flexor Carpi Radialis (FCR) and Abductor Pollicis Longus (APL) muscles. Volar cysts arise from the radiocarpal joint or the STT joint.
For a dorsal cyst, the bump or the mass is well defined, localized, smooth and not attached to the underlying skin. The mass will be translucent. The mass is obvious with flexion of the wrist, so an MRI is not needed. A volar cyst may be diagnosed with an MRI; however, ultrasound imaging is better for showing the relationship between the artery and the ganglion.