Procedure-Based Nonsurgical Management of Lumbar Zygapophyseal Joint Cyst Induced Radicular Pain

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1 1767 ORIGINAL ARTICLE Procedure-Based Nonsurgical Management of Lumbar Zygapophyseal Joint Cyst Induced Radicular Pain Steven R. Sabers, MD, Scott R. Ross, DO, Brian E. Grogg, MD, Tamara D. Lauder, MD ABSTRACT. Sabers SR, Ross SR, Grogg BE, Lauder TD. Procedure-based nonsurgical management of lumbar zygapophyseal joint cyst induced radicular pain. Arch Phys Med Rehabil 2005;86: Objective: To evaluate the success of fluoroscopically guided, contrast-enhanced lumbar zygapophyseal joint (Zjoint) aspiration and steroid injection combined with transforaminal epidural steroid injections (TFESIs) for the treatment of lumbar Z-joint cyst induced radicular pain. Design: Retrospective case series with independent follow-up. Setting: Institutional, referral center. Participants: Twenty-three patients referred to a single provider for procedure-based management of radicular pain believed secondary to lumbar Z-joint cyst. Inclusion criteria consisted of lumbar radicular pain that was consistent with the level and side of the Z-joint cyst as a causative lesion. Interventions: Eighteen patients were treated with a fluoroscopically guided, contrast-enhanced Z-joint aspiration and steroid injection at the level of the causative cyst coupled with a fluoroscopically guided, contrast-enhanced TFESI over the level of the presumably irritated spinal nerve. Main Outcome Measures: Patient satisfaction, and whether or not surgery was performed. Results: Fifty percent of patients treated with the procedure had significant long-term benefit and avoided surgical intervention at an average follow-up of 9.9 months. Conclusions: Fluoroscopically guided, contrast-enhanced spinal procedures as part of an aggressive nonsurgical treatment program are a safe and effective alternative to surgical intervention for lumbar Z-joint cyst induced radicular pain. Key Words: Cysts; Facet joint; Injections, epidural; Radiculopathy; Rehabilitation; Steroids; Zygapophyseal joint by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation COMPRESSION OF SPINAL NERVES by intraspinal cysts has been recognized as a cause of lumbar radicular pain. 1-5 The cysts can be of multiple types: extradural arachnoid cysts, Tarlov cysts, dermoid cysts, neurofibroma with cystic degeneration, and synovial or ganglion cysts. 3 Intraspinal cysts (juxta-facet cysts, juxta-articular cysts) in the immediate vicinity of the lumbar From the Departments of Physical Medicine and Rehabilitation (Sabers, Ross, Grogg, Lauder), Anesthesiology (Ross), and Neurology (Lauder), Mayo Medical School, Rochester, MN. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit on the author(s) or on any organization with which the author(s) is/are associated. Reprint requests to Brian E. Grogg, MD, Mayo Clinic, 200 First St SW, Rochester, MN 55905, grogg.brian@mayo.edu /05/ $30.00/0 doi: /j.apmr zygapophyseal joints (Z-joints) are generally accepted as representing either true synovial cysts or ganglion cysts. 3,4 The cysts are most common at the L4-5 level (50% 75% of reported cases), but are also seen at other lumbar and cervical levels. 4,6-9 While initially thought to be a rare entity, advanced imaging techniques have increased the general awareness and appreciation of this abnormality. 9,10 The diagnosis of Z-joint induced radicular pain is based on correlation of an appropriate history with imaging studies. The patient usually presents with a history of slowly progressive or intermittent radicular pain, commonly neuroclaudicatory in nature. Coupled with imaging documentation of a cyst at a level that correlates with the patient s symptoms, one can be relatively certain of the diagnosis. Imaging studies that document the presence of a cyst include myelography, Z-joint arthrography, computed tomography, and magnetic resonance imaging (MRI). 4,6,7,9-11 MRI is believed to be the best imaging modality for determining the presence of cysts and for differentiating them from other abnormalities. 6,7 Gadolinium administration provides additional helpful information with which to make a definitive diagnosis. 