1. Andrew D. Schweitzer, MD 1 Jaspal R. Singh, MD 2 J. Levi Chazen, MD 1 Depts of Radiology 1 and Rehabilitation Medicine 2 New York Presbyterian Hospital Weill Cornell Medical Center New York, NY PERCUTANEOUS CT-GUIDED FACET JOINT SYNOVIAL CYST RUPTURE: SUCCESS WITH REFRACTORY CASES AND TECHNICAL CONSIDERATIONS

2. DISCLOSURES ADS has no disclosures JRS is a consultant for Kimberly Clark and Physicians Pharmaceutical Solutions JLC has no disclosures

3. INTRODUCTION Lumbar facet joint synovial cysts are an important cause of low back pain Occur at degenerated facet joints Percutaneous rupture of synovial cysts has been correlated with avoiding subsequent surgery in half of treated patients 1 In a series of 101 patients, in 19% of cases, cyst rupture could not be confirmed fluoroscopically 1 1. Martha et al, The Spine Journal, 2009.

4. PURPOSE We describe the technique for CT-guided lumbar facet synovial cyst rupture with emphasis on technical considerations for success in refractory cases

5. PATIENTS 11 consecutive patients with symptomatic lumbar facet synovial cysts referred for percutaneous rupture 7 male, 4 female 5 were directly referred 6 had prior fluoroscopy-guided cyst drainage and/or rupture None of the 6 had any relief with fluoroscopy-guided intervention In one, facet joint could not be accessed under fluoroscopic guidance due to extensive osteophyte formation Above: unsuccessful fluoroscopy-guided aspiration Below: inability to access joint under fluoroscopy guidance due to extensive osteophytes

6. PATIENTS Location distribution of facet joint synovial cysts L3-L4: 2 patients L4-L5: 6 patients L5-S1: 3 patients

7. TECHNIQUE Place localization grid on skin over lumbar spine Plan optimal approach to access joint associated with synovial cyst Mark skin When planning approach, care is taken to avoid osteophytes blocking entry into facet joint See the following adjacent 2.5 mm images A B C  Image A chosen to avoid osteophyte and BB placed to confirm optimal approach

8. TECHNIQUE Perform sterile preparation Administer moderate sedation (the process of cyst rupture usually exacerbates pain significantly) Anesthetize skin with 1% buffered lidocaine Under serial CT guidance, advance 22 gauge spinal needle into degenerated facet joint associated with the cyst Use bevel of spinal needle to guide direction and to get past osteophytes into joint capsule Bevel directed laterally to get past osteophyte

9. TECHNIQUE Once within joint (cartilage has a more compliant “feel” than periosteum), inject a small amount of contrast into the joint Contrast should fill the cyst (it did in all of our cases) Fill cyst with increasing pressure using normal saline until loss of resistance is achieved (“indirect rupture”) Intra-articular contrast fills synovial cyst

10. TECHNIQUE After CT confirmation of successful rupture, inject steroid and local anesthetic mixture into joint Some of steroid/anesthetic mixture will enter into epidural space via new defect in synovial cyst In some cases, steroid/anesthetic mixture was administered directly into epidural space and/or transforaminally along exiting nerve root Epidural contrast confirms rupture

11. TECHNIQUE – INTERLAMINAR (“DIRECT”) APPROACH In several cases, including one where fluoroscopic guidance failed to rupture the cyst (65 y/o F), a second spinal needle was advanced via an interlaminar approach and was used to fenestrate the cyst (“direct rupture”) Both indirect and direct rupture were achieved with CT guidance Access of facet jointContrast injectionInterlaminar fenestration 

12. RESULTS 10 of 11 patients underwent successful synovial cyst rupture confirmed by CT showing loss of cyst contour and dilute contrast in surrounding epidural space One patient’s cyst could not be indirectly ruptured due to limited access to facet joint from iliac crest Interlaminar fenestration and cyst aspiration was performed in this case and patient’s symptoms improved

13. RESULTS Clinical follow-up was available for 9 of 11 patients Follow-up times ranged from 1.5 to 17 mo Among the 9 patients with clinical follow-up: 7 (78 %) experienced significant relief or resolution of pain One of these patients had recurrent pain 5 mo after cyst rupture 2 (22%) did not experience significant symptom relief 5 of 6 patients with no relief after fluoroscopic procedures had symptom relief after the CT-guided rupture

14. RESULTS – CYST RESOLUTION One patient with cyst rupture and interlaminar fenestration had follow- up MRI showing resolution of synovial cyst Most patients did not have follow-up MRI as symptoms improved  1.5 mo later

15. SUMMARY OF TECHNICAL TIPS FOR SUCCESS IN REFRACTORY CASES CT provides much better anatomic detail than fluoroscopy for: Delineating barriers to joint access such as osteophytes Confirmation of intra-articular location Confirmation of cyst rupture Use bevel to direct needle into joint capsule Use moderate sedation so that patient can tolerate distention of cyst that occurs prior to rupture Significant hydrostatic pressure can be required to achieve rupture A smaller syringe filled with saline may be helpful Interlaminar fenestration (“direct rupture”) can be performed after cyst is filled with contrast Particularly in cases where cyst rupture cannot be achieved

16. CONCLUSION In cases refractory to fluoroscopy-guided drainage/rupture: CT-guided lumbar facet synovial cyst rupture can be successful both technically and in terms of symptom relief

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