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Hi Molly and welcome :wave:

You are lucky and hit "gold" today.....I found this for you. Enjoy. :D I hope it helps you out in your decision on what needs to be done. Listen to your body, it will tell you what it needs. I think you can have a surgeon go in with a needle and remove the cyst but they say removal of cyst and fusion. hmmm... don't do that until (like wbaker says) you've done every other conservative treatment.

On the injections. I have seen such unhappy customers when it comes to those darn things. I do believe the problem with steroid epidural injections is that they are not done correctly. Both times on my injections, they did it like I was having a baby. I was sitting up and they put the needle in the thoracic region telling me it would work it's way down. [img][/img] OK, so I was naive at the time...they were doctors and I took their word--what did I know? was MY BODY after all... I knew it wasn't right the first time. My 2nd primary care doctor for this injury (my chiro) told me how they are supposed to go.

Anyway... too many failed injection therapy(s) is all I have seen on these boards. The first one gives relief up to a week, and the 2nd can start back spasms and sciatic pain. It did for me, and it seems for many others here too. But trend seems to be ... it is HOW the procedure was done. If done correctly... I have seen relief for months for those lucky few. However, in the end.... more aggressive treatments seem to bring the relief to most here. More aggressive, NOT more invasive treatments....BIG difference! ;)

Here is the article....

Pain from a synovial cyst in the lumbar spine
A synovial cyst is a relatively uncommon cause of spinal stenosis in the lumbar spine (lower back). It is a benign condition, and the symptoms and level of pain or discomfort may remain stable for many years.
A synovial cyst is a fluid-filled sac that develops as a result of degeneration in the spine. Because a synovial cyst develops from degeneration it is not often seen in patients younger than 45 and is most common in patients older than 65 years old.
The fluid-filled sac creates pressure inside the spinal canal and this in turn can give a patient all the symptoms of spinal stenosis. Spinal stenosis is a condition that occurs when degeneration in the facet joints causes pressure on the nerves as they exit the spine (see Figure 1).
Causes of a synovial cyst
Synovial cysts develop as a result of degeneration in the facet joint in the lumbar spine. It is typically a process that only happens in the lumbar spine, and it almost always develops at the L4-L5 level (rarely at L3-L4).
The pain probably comes from the venous blood around the nerves not being able to drain and this leads to pain and irritation of the nerves. Sitting down allows the blood to drain and relieves the pressure.
The facet joint of the lumbar spine is just like any other joint in the body (such as the hips or knees):
∑ It is composed of two opposing surfaces that are covered with cartilage
∑ The cartilage is the smooth, very slippery surface that allows a joint to move
∑ A thick capsule surrounds the entire joint, and within this is the synovium
∑ The synovium is a thin film of tissue that generates fluid within the joint that helps further lubricate the joint
∑ As the joint degenerates it can produce more fluid.
As it degenerates, the cartilage looses its smooth, frictionless surface and the extra fluid can help by adding extra lubrication.
It is thought that the synovial cyst develops in response this extra fluid. The fluid escapes out of the joint capsule through a one-way ball valve type hole, but stays within a synovial covering. This functionally pumps fluid one way into the fluid sac. The fluid, however, is not under a lot of pressure, as neurological deficits or cauda equina syndrome (loss of bowel and bladder control) is extremely uncommon even for very large cysts.
Symptoms and diagnosis of a synovial cyst
A synovial cyst is most commonly found in patients who are older than 65 years old. This type of cyst is benign (non-malignant) and the symptoms may remain stable and not progress for long periods of time.
Spinal stenosis from a synovial cyst can cause pain in the lower back that travels down to the legs.
Typically, there is minimal or no pain if the patient is seated, because in the seated position the spinal canal opens up and there is not as much pressure on the spinal nerves. When standing up straight or walking, however, the spinal canal closes down and creates more pressure on the nerves.
The synovial cyst is best visualized on a MRI scan of the spine. It shows up as a hyperintense lesion that has the same signal intensity as water.
X-rays, including flexion/extension motion x-rays, are also important to rule out any spinal instability. It is important to check for spinal instability because the joint is undergoing degeneration and there is often an accompanying degenerative spondylolisthesis (vertebral body that slips forward), which indicates that the joint is unstable and incompetent.
It is very important to identify any instability before surgery for the synovial cyst, because if the instability is not addressed at the time of surgery, often a revision surgery will be required at a later date.
Treatment options for synovial cysts
There are three main treatment choices for synovial cysts in the lumbar spine:
∑ Observation and activity modifications
∑ Injections
∑ Surgery
Observation and activity modification
If the synovial cyst is not creating a lot of dysfunction or pain in the patientís daily life, no medical treatments may be necessary. Since the pain is usually caused by certain positions, changing positions is a reasonable way to deal with the pain as long as a patient can still function adequately.
For exercise, it may be preferable for the patient to try stationary biking instead of walking, because in the seated position the patient should be fairly comfortable.
Injections for synovial cysts
There are two types of injections that can be helpful to alleviate the pain: facet injections or epidural injections.
∑ Facet injection. The facet joint can be entered with a small needle and occasionally the cyst can be drained by aspirating it through the joint. Afterwards, the joint is then injected with steroid to decrease inflammation.
∑ Epidural steroid injection. The more common injection technique is to inject around the cyst with steroid in the epidural space (an epidural injection). It does not reduce the cyst but can reduce the pain.