6 Z-joint cysts can be found in asymptomatic people. They are known to resolve occasionally without specific treatment. Radicular symptoms, however, can be disabling and commonly warrant therapeutic intervention. Several treatments for Z-joint cyst induced radiculopathy have been discussed in the literature, ranging from observation and bracing to oral steroids, Z-joint injection, epidural steroid injections, cyst puncture, and surgical excision with or without partial facetectomy Most of the literature is anecdotal; some of the more recent studies are larger but retrospective. Slipman et al 20 recently did a retrospective review of 14 patients with Z-joint cyst induced radicular pain treated with various spinal procedures. The procedures included transforaminal epidural steroid injection (TFESI) alone (8 patients) and intra-articular Z-joint steroid injection with TFESI (6 patients, of whom 5 also received attempted cyst puncture). The majority (71%) of cysts occurred at the L4-5 level and 29% of patients had a good or excellent outcome at an average of 1.4 years posttreatment. Half of the patients subsequently had surgery. There was no significant morbidity reported. An earlier report by Parlier-Cuau et al 19 retrospectively evaluated 28 patients with Z-joint cyst induced radiculopathy treated with fluoroscopically guided intra-articular Z-joint steroid injection. After 1 month, 67% of patients were classified as excellent or good, while only 33% were classified as excellent or good after 6 months. These 33% maintained their classification at an average follow-up of 26 months. Fifty percent of the original 28 patients underwent surgery to relieve persisting radicular symptoms. In the largest review to date of surgical intervention for Z-joint cyst induced radiculopathy, Lyons et al 18 retrospectively reviewed the experience at the Mayo Clinic between 1976 and One hundred ninety-four patients were surgically treated for symptomatic Z-joint cyst induced symptoms

2 1768 LUMBAR ZYGAPOPHYSEAL JOINT CYST RADICULAR PAIN, Sabers with cyst excision and varying degrees of laminectomy and facetectomy. Concomitant spinal fusion was performed on 18 patients. Ninety-one percent of patients reported good pain relief. We retrospectively evaluated 23 patients with Z-joint cyst induced radicular pain. Eighteen patients were treated with a standardized fluoroscopically guided spinal procedure coupled with physical therapy (PT), and are the focus of this study. METHODS All patients referred with a diagnosis of Z-joint cyst induced radiculopathy from May 1999 through December 2000 were eligible. Inclusion criteria were lower-extremity radicular pain with MRI evidence of a potentially causative Z-joint cyst. We defined radicular pain as pain radiating from the lumbar region into the lower extremity. The L4 spinal nerve distribution was defined as pain radiating through the anterolateral thigh and medial leg. An L5 distribution was defined as posterolateral thigh and lateral leg with or without dorsal foot. An S1 distribution was defined as posterior thigh and calf with or without lateral foot. If the pain included more than 1 distribution or did not radiate distal enough for differentiation, it was listed as other. In addition to formal neuroradiology review, the first author reviewed all MRI scans. Electromyographic evidence of a radiculopathy or selective spinal nerve block response was not required for patients to be included in the study. Exclusion criteria included absolute contraindication to injection (eg, infection or uncontrolled diabetes) or prior surgery at the index level. Superimposed spinal pathology did not exclude participation. All patients had limiting pain despite participation in an appropriate PT program that was generally combined with a regularly scheduled nonsteroidal anti-inflammatory medication. In the absence of a contraindication to spinal injections, procedure-based pain management was offered as an adjunct to a nonsurgical treatment program of dynamic lumbar stabilization and spine protection principles. All procedures were performed by the same physician (SRS). All patients underwent the same treatment, that is, Z-joint aspiration and steroid injection coupled with a TFESI. Procedure Description Z-joint aspiration and injection. The patient was placed in the prone position on the procedure table. We used a slight ipsilateral oblique view to fluoroscopically identify the posterior aspect of the Z-joint (associated with the cyst). The skin entry point was anesthetized. A 22-gauge 3.5-in spinal needle was advanced under fluoroscopic guidance into the subcapsular region of the Z-joint. After negative aspiration, we injected 0.1 to 0.3mL of iopamidol (Isovue 200) under live fluoroscopic visualization to confirm subcapsular placement without vascular uptake. We then used a separate syringe to attempt aspiration from the Z-joint, with varying degrees of success. We