Facet cysts

[Pain Applicant1]

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Has anyone ever drained these cysts? A colleague of mine who often does facet injections told me that he is sometimes able to aspirate clear fluid in relatively high amounts from facet joint when cysts are noted.

I now have a patient with stenosis mainly due to a facet cyst. Has anyone ever aspirated this and gotten a good response?

 

[Jcm800]

Has anyone ever drained these cysts? A colleague of mine who often does facet injections told me that he is sometimes able to aspirate clear fluid in relatively high amounts from facet joint when cysts are noted.

I now have a patient with stenosis mainly due to a facet cyst. Has anyone ever aspirated this and gotten a good response?

Yes, numerous times. I have gotten a cc or more out. Often this works very well.

 

[lobelsteve]

A facet is just a tiny knee. Very easy to aspirate 1-2cc fluid and this is very rewarding in providing up to 2 whole weeks of relief. Then the fluid re-accumulates and back to square one. This is a surgical problem if recess compromise leads to radic or if the canal is stenotic with claudication.

 

[101N]

A facet is just a tiny knee. Very easy to aspirate 1-2cc fluid and this is very rewarding in providing up to 2 whole weeks of relief. Then the fluid re-accumulates and back to square one. This is a surgical problem if recess compromise leads to radic or if the canal is stenotic with claudication.

1+.

And furthermore, jello and water look the same on a T2 MRI. Good luck aspirating jello. Often times the cysts are covered with a dark calcified cap that wont rupture. Better to puncture the capsule three or four times and then CAREFULLY try to rupture it with omnipaque. Do the patient a favor and block the nerve that runs past the cyst prior to attempted rupture.

SOMETIMES CAPSULES ARE EXPANSILE SO YOU GOTTA THINK TWICE ABOUT RUPTURE. IT COULD JUST FILL LIKE A WATER BALOON AND CAUSE A CAUDA EQUINA.


1. Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients. Martha JF, Swaim B, Wang DA, Kim DH, Hill J, Bode R, Schwartz CE.
Spine J. 2009 Nov;9(11):899-904. Epub 2009 Aug 6.


2. Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: a clinical outcome study. Allen TL, Tatli Y, Lutz GE. Spine J. 2009 May;9(5):387-95. Epub 2008 Sep 21.

3. Percutaneous puncture of zygapophysial joint synovial cyst with fluoroscopic guidance.
Melfi RS, Aprill CN. Pain Med. 2005 Mar-Apr;6(2):122-8.

 

[Pain Applicant1]

I did block the nerve already, unfortunately very short term relief only although my TFESIs are performed with dex. I'd rather avoid the series of three injections but maybe I'll give it another go with a particulate or something. It's a low level but I'm paranoid about particulates these days. Thanks for the articles.

 

[Jcm800]

A facet is just a tiny knee. Very easy to aspirate 1-2cc fluid and this is very rewarding in providing up to 2 whole weeks of relief. Then the fluid re-accumulates and back to square one. This is a surgical problem if recess compromise leads to radic or if the canal is stenotic with claudication.

Untrue. I have patients that have had aspirations and "popping" without significant return in symptoms, and I have a few that have similar problems recurr but get sustained relief for over 6 months. Some obviously do not improve and require surgery, but I wouldn't say all

 

[Doctodd]

break them up by poking it 6 times on the procedure day.....8 is too many and 4 is not enough. I have accumulated a few patients and they have done well. Modify activity so they dont come back.

 

[lobelsteve]

Untrue. I have patients that have had aspirations and "popping" without significant return in symptoms, and I have a few that have similar problems recurr but get sustained relief for over 6 months. Some obviously do not improve and require surgery, but I wouldn't say all

You should publish as the current literature reflects otherwise. It could change treatment for many folks and help them avoid surgery.

 

[Jcm800]

You should publish as the current literature reflects otherwise. It could change treatment for many folks and help them avoid surgery.

i actually did think about it a few years ago, that and my mini experiment that has proven contrast prevents blood from clotting, and, and despite in blood patches we believe we dont "clot" the hole, blood patches fail with contrast use...but i am lazy...

 

[SSdoc33]

try to aspirate, and when that fails, inject some cortisone into the z-joint. then, do a TFESI at that level. may help, may not. whats his butt at VCU, dipalma wrote a recent article about this

 

[PMR 4 MSK]

If the cyst is causing radiculopathy, I do TFESI at that level. If that does not help, I send them for surgery.

If they have facet-mediated pain, I poke a needle in the facet joint. If anything comes out, I discard it then inject steroid.

