Spinal cord cysts are often a result of degenerative changes in the spine or repeated minor trauma to the joint surfaces. These issues can cause a build-up of joint fluid and subsequent leakage, leading to the development of synovial cysts, which sometimes may present with severe symptoms indicating appropriate treatment. These cysts are frequently located near the joint surfaces and are particularly prevalent in the most mobile regions of the lumbar spine, such as at the L4–L5 level [3,4,5,6,7,8,9,10,11,12]. In the patient’s medical history, she experienced intermittent lumbar pain attributed to external factors, which aligns with the degenerative etiology of these cysts.
Synovial cysts are consistently located posterolateral to the thecal sac and can cause central or lateral spinal stenosis. Symptoms may include radiculopathy, back pain, sensory deficit, motor deficit, neurogenic claudication, and cauda equine syndrome. These cysts can appear at any level in the spinal column, including the C1–C2 level, but 92% of cases occur in the lumbar spine. The cervical and thoracic spines are less frequently affected, with rates of 6.3% and 1.6%, respectively [12].
The available treatment options for these spinal cysts include interventional treatments, such as surgical procedures with or without spinal instrumental fusion, or aspiration of the cyst along with steroid injections. Noninterventional treatments, such as pain management, physical therapy, and lumbar bracing, may also be considered. Surgical intervention with cyst removal to relieve pressure on the spine is considered the most common procedure for treating these symptomatic cysts in medical literature, as it has shown lower recurrence rates than any other approaches [10, 12]. The type of surgical procedure, whether it involves cyst removal or decompression with or without fusion, remains the best and in most cases the primary treatment for any symptomatic lumbar synovial cyst [13, 14].
The spontaneous resolution of these cysts is very rare in the medical literature, with only 26 cases recorded. Adding our case brings the total number recorded to 27 to date. Chiarella et al. [11] collected data on the spontaneous resolution of spinal cysts, which they referred to as “ganglion cysts.” They suggested noninvasive treatment for at least 6 months including anti-inflammatory drugs and light unloading exercises to control pain and reduce intra-cystic fluid, rest, and lumbar bracing. But they did not mention any specific indication for conservative treatment, and most of the reviewed cases did not mention severe symptoms.
Considering the pathological mechanism of these cysts, as well as the absence of alternative causes for the patient’s pain in the clinical and radiological examinations, a conservative treatment plan was implemented. This involved the administration of painkillers and physical therapy over a period of 3 months. Following this initial treatment, the patient reported a reduction in pain from 10 out of 10 to 7 out of 10 on the pain scale, prompting an extension of the conservative treatment. After 10 months from the onset of symptoms, the patient reported intermittent pain at an intensity of 1 out of 10 on the pain scale. Subsequent MRI scans after 12 months demonstrated a 90% reduction in the size of the cyst, with decreased signal intensity at both T1 and T2. This case illustrates that physical therapy and long rest, which alleviated external pressures on joint surfaces and relieved spinal pressure, facilitated the gradual reabsorption and reduction in cyst size over time.
Lumber bracing is a controversial issue. While lumbar spine stabilizers may offer short-term benefits, they may also lead to muscle weakness in this area, potentially resulting in increased pain and subsequent complications.
Noninvasive treatment methods may hold significant promise for the future, with the potential to reduce the need for surgical intervention, thereby decreasing financial burdens and mitigating potential post-operative complications. However, this case, along with the other 26 cases of spontaneous resolution in the medical literature, does not provide sufficient evidence to consider it as the optimal method for managing spinal synovial cysts. Hopefully, the number of these cases will increase in the future so that a large study on this treatment method can be done.
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