then injected 0.5mL (20mg) of triamcinolone. No attempt was made to puncture the cyst. Epidural steroid injection. After the Z-joint portion of the procedure, we did a TFESI, which was performed using a lumbar or S1 transforaminal approach, depending on the level and location of the Z-joint cyst. Lumbar TFESI. An ipsilateral oblique view was used to identify fluoroscopically the pedicle of the desired level. The skin entry point was anesthetized. A 22- (or 25-) gauge 3.5-in (or 5.0-in) needle was advanced under fluoroscopic guidance to the anterosuperior aspect of the intervertebral foramen at approximately the 6 o clock position relative to the pedicle in the anteroposterior view. After negative aspiration, 1 to 2mL of iopamidol was injected under live fluoroscopic imaging to confirm flow along the appropriate spinal nerve medially into the epidural space without vascular or intrathecal flow. Then, 3.5mL of injectate (2mL preservative-free 1% lidocaine with 1.5mL triamcinolone) was injected slowly. S1 TFESI. Using a slightly ipsilateral oblique and cephalocaudad view, the anterior and posterior S1 foramina were superimposed. The skin entry point above the superolateral aspect of the posterior S1 foramen was anesthetized. A 22- (or 25-) gauge 3.5-in spinal needle was atraumatically introduced and advanced under fluoroscopic guidance to the anterior aspect of the sacral canal. After negative aspiration, 1 to 2mL of iopamidol was injected to confirm appropriate flow along the S1 spinal nerve proximally without vascular or intrathecal uptake. Then, 3.5mL of injectate (2mL preservative-free 1% lidocaine with 1.5mL triamcinolone) was injected slowly. Decisions to repeat the procedure were based solely on response to the initial procedure. If the patient derived no benefit or became pain-free, the procedure was not repeated. If there was partial benefit or good initial benefit followed by a return of limiting pain over the ensuing weeks or months, the patient was offered a repeat procedure. No patient received more than 4 procedures in a year s time. Lack of response or failure of long-term benefit resulted in surgical consultation. Patient charts were reviewed by independent physicians. Follow-up phone calls were made to determine long-term response rates (percentage of benefit and duration), satisfaction with treatment, and whether there had been any intervening injections or surgery. We assessed patient satisfaction using 2 scales (appendixes 1, 2) that were adapted from the Patient Satisfaction Index (PSI) as described by Slosar et al. 21 These were based on components of the North American Spine Society Lumbar Spine Outcome Questionnaire, 22 but have not been evaluated from a validity or reliability standpoint. RESULTS Over the 2-year period of study, 23 patients with radicular leg pain were identified as having Z-joint cysts that were thought to be contributing to their pain. The patients included 11 men and 12 women (average age, 64y; range, 28 81y), whose presenting features are listed in table 1. All patients had lower-extremity pain for an average of 10.5 months (range, 2wk 48mo). Twelve patients (52%) had low back pain in addition to lower-extremity pain. Neuroclaudication was experienced 52% of the time, paresthesias 44% of the time, and weakness 26% of the time. Z-joint cysts were found most commonly at the L4-5 level (65%), then at the L5-S1 (31%), and the L3-4 (4%). The presumed affected nerve root corresponding to the location of the cyst is summarized in table 2. Thirty-five percent of patients described pain that did not radiate distally enough to differentiate it into a specific radicular distribution. The distribution of weakness or paresthesias helped to differentiate spinal nerve distributions in some cases. Superimposed spinal pathology was present on MRI 70% of the time. Central spinal stenosis was the most common, being present 48% of the time. Five of the 23 described patients did not receive the studied intervention (Z-joint aspiration and steroid injection coupled with a TFESI). Four of the 5 opted for surgical intervention on presentation at our facility, and 1 chose not to undergo surgery or the intervention. Therefore, 18 patients received the intervention, with an average of 2 injections (range, 1 4) being given per subject. Nine of the 18 patients eventually underwent a surgical procedure after a trial of Z-joint aspiration and steroid injec-

