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      Microdecompression for lumbar synovial cysts: an independent assessment of long term outcomes

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          Abstract

          Background

          Outcomes of surgical intervention for lumbar synovial cysts have been evaluated in the short and intermediate term. Concerns regarding cyst recurrence, the development of late instability at the involved level, and instability/stenosis at adjacent levels (when concomitant) fusion is performed suggest that long term follow-up is needed. This study aims to fill that void.

          Methods

          Forty-six patients operated by a single surgeon not involved in the study were followed up long term at an average of 9.7 years (range 5 to 22 years) post-operatively. All patients underwent decompression (+/- concomitant arthrodesis in the presence of associated degenerative spondylolisthesis) using the operative microscope for magnification/illumination. Outcomes were assessed using a customized questionnaire evaluating: relief of pain/claudicant symptoms, numbness/parasthesias, and weakness; as well as late onset low back pain, new radicular symptoms, need for additional surgery, and patient satisfaction. Outcomes in patients with or without fusion were compared as well.

          Results

          87% of patients noted resolution of their pre-operative pain, numbness, and weakness. 28% of patients developed late onset low back pain. 17% developed late onset radicular symptoms in a new nerve root distribution. 15% required subsequent additional surgery. 89% of patients were satisfied with the surgical outcome. No differences were found for any outcome measure between patients undergoing concomitant fusion and those undergoing decompression alone using the two-sample t-test.

          Conclusion

          This study provides outcome data at an average of nearly ten years post-operative. This information should allow surgeons to provide realistic expectations for their patients regarding outcomes and should enhance the informed consent and surgical decision-making process.

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          Most cited references27

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          Synovial cyst of spinal facet. Case report.

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            Surgical evaluation and management of lumbar synovial cysts: the Mayo Clinic experience.

            The authors report a retrospective analysis of 194 patients surgically treated at their institutions for symptomatic lumbar synovial cysts from January 1974 to January 1996. Patient characteristics including age, sex, symptoms, signs, and preoperative neuroimaging studies were reviewed. Surgical procedures, complications, results, and pathological findings were correlated with preoperative assessment. One hundred ninety-four patients were surgically treated for symptomatic lumbar synovial cysts. Eighty percent were diagnosed and treated between 1987 and 1996. There were 100 men and 94 women with an average age of 66 years (range 28-94 years). The most common symptoms were painful radiculopathy (85%) and neurogenic single or multiroot claudication (44%). However, sensory loss (43%) and motor weakness (27%) were also presenting symptoms. Eleven percent of patients had undergone previous lumbar surgery prior to being referred to the Mayo Clinic. Preoperative neurological examination demonstrated motor weakness (40%), sensory loss (45%), reflex changes (57%), and variants of cauda equina syndrome (13%). In 19% of patients, normal neurological status was demonstrated. There was equal left/right-sided laterality, and eight patients presented with bilateral synovial cysts. The most commonly affected level was L4-5 (64%). All patients underwent laminectomy and resection of the cyst. Concomitant fusion was performed in 18 patients in whom clinical evidence of instability had been observed. However, subsequent fusion was required in only four patients who developed symptomatic spondylolisthesis. Surgery-related complications included cerebrospinal fluid leak (three patients), discitis (one patient), epidural hematoma (one patient), seroma (one patient), and deep vein thrombosis (one patient). One patient died 3 days after surgery of cardiac dysrhythmia. Follow-up data obtained for at least 6 months postoperatively were available in 147 patients. Of these, 134 (91%) reported good relief of their pain and 82% experienced improvement in their motor deficits. Lumbar synovial cysts are a more common cause of lumbar radicular pain than previously thought. Surgical removal of the cyst is a safe and effective treatment for symptomatic relief in patients with lumbar synovial cysts. A concomitant fusion procedure may be performed in select cases. In this study, only a few patients developed symptomatic spinal instability requiring a second operation.
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              Microdecompression for lumbar spinal canal stenosis.

              A description of the technique for lumbar microdecompression and a prospective study of the outcomes. To describe and analyze a technique that affords an excellent decompression while minimizing damage to surrounding tissues. Commonly used techniques of lumbar decompression that include bilateral takedown of paraspinal musculature and aggressive bony resection can result in significant iatrogenic sequelae. A less destructive alternative is needed. Unilateral limited takedown of multifidus was undertaken, and ipsilateral decompression performed. The contralateral side then was addressed under the midline structures with microscopic visualization--thereby preserving the supra-/interspinous ligament complex and the contralateral musculature. Thirty consecutive patients undergoing the procedure were analyzed prospectively and after a follow-up period by independent observers using a modified validated functional outcome score and patient satisfaction measures. The technique affords an excellent decompression while minimizing destruction to tissues not directly involved in the pathologic process. Functional outcome scores doubled, and 87% of patients reported high satisfaction rates. Lumbar microdecompression is a minimally invasive technique that appears to provide excellent functional outcomes.
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                Author and article information

                Journal
                J Orthop Surg
                Journal of Orthopaedic Surgery and Research
                BioMed Central (London )
                1749-799X
                2007
                3 April 2007
                : 2
                : 5
                Affiliations
                [1 ]Division of Spinal Surgery The Methodist Hospital 6550 Fannin, Suite 2500 Houston, Texas 77030, USA
                [2 ]Department of Orthopaedics Dartmouth Hitchcock Medical Center Hanover, New Hampshire, USA
                [3 ]Penn State College of Medicine Hershey, Pennsylvania, USA
                Article
                1749-799X-2-5
                10.1186/1749-799X-2-5
                1853071
                17407585
                8e54a945-b6ef-46c2-bb82-e0b29f7116fb
                Copyright © 2007 Weiner et al; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 10 October 2006
                : 3 April 2007
                Categories
                Research Article

                Surgery
                Surgery

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