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INTV3

INTV3. PERCUTANEOUS TREATMENT OF FACET JOINT SYNOVIAL CYST DEVELOPPED IN INTRA DUCTAL S. KOUKI ,W. AMORRI, M. LANDOULSI , S. BOUGUERRA , Y.AROUS , H. BOUJEMAA , N. BEN ABDALLAH Military Hospital of Tunis. objective:.

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INTV3

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  1. INTV3 PERCUTANEOUS TREATMENT OF FACET JOINT SYNOVIAL CYST DEVELOPPED IN INTRA DUCTALS. KOUKI ,W. AMORRI, M. LANDOULSI , S. BOUGUERRA , Y.AROUS , H. BOUJEMAA , N. BEN ABDALLAHMilitaryHospital of Tunis

  2. objective: To study the results of facet joint intraarticular steroid injections in a patient with symptomatic lumbar facet joint synovial cysts developped in intra ductal.

  3. Introduction Facet joint synovial cyst is an Expansion of the joint capsule and synovium into the spinal canal By definition it communicates with the adjacent joint The average age when it occured is 60 years It‘s a rare cause of radicular pain Clinical signs are unilateral nerve root or radicular claudication bilateral lower Is easily diagnosed by new medical imaging modalities Image-guided percutaneous steroid injections presents often an effective alternative to surgery

  4. Case report The patient is a 59-years woman Without individual medical history outside of an overweight complaining of low back sciatica type left L5, associated with a left cruralgia, refractory to medical treatment

  5. exploration by imaging Radiographs of the lumbosacral spine : a degenerative spinal disco, more advanced at L4-L5 segment, associated with a degenerative Low-grade isthmic spondylolisthesis. The CT scan : an intra ductal synovial cyst, next to the left posterior facet joint L4-L5, measuring 2cm long axis, which causes a conflict with the L5 root at its emergence, and L4 ipsilateral root.

  6. therapeutic management A well conducted medical treatment with rest did not lead to a favorable outcome. A surgical treatment proposed refused by the patient She was entrusted to us for a percutaneous treatment

  7. percutaneoustreatmentunder scanner 1/ installation of the patient, and tracking: The patient ispronepositioned. The procedureisperformed in the interventional scanner room Weconducted a helixcentered on the lumbarspine to identify the leftfacet joint L4-L5. The CT features of the facet joint synovial cystis a Roundedpicture of homogeneousfluiddensity intra ductalwith hyper dense fibrousshell.

  8. 2/ PROGRESS OF interventionalgesture: After local anesthesia and surgical skin disinfection Joint aspiration and injection of 1 ml of iodinatedcontrast in facet joint, opacifiedboth the joint and the cyst intra canal, objectifying the communication betweenthem. fluid content wasaspirated Thenwe have inject a bulb of a prolonged action corticosteroid (Altim®) combinedwith 1cc of Xylocaine® under pressure until rupture of the cyst, as evidenced by a loss of strength and opacification of the epiduralspace on the acquisition of control.

  9. Fig 1: Axial CT scan of L4 in bone window showing the average load of intra ductal cyst with mass effect on the dural sheath

  10. Fig 2: Axial CT scan of L4 in bone window showing the complete filling of the cyst with early extra vasation of contrast

  11. Fig 3 : Axial CT scan of L4 in bone window showing the complete filling of the cyst with clear extravasation of contrast material by cracking cystic

  12. Fig 4 : Sagittal reconstructions showing opacification and signs of intra ductal cyst

  13. 3/ result and evolution: Immediately, the patient describes an exaggeration of pain followed by a relief This islikely due to the effect of Xylocaine® and the reduction of pressure in the cystafterits cracks. This cracking is a cure of thiscyst, itisevidenced by the extravasation of contrastoutside the cyst. The decline in twoyearswasmarked by a favorable clinical course, especiallysince the patient has lostweight and alwayswore a lumbar corset.

  14. Discussion 1/ Pathophysiology (1)(4): • It’s a manifestation of progressive posterior facet arthrosis : during outbreaks of effusion, the normal joint recess become diverticula, synovial recesseswouldenlarge with progressive fibrous thickening and inflammation of their walls.

  15. By definition, intraspinal synovial cystscommunicatewith the adjacent facet joint. • They are characterized by the presence of synovial lining and clear or xanthochromic content • Opposed to ganglion cyststhat do not communicatewith the facet joint, have a fibrouswall, and containgelatinousmyxoidmaterial

  16. Both entities often are described as juxta-articular or synovial cysts. • Synovial cysts would be a manifestation of facet degeneration: • The L4-5 level is most commonly involved because it corresponds to the level of maximal mechanical stress and motion.

  17. 2/imagingstudy (1)(2)(3)(4): • CT-arthrographycanidentified synovial cystscommunicatingwith the adjacent facet joint withmarkeddegeneration and a spondylolisthesis • Diagnosisat non contrast CT isbased on the detection of a cystic structure next to a degeneratedfacet joint, such as in our case. The cystmaysometimesextendinto the lateralrecess. • The presence of bonyerosions or remodelingsuggest the possibility of Tarlovcyst, arachnoidcyst, or cystic nerve sheathtumor, but these changes have also been described in patients with synovial cysts. • Facet joint injection demonstrating communication of the facet joint with the cystispathognomonic for the presence of a synovial cyst.