3 LUMBAR ZYGAPOPHYSEAL JOINT CYST RADICULAR PAIN, Sabers 1769 Table 1: Presenting Features of the 23 Patients With Z-Joint Cysts Over a 2-Year Period Presenting Feature Frequency (%) Back pain Present 12 (52) Absent 11 (48) Lower-limb radicular pain L4 1 (4) L4-5 1 (4) L5 5 (22) S1 7 (31) Other* 8 (35) Presence of paresthesias None 13 (56) L4 0 (0) L5 5 (22) S1 2 (9) Other* 2 (9) Presence of weakness None 17 (74) L4 0 (0) L5 3 (13) S1 1 (4) Other (unable to determine due to old injury with weakness) 1 (4) Neuroclaudication None 11 (52) Present 12 (48) Cyst Side (left/right/bilateral) 10/12/1 Level L3-4 1 (4) L (65) L5-S1 7 (31) Superimposed pathology None 7 (31) Present Spinal stenosis 11 (48) Neural foraminal stenosis 7 (31) Herniated nucleus pulposus 3 (13) Spondylolisthesis 3 (13) Arachnoiditis 1 (4) Cauda equina compression from cyst 1 (4) High-intensity zone in disk 1 (4) Peripheral neuropathy 1 (4) Trochanteric bursitis 1 (4) * Pain or paresthesias did not radiate distally enough to differentiate into a specific radicular distribution. Each patient can have more than 1 superimposed pathology. tions. All 18 were available for telephone follow-up, with data being collected at an average of 9.1 months (range, mo) after their last injection. At follow-up, patients were asked about their satisfaction with their treatment of choice either injections or surgery. We recorded the characteristics, treatment response, and satisfaction of the 9 patients who were treated with Z-joint injections only and the 9 patients who received Z-joint injections and subsequently had a surgical procedure (table 3). All 4 patients who had surgery without receiving the studied procedure reported having 100% relief of their pain. At followup, the time postsurgery ranged from 6 to 30 months. The patient who declined both injections and surgery did well over time with little reported pain and no limitation, so there were no significant complications in any of the 23 patients. DISCUSSION The growing body of literature on Z-joint cyst induced radiculopathy has increased general awareness of an entity that was once thought to be rare. The study by Lyons et al 18 established that surgical treatment appears to be quite successful in reducing pain, with a low rate of serious complications. The studies by Parlier-Cuau 19 and Slipman 20 and colleagues raise the possibility that these patients could be managed nonsurgically, with good results in a certain percentage. This study demonstrates that 50% of patients treated with a standardized procedure (Z-joint aspiration and steroid injection and TFESI) as an adjunct to a conservative treatment program received significant benefit and can avoid surgery. This is a result similar to those of Parlier-Cuau 19 and Slipman. 20 The natural history of Z-joint cyst induced radiculopathy is not known; therefore, additional study is needed to determine if this intervention improves on the outcome expected without intervention. Also, the small study size of this and other studies 19,20 precludes determining the characteristics that may identify a subgroup of patients who would respond to procedurebased nonsurgical management. The treatment that we describe is theoretically dependent, in part, on a communication between the Z-joint and the adjacent cyst. If the Z-joint does not communicate with the cyst, placement of steroid into the Z-joint cannot be expected to affect the cyst. Injection of contrast into the Z-joint frequently partially opacified the cyst, although this phenomenon was not recorded with such regularity as to be reported or studied as a predictor of response. Attempts were made to minimize the amount of contrast injected into the Z-joint to prevent possible distension of the cyst. No attempt was made to puncture the cyst during the procedure. Fenestration of the cyst has been discussed as a means of decompressing the cyst. This option was not pursued because of the proximity of the treated cysts to the traversing neurologic structures. Given that the combined procedure was done on all patients, it is not possible to determine whether it was the combination (Z-joint aspiration and steroid injection and TFESI) or a single component that resulted in the therapeutic benefit. Both components of the procedure are safe and were tolerated without difficulty by our subjects. Table 2: Z-Cyst Location and Presumed Affected Nerve Roots Cyst Level Cyst Frequency n (%) Nerve Root Affected Frequency of Affected Root L3-4 1 (4) L4-5 1 L (65) L4 1 (large cyst, part of cauda equina syndrome) L5 6 L5-S1 2 S1 2 Other* 4 L5-S1 7 (31) L5-S1 1 S1 3 Other* 3 *Pain or paresthesias did not radiate distally enough to differentiate into a specific radicular distribution.

