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Worsening Right Greater Than Left Leg Paresthesia

History

A pleasant 64-year-old male presented to our office with complaints of right greater than left leg pain and numbness/tingling. He states that when he walks his symptoms are worse, but always has some degree of right buttock/ hip/ leg discomfort.

For weeks prior to his appointment, he has noticed increasing right leg pain (draws a line down the anterior lateral aspect of his leg past the thigh into the lateral calf) after doing his morning work out and walk. He denies any single particular event that started this problem.

He has tried NSAIDs and acetaminophen without much help. His symptoms have progressively worsened despite trying to stay active. He denies any recent injury or illness.

His medical history includes:

  • GERD: Prevacid 15 mg daily
  • Appendectomy (childhood)
  • Penicillin causes rash
  • Acetylsalicylic acid 81 mg daily for cardiac protection
  • Multivitamin daily

Examination

He is a well-developed, well-nourished Caucasian male in no acute distress. He is alert and orientated x3. Appears to have some degree of discomfort, and is found sitting on the left side of his buttock.

Skin: Intact without rash or lesion. No obvious areas of atrophy left lower extremity.

Musculoskeletal:

  • Right lower extremity is normal without deficit.
  • Left lower extremity 5/5 plantar flexion, 4+/5 dorsi-flexion, 5/5 quadriceps, 5/5 hip flexors.
  • No pain with range of motion of the hips or knees bilaterally.
  • Negative Tinel’s over the fibular head and medial ankle bilaterally.

Neurological:

  • Deep tendon reflexes 2/4 bilateral Achilles and Patella.
  • Sensation decreased on the anterior lateral thigh, calf, and dorsal aspect of the foot.
  • Slight decrease in strength noted with dorsiflexion right only.
  • Vibration sensation intact.

Vascular:

  • +2 pulses: dorsal pedis and posterior tibialis.
  • Calf soft and non-tender.

Pretreatment Imaging

Lumbar radiographs are shown below (Fig. 1, Fig. 2).

preoperative lateral lumbar x-ray

Figure 1

preoperative anteroposterior lumbar x-ray

Figure 2

In light of the patient’s specific findings, as well as motor weakness, we sent him for T2 weighted MRIs of the lumbar spine without gadolinium. Both the sagittal (Fig. 3) and axial (Fig. 4) reveal a soft, fluid-filled tissue structure at L4-L5.

preoperative T2 weighted MRI, sagittal lumbar spine, synovial cyst at L4-L5

Figure 3

preoperative T2 weighted MRI, axial lumbar spine, synovial cyst at L4-L5

Figure 4

Prior Treatment

Considering the synovial/facet cyst was symptomatic, we performed a fluoroscopy-guided cyst aspiration and facet injection. However, symptom improvement was temporary.

Rationale: A symptomatic synovial cyst can be treated interventionally with an intra-articular facet injection. Attempts to aspirate or inject through the facet joint may risk cyst rupture. However, statistically, this treatment is likely to help about 1/3 of the cases.1,2

Diagnosis

Benign synovial cyst

Suggest Treatment

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Selected Treatment

The patient agreed to undergo surgical decompression and removal of the synovial cyst. The blue arrow (Fig. 5) represents the cyst being separated from the dura via Penfield dissector.

intraoperative picture shows a synovial cyst separated from the dura via Penfield dissector

Outcome

The postoperative outcome was excellent.

 

References

1. Allen TL, Tatli Y, Lutz G. Fluoroscopic percutaneous lumbar zygapophyseal joint cyst rupture: A clinical outcome study. Spine Journal 2009; 9(5):387-395.

2. Martha JF, Swaim B, Wang DA, et a. Outcome of percutaneous rupture of lumbar synovial cysts: A case series of 101 patients. Spine Journal 2009; 9(11): 899-904.

 

Case Discusson

This is an interesting case of synovial cyst causing spinal stenosis and radicular symptoms in a 64-year-old male. Synovial cyst is a relatively common condition, and it may or may not cause symptoms depending on its size and location. In this patient, the location of the cyst at L4-L5 and L5 radiculopathy due to lateral recess stenosis did correlate well.

It should be noted that in many patients, synovial cyst is associated with fluid in the facet joints (as shown on T2 weighted axial MRI in this patient), which is sometimes associated with hypermobility or instability such as degenerative spondylolisthesis. Preoperative flexion-extension radiographs can assess the presence of potential instability.

The initial treatment includes NSAIDs, an exercise program, physical therapy, epidural steroid injection/s as in any other patients with symptomatic stenosis and radiculopathy. If these treatments fail to relieve the patient's symptoms, cyst aspiration can be attempted. It should be explained to the patient that cyst aspiration does not give predictable relief, and it again depends on the size and location of the cyst and the skill level of the physician. If all nonoperative treatments fail to relieve the patient's symptoms, surgery is considered as in this patient. Microscopic decompression and cyst removal is the mainstay of surgical treatment, but in patients with instability, such as spondylolisthesis, decompression and fusion should be considered.

The authors of this case report should be congratulated for their great care of the patient and illustrating the case well with great images and concise case summary.

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