We know synovial fluid can irritate the crap ouuta soft tissues when it gets out - ala ruptured baker's cyst. So I would not want to deliberately pop a cyst in the epidural space, or take the chance that my needle goes intrathecal while attempting to rupture the cyst.

 

[jsaul]

try to aspirate, and when that fails, inject some cortisone into the z-joint. then, do a TFESI at that level. may help, may not. whats his butt at VCU, dipalma wrote a recent article about this

this is what I do. Half the time these patients gets symptoms coming back anywhere from 3 weeks to 6 months. I repeat and if symptoms come back again then I refer to surgery. I have seen people get surgery and it comes back as well

 

[geauxg8rs]

saw someone about 18 months ago with big facet cyst, unable to get fluid back. Injected some steroid into joint and it helped for 11 months. repeated and still getting relief >6months.
So far it is saving her from surgery, will see how it goes.

 

[TX PAIN DOC]

If the cyst is causing radiculopathy, I do TFESI at that level. If that does not help, I send them for surgery.

I do the same. Have had surgeon send some patients back to me for facet injection/aspiration. It helps to have surgical opinion before attempting, especially if it is a very large cyst.

 

[bedrock]

this is what I do. Half the time these patients gets symptoms coming back anywhere from 3 weeks to 6 months. I repeat and if symptoms come back again then I refer to surgery. I have seen people get surgery and it comes back as well

The key point is that these cysts sometimes come back after surgery. Surgery isn't perfect and is much more invasive.

I figure my success rate is 30% with these, but I save a third of them from surgery, and so they're worth doing.

 

[101N]

The key point is that these cysts sometimes come back after surgery. Surgery isn't perfect and is much more invasive.

I figure my success rate is 30% with these, but I save a third of them from surgery, and so they're worth doing.

Why do you say this? Show me the published data showing recurrence of facet cysts after decompression. Decompression usually means a medial facetectomy and removal of the flavum. They don't come back.

 

[SIIMS]

I would say (I'm young btw) out of about 10 facet cysts I tried to aspirate despite good needle placement (confirmed of course with good IA spread of small amount of contrast) I have successfully aspirated fluid that was straw colored, not clear, about 3 times.

I just had a case (last week) with a rather distraught female who had "chronic" back pain but was seeing me for "disabling" leg pain acute onset 3 weeks, new MRI showed a very small facet cyst from anterior superior facet at L4-5. I told her I would try and help with her leg pain as that is why she came to see me.

I did an aspiration and got back about 1cc of very straw colored fluid (did not inject steroid) and then followed with an L5 TFESI

Just saw back in clinic, she looked angry and I asked if the injection helped, she abruptly told me NO!

I asked where her pain was and she told me "My leg pain has completely resolved but I still have my chronic back pain"

The people we deal with on a daily basis.....I question if my motor will stay gassed and lubed for the next 30 years

 

[bedrock]

Why do you say this? Show me the published data showing recurrence of facet cysts after decompression. Decompression usually means a medial facetectomy and removal of the flavum. They don't come back.

Any minimally invasive procedure that takes 15 minutes and has a 30% chance of sparing someone from surgery is indicated in my book.

 

[PinchandBurn]

only seen a few of these in training. Haven tdont one in practice yet.

Seems pretty benign.

Someone above shared a case report of uncontrolled bleeding etc. In practice any of you all see this? Especially if "aspiration" is done instead of 'blowing up the facet cyst'.

It seems like a 25G needle into a cyst and aspirating could have minimal sequalae..

 

[ghost dog]

I would say (I'm young btw) out of about 10 facet cysts I tried to aspirate despite good needle placement (confirmed of course with good IA spread of small amount of contrast) I have successfully aspirated fluid that was straw colored, not clear, about 3 times.

I just had a case (last week) with a rather distraught female who had "chronic" back pain but was seeing me for "disabling" leg pain acute onset 3 weeks, new MRI showed a very small facet cyst from anterior superior facet at L4-5. I told her I would try and help with her leg pain as that is why she came to see me.

I did an aspiration and got back about 1cc of very straw colored fluid (did not inject steroid) and then followed with an L5 TFESI

Just saw back in clinic, she looked angry and I asked if the injection helped, she abruptly told me NO!

I asked where her pain was and she told me "My leg pain has completely resolved but I still have my chronic back pain"

The people we deal with on a daily basis.....I question if my motor will stay gassed and lubed for the next 30 years

Hx of sexual abuse ?

Daily opioid use ?

Crap job ?

I would be EXTREMELY surprised if all of these are negative on history.

