This is a 50 y old woman with a 10 y history of intermittent low back pain, whom we saw for the first time a little over a month ago. A year ago she started to have pain irradiating along the L5 segment on the left side at the same time as her back pain became constantly present. The irradiation into the left lower extremity was described as electrical and was clearly position dependent. She also described periods when her lumbar spine became suddenly blocked, forcing her to spend a couple of days in bed till the blockade resolved. She consulted her GP who told her to loose weight and sent her for physiotherapy and osteopathy, none of which was of any benefit. After almost a year of suffering she decided to see another physician who immediately sent her for an MRI, the result of which is shown on the subsequent to images.
A large cyst emerging from the L4/5 facet joint on the left side, displacing the contents of the dural sac to the right.
On the sagittal projection on can observe the cyst and also an antelisthesis of L4 on L5 with a segmental instability L4/5, as later documented by functional images. A moderate spinal stenosis was also observed just below the L4/5 disc. The cyst and the instability in the same segment probably contributed to produce a dynamic spinal stenosis of a considerable degree.
After a thorough discussion with our spine surgeons it was decided to attempt a puncture of the facet joint cyst despite its difficult location anterior to the lamina of L5.
On this a-p film one observes the facet joint filled with contrast and to the right at its base the cyst behind the lamina.
A needle could be inserted from a cranial direction into the cyst, from which we subsequently drained 1.5 cc of sanguinolent fluid. Twenty mg of depomedone were injected into the facet joint in an attempt to reduce a presumed inflammatory reaction likely to be responsible for the cyst formation.
The patient was seen back one month after the procedure and reported complete disappearance of her sciatica and return to her old pattern of back pain from several years back, starting a couple of days after the procedure. She was informed that there is a risk of return of symptoms since the cyst might fill up again. She was told this might require another puncture.
We have a large experience taking care of patients with facet joint cysts. These are some interesting statistics collected prospectively over the past 9 years:
Number of patients treated: 68
Females/Males: 62/6
Regions: lumbar/thoracic/cervical: 64/1/3
Localization in the lumbar spine:
Levels: L4/5: 61 of 64
Side (L4/5): left/right: 54/7
Hence, the typcial patient with a facet joint cyst is a female who presents with left sided L5 sciatica!
Number of puncutures of lumbar cysts (n=62) till disappearance of sciatica:
1 puncture: 9
2 punctures: 32
3 punctures: 15
4 punctures: 6
Two patients of 64 had to be sent for surgical excision since they did not respond favourably despite four punctures.
Conclusion: Over 95% of patients with lumbar facet joint cysts can be managed sucessfully without surgery!
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