Aspirate synovial cyst?

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TIVAndy

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To all yee pain jedis.. L45 right synovial cyst. Aspirate? If so how do u do it?
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Patients don’t tend to do well in the long term with simply aspiration/injection. Even with a 22g, the cystic fluid is typically pretty viscous and difficult to aspirate much. Some case reports/series about bursting the cyst by pressurizing with saline, but some complications reported with siimply enlarging the cyst.
Guaranteed your patient has a radic with that thing. You could try to aspirate, but I probably would surgerize and be done with it.
 
tmvguy03 said:
Patients don’t tend to do well in the long term with simply aspiration/injection. Even with a 22g, the cystic fluid is typically pretty viscous and difficult to aspirate much. Some case reports/series about bursting the cyst by pressurizing with saline, but some complications reported with siimply enlarging the cyst.
Guaranteed your patient has a radic with that thing. You could try to aspirate, but I probably would surgerize and be done with it.
Click to expand...

yes clear radic sx. thank you for your input i was also thinking if it was truly a contiguous cyst from the facet, if i can somehow shove that 22g into the right facet and aspirate instead of transforaminal.. just a thought.
 
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I'll put dex in it once or twice and then send them for surgery.

The problem is when that cyst is there but they also have multilevel changes that are asymptomatic and they come back to you a year later with a multilevel fusion and laminectomy.
 
tmvguy03 said:
Patients don’t tend to do well in the long term with simply aspiration/injection. Even with a 22g, the cystic fluid is typically pretty viscous and difficult to aspirate much. Some case reports/series about bursting the cyst by pressurizing with saline, but some complications reported with siimply enlarging the cyst.
Guaranteed your patient has a radic with that thing. You could try to aspirate, but I probably would surgerize and be done with it.
Click to expand...


Actually, surgical outcomes are not that great with cysts. There was a nice article in SPINE about that ten years ago. They not only need a decompression, but usually a fusion as well, given that there is usually a slip at that level. If you are going to treat it surgically, generally it will be a decompression and fusion, not just a decompression.

World Neurosurg. 2017 Feb;98:492-502. doi: 10.1016/j.wneu.2016.11.044. Epub 2016 Nov 17.
Interventions for Lumbar Synovial Facet Joint Cysts: A Comparison of Percutaneous, Surgical Decompression and Fusion Approaches.
Campbell RJ1, Mobbs RJ1, Rao PJ1, Phan K2.
Author information
1Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, NSW, Australia.2Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia; NeuroSpine Surgery Research Group, Prince of Wales Private Hospital, Sydney, NSW, Australia; Faculty of Medicine, University of Sydney, Sydney, NSW, Australia. Electronic address: [email protected].
Abstract
OBJECTIVE:
Facet joint cysts (FJCs) of the lumbar spine are an increasingly reported cause of radiculopathy, lower back pain, and neurologic deficits. Currently, there is a lack of conclusive evidence outlining when a particular treatment should be undertaken and what patient indications suit a particular approach. The present systematic review and meta-analysis aims to evaluate the efficacy of percutaneous treatment and surgical decompression with or without fusion.
METHODS:
A systematic literature search of scientific databases from their inception to February 2016 was performed by 2 reviewers. Studies pertaining to percutaneous procedures, decompressive surgeries, or decompressive surgeries with fusion for the treatment of lumbar facet joint cysts were identified. Data for resolution of symptoms, repeat procedures, and subsequent fusion were extracted and analyzed.
RESULTS:
Fifty studies comprising 870 patients with lumbar FJCs were identified for inclusion. Decompressive procedures were performed in 62.8% of patients, whereas 36.1% were treated by percutaneous aspiration or rupture, and only 1.1% were treated by decompression with fusion. Pooled analysis showed the rate of cyst resolution to be 90% for decompressive procedures with or without fusion and 58% for percutaneous procedures. Repeat procedures were required in 29% of percutaneous procedures, but less than 1% for all decompression operations.
CONCLUSIONS:
Evaluation of the literature shows surgical intervention to be advantageous over percutaneous procedures for the treatment of lumbar FJCs. There is no evidence suggesting when fusion should be undertaken because of the limited data available.
Copyright © 2016 Elsevier Inc. All rights reserved.

There is almost always a spondylolisthesis hiding when you have a cyst. The cyst results from movement, so look for a slip. Always get flexion/extention films on these patients.

I have always aspirated with an 18 gauge epidural needle. The material is viscous and you need a larger needle. I "lavage" gently with saline after aspiration, but try not to pressurize the cyst.