Although the mechanism of the pain reduction is not well understood it is thought to be due to a reduction in inflammation. It works well about 50% of the time and not so well 50% of the time, and unfortunately, the pain relief tends to be temporary.
Still, even though either injection is not all that reliable in the long run it is reasonable to try since the only other alternative is surgery. Generally, no more than three injections within a year are recommended.
Surgery for synovial cysts
Surgery for synovial cysts can be either a decompression alone or a decompression with a spine fusion.
If there is no associated instability with the cyst (e.g. no degenerative spondylolisthesis as seen on flexion/extension x-rays) then a microdecompression of the nerve root with removal of the cyst is reasonable. Basically, this is the same approach as would be used for a microdiscectomy, and is a minimally invasive surgery with a relatively quick recovery. (See also Microdisectomy).
However, since the joint pathology (which caused the original synovial cyst) is still present the cyst can re-form at a later date.
Decompression with fusion
The most reliable treatment method for a synovial cyst is to remove the cyst and then fuse the joint. Fusing the joint stops all the motion at that level, and without any motion the cyst should not regenerate.
This is the most reliable treatment, but it is also the most to go through. It changes the biomechanics in the back because one of the joints will no longer function. The L4-L5 level has the most motion, and fusing it creates more stress on the other non-fused levels of the lower spine. Also, the surgery is more to go through since this is an open procedure, and it takes about six to nine months or more for the fusion to heal. (See also Decompression and Fusion).
When deciding which treatment to pursue, patients need to base their decisions on three primary factors:
∑ The amount of pain they are having
∑ The length of time of their symptoms
∑ The amount of dysfunction it causes in their life.
If the pain is relatively acute and tolerable, it is probably reasonable for the patient to modify his or her activities. If the pain is severe, then an injection might be more reasonable. If the pain is severe and has been going on for a while (e.g. years) or if the injections have not worked then surgery is more reasonable.
For younger more active patients, a trial of a microdecompression is probably a reasonable consideration (as long as there is no gross instability of the joints), with the knowledge that a fusion may be necessary in the future. For more elderly or less active patients, it may be more reasonable to jump to the definitive procedure of a fusion, since the stress transfer the fusion creates to the other joints is not as great in these patients and only one procedure would then be necessary.
Synovial cysts are an uncommon cause of lumbar stenosis, and the treatment is largely the same as for spinal stenosis with the exception that there is often accompanying spinal instability at the same joint that needs to be considered if surgery becomes necessary.
Surgery is only necessary for those patients that would like to do more activity with less pain. The surgery is very effective for treatment of this condition. The most successful surgery tends to be a decompression with a fusion (approximately a 90-95% success rate should be expected, which means a significant reduction in pain, not necessarily pain free), but this is also the treatment that is the hardest to go through and changes the biomechanics of the spine. It should be considered for people with moderate to severe activity limitations that have joint instability along with the cyst, and who have failed conservative treatments such as injections.
By: Stephen H. Hochschuler, MD
September 9, 2002


Oct 2000: Repetitive Stress Injury-Inverted Hernia
Feb 2001: MRI. Shows only slight bulge at L4-L5
Dec 2001: Discogram/CT scan shows Inverted Hernia at L5-S1. L4-L5 & L5-S1 ruptured in all 4 quadrants. Unable to walk.
Feb 2002: IDET, Nucleoplasty, Intra-Discal Injections
Sept 2002: Rated in the top 10% for successful patients. Retraining for new career.

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