 

[Pacman27]

Any new updates or thought

I have a guy with an L4/5 Synovial Cyst compressing the L5 nerve root. I believe I drained it and injected the cyst with steroid. I also did a L4/5 TFESI. He was pain free for 10 days and then his pain returned.
I want to repeat again to see if we can get longer relief

Any other thoughts or suggestions

Thanks

 

[freddydpt]

CT guided needle aspiration followed by injection of a small amt of steroid. Works like a charm. No guess work involved to find the cyst. There are single needle and dual needle techniques.

 

[lonelobo]

Who on here does CT guided injections?

 

[willabeast]

i do CT guided neurolytic celiac plexus blocks when pushed.
BTW check a flexion extension L spine, see if patient is unstable. sometimes instability generates these cysts.

 

[SSdoc33]

Who on here does CT guided injections?

physical therapists turned radiologists, turned pain docs. duh

 

[lonelobo]

physical therapists turned radiologists, turned pain docs. duh

ahhh...Bach

 

[freddydpt]

I do CT guided pudendal injections and if I ever get a celiac block referral, I'll be using CT. If I come across a kypho that has very poor imaging on fluoro then I would consider it under CT guidance. Otherwise, I do 99% fluoro with an occasional US guided injection for fun.

 

[joshmir]

BUMP from earlier thread


Have done a few under ct guidance with ir at kaiser, saved some from spine surgery, but half or less. I make sure they are seen by spine surgery and consent to surgery first before trying, as you can for sure make these bigger

Do your adjacent tfesi prior to going after the cyst

Use a big needle in the cyst

If you are worried, doing them under ct gives you an instant assessment of if the cauda equina are squished or not

 

[Taus]

BUMP from earlier thread


Have done a few under ct guidance with ir at kaiser, saved some from spine surgery, but half or less. I make sure they are seen by spine surgery and consent to surgery first before trying, as you can for sure make these bigger

Do your adjacent tfesi prior to going after the cyst

Use a big needle in the cyst

If you are worried, doing them under ct gives you an instant assessment of if the cauda equina are squished or not

My approach is that I'm willing to try it once (facet aspiration + tfesi at same time). If works prolonged, great. If not- see surgeon. Expectations clearly expressed to patient.

 

[NJPAIN]

Any suggestions from the radiologists and non-radiologists among us regarding doing CT guided injections in general in PP? I can't get a radiologist interested in helping. Is there a way to motivate them? Is it feasible to do this myself with an experienced tech if they will allow?

 

[freddydpt]

What kind of procedures have you asked a radiologist to perform? I'm shocked they'd say no if you spoke to them directly. Talking to their office staff is a completely different story. The motivation is... "I'll send you my referrals for imaging." It's definitely feasible to do it with an experienced tech, but not for the first 2 or 3. After that, CT guided anything is so easy, you'll think of fluoro as the dark ages.

 

[hyperalgesia]

What kind of procedures have you asked a radiologist to perform? I'm shocked they'd say no if you spoke to them directly. Talking to their office staff is a completely different story. The motivation is... "I'll send you my referrals for imaging." It's definitely feasible to do it with an experienced tech, but not for the first 2 or 3. After that, CT guided anything is so easy, you'll think of fluoro as the dark ages.

Aren't you worried about the exposure? That seems like a ton of radiation...

 

[freddydpt]

Aren't you worried about the exposure? That seems like a ton of radiation...

Use a low dose flouro setting. This is not a ton of exposure. Don't do it on a pregnant woman. You are not doing a full body scan... just a level at the affected facet. When you expose for a CT guided fluoro technique you get four slices... not 500+ for a chest or abdomen.

 

[NJPAIN]

What kind of procedures have you asked a radiologist to perform? I'm shocked they'd say no if you spoke to them directly. Talking to their office staff is a completely different story. The motivation is... "I'll send you my referrals for imaging." It's definitely feasible to do it with an experienced tech, but not for the first 2 or 3. After that, CT guided anything is so easy, you'll think of fluoro as the dark ages.

Anything from a facet cyst aspiration to high thoracic TFESI to celiac plexus block. When I was in academics I had difficulty also. Typically only the most junior radiologist would do it and only if they did not have to touch the needle.

 

[freddydpt]

Anything from a facet cyst aspiration to high thoracic TFESI to celiac plexus block. When I was in academics I had difficulty also. Typically only the most junior radiologist would do it and only if they did not have to touch the needle.

I'm shocked. Where I trained, radiologists jumped on those procedures. I sometimes refer for CT guided procedures where I am because I don't have nursing staff access at the CT. The radiologists at the local hospital are always willing to help out.