I have had decent luck with aspiration. Heck, my wife is a good example. Aspirated X3 over a 6 month period and her cyst is gone both radiographically and clinically. That was five years ago.



World Neurosurg. 2019 Feb;122:e1059-e1068. doi: 10.1016/j.wneu.2018.10.228. Epub 2018 Nov 9.
Synovial Cyst as a Marker for Lumbar Instability: A Systematic Review and Meta-Analysis.
Ramhmdani S1, Ishida W2, Perdomo-Pantoja A2, Witham TF2, Lo SL2, Bydon A3.
Author information
1Spinal Column Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.2Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.3Spinal Column Biomechanics and Surgical Outcomes Laboratory, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA; Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address: [email protected].
Abstract
BACKGROUND:
The pathogenesis of synovial cysts is largely unknown; however, they have been increasingly thought of as markers of spinal facet instability and typically associated with degenerative spondylosis. We specifically investigated the incidence of concomitant synovial cysts with underlying degenerative spondylolisthesis.
METHODS:
A literature search was performed using 4 online databases to assess the association between lumbar synovial cysts and degenerative spinal pathological features. Meta-analyses were performed on the prevalence rates of coexisting degenerative spinal pathological entities and treatment modalities. A random effects model was used to calculate the mean and 95% confidence intervals.
RESULTS:
A total of 17 studies encompassing 824 cases met the inclusion criteria. The pooled prevalence rates of concurrent spondylolisthesis, facet arthropathy, and degenerative disc disease at the same level of the synovial cysts were 42.5% (range, 39.0%-46.1%), 89.3% (range, 79.0%-94.8%), and 48.8% (range, 43.8%-53.9%), respectively. Among these, patients with coexisting spondylolisthesis were more likely to undergo spinal fusion surgery (vs. laminectomy alone) and reoperation than were patients without spondylolisthesis with a pooled odds ratio of 11.5 (95% confidence interval, 4.5-29.1; P < 0.0001) and 2.0 (95% confidence interval, 0.9-4.2; P = 0.088), respectively.
CONCLUSIONS:
Patients with a combination of synovial cysts and degenerative spondylolisthesis are more likely to undergo spinal fusion surgery than laminectomy alone compared with patients with synovial cysts and no preoperative spondylolisthesis. Furthermore, patients with synovial cysts and spondylolisthesis are more likely to require additional fusion surgery. The results from the present review lend credence to the argument that synovial cyst herniation might be a manifestation of an unstable spinal level.
Copyright © 2018 Elsevier Inc. All rights reserved.
KEYWORDS:
Degenerative disc disease; Facet arthropathy; Lumbar spondylosis; Spondylolisthesis; Synovial cyst
PMID: 30415048 DOI: 10.1016/j.wneu.2018.10.228
[Indexed for MEDLINE]
 
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if you try to only aspirate the cyst, you A. might not get any fluid, and B. might have the fluid simple just recur.

I haven't had the best luck pulling fluid out, but sometimes I get some. my approach to this would be to try to aspirate, then inject steroid intra-articular while im there. however, in doing so, you are not really treating the patients primary complain (leg pain), so I would also add in a R L5 TFESI at the same time. I have had some success with these. I agree that it works maybe half the time. if it was my back, I would first opt for a cystectomy vs. fusion in the absence of any clear spondylolisthesis.
 
SSdoc33 said:
if you try to only aspirate the cyst, you A. might not get any fluid, and B. might have the fluid simple just recur.

I haven't had the best luck pulling fluid out, but sometimes I get some. my approach to this would be to try to aspirate, then inject steroid intra-articular while im there. however, in doing so, you are not really treating the patients primary complain (leg pain), so I would also add in a R L5 TFESI at the same time. I have had some success with these. I agree that it works maybe half the time. if it was my back, I would first opt for a cystectomy vs. fusion in the absence of any clear spondylolisthesis.
Click to expand...


They always re-cur. However, if you have repeated aspirations (3-4 times), you can beat up the cyst and get longer term results. Also using a larger gauge needle (sometimes tough to get into the joint) can help. Lastly, I'm sure most have run into cysts at L4/L5 by starting at L5/S1 and doing a midline injection directed laterally. You think you have a wet tap until realizing it is cystic fluid.
 
hawkeye2009 said:
They always re-cur. However, if you have repeated aspirations (3-4 times), you can beat up the cyst and get longer term results. Also using a larger gauge needle (sometimes tough to get into the joint) can help. Lastly, I'm sure most have run into cysts at L4/L5 by starting at L5/S1 and doing a midline injection directed laterally. You think you have a wet tap until realizing it is cystic fluid.
Click to expand...

r u able to get 18 G into facet joint? i can barely fit in 22 usually.. also how do you code for the aspiration?
 
ive used 64493 but looking online I think I'm wrong. I think 62268 is correct.

you could use 10060, but that is skin cyst.