4 1770 LUMBAR ZYGAPOPHYSEAL JOINT CYST RADICULAR PAIN, Sabers Table 3: Characteristics, Treatment Response, and Satisfaction of the 18 Patients Receiving a Z-Joint Cyst Aspiration/Steroid Injection With TFESI Variable Injection Only, No Surgery (n 9) Injection Trial First, Resulted in Surgery (n 9) Age (y) Mean (range) 65 (47 80) 65 (42 81) Patients with superimposed central stenosis or foraminal stenosis at involved site, n (%) 4 (44) 6 (67) No. of injections Mean (range) 2 (1 4) 2 (2 4) Relief after last injection Average % relief %, n (%) 8 patients (89) 5 patients (55) 50%, n (%) 1 patient (11) 4 patients (45) Duration of relief after last injection (mo) Mean (range) 9.9 (3 21) 2.3 (0 8) Injection outcome, n (%) PSI 1 4 (44) NA PSI 2 5 (56) NA PSI 3 0 NA PSI 4 0 NA Surgical outcome, n (%) PSI 1 NA 6 (67) PSI 2 NA 1 (11) PSI 3 NA 1 (11) PSI 4 NA 1 (11) Abbreviation: NA, not available. This study presents a different approach to the treatment of Z-joint cyst induced radiculopathy, with its strength stemming from the standardized and reproducible treatment applied, and the completeness of follow-up. The study is limited by the following factors: (1) sample size was small; (2) it was a noncontrolled, retrospective case series with the inherent weaknesses of such a study; and (3) patient satisfaction was the sole outcome measure. Additionally, one might argue that with superimposed spinal pathology, the patient s symptoms may not be related to the Z-joint cyst, but rather, in reality, the cysts occur in the presence of additional pathology. The sample size was too small to conclude that superimposed pathology affected the outcome, because 4 of 9 who avoided surgery had superimposed pathology, compared with 6 of 9 in the surgery group. CONCLUSIONS While patients with Z-joint cyst induced radicular pain do well with surgery, aggressive nonoperative management with adjunctive injections appear to offer a less invasive treatment option that obviates the need for surgery in 50% of treated patients. Further studies are needed to define the natural history, and to determine whether presenting characteristics can identify the subgroup of patients who may respond to nonsurgical management. APPENDIX 1: PATIENT SATISFACTION INDEX FOR SURGICAL INTERVENTION Please choose one of the following: (1) Surgery met my expectations. (2) I did not improve as much as I had hoped but I would undergo the same surgery for the same outcome. (3) Surgery helped but I would not undergo the same treatment for the same outcome. (4) I am the same or worse than before the surgery. From Slosar et al. 21 Reprinted with permission. APPENDIX 2: PATIENT SATISFACTION INDEX FOR NONSURGICAL INTERVENTION Please choose one of the following: (1) Treatment met my expectations. (2) I did not improve as much as I had hoped but I would undergo the same treatment for the same outcome. (3) Treatment helped but I would not undergo the same treatment for the same outcome. (4) I am the same or worse than before the treatment. Adapted from Slosar et al. 21 Reprinted with permission. References 1. Abdullah A, Chambers R, Daut D. Lumbar nerve root compression by synovial cysts of the ligamentum flavum. Report of four cases. J Neurosurg 1984;60: Baum J, Hanley E. Intraspinal synovial cyst simulating spinal stenosis. A case report. Spine 1986;11: Kao C, Uihlein A, Bickel W, Soule E. Lumbar intraspinal extradural ganglion cyst. J Neurosurg 1968;29: Knox A, Fon G. The appearances of lumbar intraspinal synovial cysts. Clin Radiol 1991;44: Schreiber F, Nielsen A. Lumbar spinal extradural cysts. Am J Surg 1950;80: Yuh W, Drew J, Weinstein J, et al. Intraspinal synovial cysts. Magnetic resonance evaluation. Spine 1990;16: Jackson DE Jr, Atlas SW, Mani JR, Norman D. Intraspinal synovial cysts: MR imaging. Radiology 1989;170: Hemminghytt S, Daniels D, Williams A, Haughton V. Intraspinal synovial cysts: natural history and diagnosis by CT. Radiology 1982;145:375-6.

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