  18. In the MRI signal is variable: * HypoT1, hyperT2: type fluid* HyperT1, hypoT2: type haem* HypoT1, hypoT2: gas, calcification, hemosiderin* HyperT1, hyperT2: blood, fat • The differentialdiagnosisincludes ganglion cysts, posterior longitudinal ligament cysts, and ligamentumflavumcysts; however, thesecysts do not communicatewith the facet joint and are not linedwithepithelium. • The cystsoften are of fluiddensity, theyrarelycontainbloodproducts, calcium, or gas (gas in the facet joint). • The presence of increasedwalldensityimprovesdiagnosis and narrows the differentialdiagnosis.

  19. 3/ Type of therapeutic management : • At the time of imaging, our patient hadalreadyundergonemedical management, combiningrest and NSAIDs, with support device. • The detection of a symptomatic synovial cystmayrequirepercutaneoussteroid injection or surgery. • Surgery, performedinitially, allowsresection of the cyst and treatment of otherpotentialabnormalities: diskherniation, spinal stenosis, narrowing of the lateralrecess, spondylolisthesis.

  20. Long-termfollow-up for surgical excision of symptomaticjuxtafacetcystswithout spinal fusion revealed excellent to good results in 92% of the patients, with a satisfaction rate of 80%, in the study of El Shazly AA.(3). • Common surgicalrisksinclude spinal instability, dural tear, neurologicinjury, epiduralhemorrhage and hematoma, seroma, and cystrecurrence • Whilesurgeryis the gold standard for the treatment for symptomaticfacet joint cysts, conservative options includebedrest, physicaltherapy, acupuncture, oral analgesics and anti-inflammatories, and percutaneous injection and aspiration

  21. Arthrography-infiltration is a good alternative in case of cons-indication to surgery or refusal • Percutaneous interventions are usuallyindicated in elderly or high-risk patients (1)(2)(3).  • Under image-guided assistance, transforaminal or interlaminarepiduralcorticosteroid and anesthetic injection canbeperformedpre-emptively or concurrently to reduce the risk of procedure-related pain (1)(2)(3).

  22. In long-termfollow, C Parlier-Cuau(6), in hisstudy of 30 Patients, found thatOne-third had long-lasting acceptable benefit, and Bureau NJ(5) objective thatamonghis 12 patients, 75% experienced complete resolution of their radiculopathy and 50% of patients, long-term follow-up imaging demonstrated complete regression of the lumbar facet synovial cyst. • Althoughresults are variable and the significantfailure rate, thisgesturecanusuallypass a course of acute pain. In most cases, the improvement made possible the resumption of professionalactivity or at least allows to establish the normal posture (1)(4).

  23. In our case, CT-guidedpercutaneous infiltration, has enabled us to confirm the diagnosis, and treat the cyst, whichallowed an immediate relief of pain withoutrecurrenceafter a decline of threeyears. • J.F.Martha et al.(1) Have a large series of 101 injections with rupture of the cystshowed an immediateanalgesiceffect in 80% of cases and stressedthat the infiltration allowed to postponesurgery in half of cases and follow up to 3 yearsshowed an analgesiceffect the same on boththerapeutic. • Complications of facet infiltrations in the lumbarspine are rare, sharedwithcorticosteroid infiltrations to other sites such as risks of infection or local hematoma(1)(4).

  24. In the study by Allen et al.(2) Another alternative of treatmentis the underfluoroscopicspercutaneouscontrastdistention, and rupture of the lumbar Z-joint cyst, itcanexpect about a 70% chance of a successful long-termoutcome. Recurrence rate ishigh (37.5%) and usuallyoccurs in the first 3 months. However, patients still have a 45% chance of a successfuloutcomeafter the second cyst rupture. • The advantage of CT over fluoroscopyis the direct treatment of synovial cysts as well as ganglion, posterior longitudinal ligament, and ligamentumflavumcyststhat do not communicatewith the facet joint, thereforeallowing direct, safe, and reliablepuncture of the cystwithout dural violation

  25. conclusion Arthrography of the facet joint, supplemented by intra-articular injection of corticosteroids, is the last step of medical management, it’s simple to perform, useful to confirm the diagnosis, may provides complete or significant regression of radicular symptoms, and may be an alternative to surgical excision of the cyst.

  26. References • Martha JF, SwaimB,WangDA,KimDH, Hill J, Bode R, et al. Outcome of percutaneous rupture of lumbar synovial cysts: a case series of 101 patients. Spine J 2009;9:899-904. • Allen TL, Tatli Y, Lutz GE. Fluoroscopicpercutaneouslumbarzygapophyseal joint cyst rupture: a clinicaloutcomestudy. Spine J 2009;9:387-95. • El Shazly AA, Khattab MF. Surgical excision of a Juxtafacet cyst in the lumbar spine: A report of thirteen cases with long-term follow up. Asian J Neurosurg 2011;6:78-82 • Anthony Chang. Percutaneous CT-Guided Treatment of Lumbar Facet Joint Synovial Cysts. HSS Journal 5:2, 165-168. • Bureau NJ, Kaplan PA, Dussault RG. LumbarFacet Joint Synovial Cyst: PercutaneousTreatmentwithSteroid Injections and Distention-Clinical and Imaging Follow-up in 12 Patients. Radiology 2001;221:179-185. • C Parlier-Cuau; M Wybier; R Nizard; P Champsaur; P Le Hir; J D Laredo. Symptomaticlumbarfacet joint synovial cysts: clinicalassessment of facet joint steroid injection after 1 and 6 months and long-termfollow-up in 30 patients. Radiology 1999;210(2):509-13.

  27. THANX

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