62268 seems most appropriate.

and at least, best in terms of reimbursement. looking at 2 separate carriers, (this is a broad non-inclusive statement...) 62268 would pay more - roughly $360 vs. $150 for 10060 and $230 for 64493...
 
TIVAndy said:
r u able to get 18 G into facet joint? i can barely fit in 22 usually.. also how do you code for the aspiration?
Click to expand...
You can usually fit that bad boy into the inferior recess. I code same as a facet for injection. Although I have done some facet cyst ruptures where I combine it with a transforminal (with lido) at the affected level first before I rupture
 
You can put a needle in the superior pole and one in the inferior pole and lavage with saline to get the juice out. NO idea if this works better and my n is very small. I do not do many of them. I do agree the juice is VERY viscous. Also, aspirate with a 1cc BD syringe; they are very strong and generate more sucking pressure than any socialist pain doc on this forum.
 
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Ligament said:
You can put a needle in the superior pole and one in the inferior pole and lavage with saline to get the juice out. NO idea if this works better and my n is very small. I do not do many of them. I do agree the juice is VERY viscus. Also, aspirate with a 1cc BD syringe; they are very strong and generate more sucking pressure than any socialist pain doc on this forum.
Click to expand...

i disagree with this post. you have no idea how hard i can suck
 
My understanding was that it isn't just the material within the cyst per se, but also the lining of the cyst that's the issue? Have y'all ever RFed a cyst?
 
lobelsteve said:
Apparently, at shoulders rf. I taught this for Neurotherm 5 yrs ago. Super easy
Click to expand...

Touche, gods gift to pain medicine.

No interest, doesnt pay well, not sure it will work anyway. Patient wanted me to ask around.
 
Ligament said:
one needle in superior pole and another in inferior pole and bipolar RF lesion?
Click to expand...

That is what I was thinking or one needle with the active tip along the long axis of the cyst, with appropriate caution where needed due to the epidural/neuroforaminal proximity of some cysts. In the image shown for example, it would be difficult to envision a lesion that doesn't lead to heat damage of the nearby nerve roots, although CSF is a decent heat sink.
 
TIVAndy said:
r u able to get 18 G into facet joint? i can barely fit in 22 usually.. also how do you code for the aspiration?
Click to expand...

Not always, but usually you can. Often people with a spondylolisthesis will actually have a wider joint.

Given that the other option is not only a decompression, but a fusion as well, it is certainly worth the effort.
 
we arent operating on every baker's cyst.....make as many holes as you can in the cyst, steroid, physical therapy. Have done plenty and it is better than 50/50
 
Last one of these was debating to try to drain. He already had a surgery referral so I said it'd be worth seeing them to weigh your options and discuss after. Next thing I know he had surgery with airway issue, extended ICU stay, PNA, etc... several months later recovered with pain mildly improved.
 
TIVAndy said:
L45 right synovial cyst. Aspirate? If so how do u do it?
Click to expand...

Perform a Right L4 and L5 TFESI.

Then, stick a 25-gauge Quincke into the joint. Squirt 2 cc of contrast then follow with PF NS using a 3 cc leur lock syringe under live fluoro.....watch for the contrast spread and feel for the 'pop.'

Finally, 'poke' the facet multiple times for fenestration.
TFESI.png
Lysis.png
 
NOSfan said:
Perform a Right L4 and L5 TFESI.

Then, stick a 25-gauge Quincke into the joint. Squirt 2 cc of contrast then follow with PF NS using a 3 cc leur lock syringe under live fluoro.....watch for the contrast spread and feel for the 'pop.'

Finally, 'poke' the facet multiple times for fenestration.View attachment 275903View attachment 275902
Click to expand...
fascinating. so rather than aspirating you just burst it. must be real tight with 25g. also noticed you target you TFESI in the inferior NF.
 
TIVAndy said:
fascinating. so rather than aspirating you just burst it. must be real tight with 25g. also noticed you target you TFESI in the inferior NF.
Click to expand...

Aspiration has an almost 100% re-occurrence rate. Lysis re-occurrence, anecdotally, has about a 30% re-occurrence rate.

Typically, one should find the joint amiable for 25-gauge.

Yes, the nerve at the exiting foramen and below are blocked. Otherwise the patient may experience a good bit of discomfort.
 
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