CHAPTER
75
574  IMAGING PAINFUL SPINE DISORDERS
SYNOVIAL CYST
Leo F. Czervionke, M.D.
CLINICAL PRESENTATION
The patient is a 58-year-old man with 4- to 6-week history of low
back pain, bilateral buttock pain, right lower extremity pain, numb-
ness of both feet, and difficulty walking. He has weakness in both
hip extensors, both hip abductors, and bilateral weakness of the
foot, right greater than left. Clinical findings are consistent with
multilevel radiculopathy and neurogenic claudication.
IMAGING PRESENTATION
Magnetic resonance (MR) imaging of the lumbar spine reveals a
large, lobulated synovial cyst arising from the anteromedial aspect
of the right L4-5 facet joint. The cyst encroaches upon the medial
aspect of the right L4-5 neural foramen and causes marked com-
pression and displacement of the thecal sac from right to left (Figs.
75-1 to 75-6).
DISCUSSION
Synovial cysts are synovial-lined cystic outpouchings that
communicate with the facet joint. Synovial cysts arise within
thickened, redundant synovium and facet capsular tissue. Synovial
cysts most commonly arise in the setting of facet joint osteo­
arthritis, as a result of chronic inflammation and facet degenera-
tion, but can arise secondary to acute or repeated trauma,
rheumatoid arthritis, or calcium pyrophosphate deposition disease
(CPPD).1,2
Most synovial cysts arise in the lower lumbar region, likely sec-
ondary to mechanical stress. These cysts contain gelatinous liquid
or synovial fluid. Hypermobility of the facet joint (facet sublux-
ation) is considered an important predisposing factor in synovial
cyst formation.3 There is an increased incidence of symptomatic
synovial cyst formation in patients with facet joint mobility or
spondylolisthesis.4 In the lumbar region, the greatest mobility is at
the L4-5 level, and the majority (80%) of lumbar synovial cysts
arise at the L4-5 level,3 more frequently occurring on the right side,
for reasons unknown. Tiny (less than 5 mm diameter) synovial
cystic outpouchings from the posterior-inferior facet joint capsule
are very common and usually asymptomatic. Synovial cysts that
project from the facet joint medially extend into the spinal canal
where they may cause significant compression of the lateral aspect
of the thecal sac (see Figs. 75-4 to 75-6). Most of these cysts are
less than 1.5 cm in diameter, but they can be larger. Some medial
projecting synovial cysts extend into the potential space between
the lamina and ligamentum flavum, displacing the ligamentum
flavum medially; these cysts communicate with the facet joint (Fig.
75-7). These cysts may be confused with nonsynovial-lined flavum
cysts that are attached to or embedded within the ligamentum
flavum that do not communicate with the facet joint (Figs. 75-8
and 75-9).1,5 Synovial cysts may also project from the anterosupe-
rior margin of the facet joint into the neural foramina (Figs. 75-10
and 75-11), where they may be confused for nerve sheath cysts
that also occur in the neural foramen.
Some cysts located adjacent to the facet joint are not lined by
synovium and do not communicate with the facet joint. The nature
of these nonsynovial-lined parafacetal cysts has been a subject of
debate in the literature.6,7 The terminology used to describe these
cysts varies, sometimes referred to as pseudocysts, juxtafacet cysts,
or ganglion cysts.1,5,8,9 Some believe that these cysts originated from
synovial cysts that became walled-off, no longer communicating
with the facet joint, but their precise etiology is unknown.10
Parafacetal pseudocysts usually contain tan or yellow gelatinous or
mucoid liquid. Hemosiderin, secondary to previous intracystic
hemorrhage, may be present in synovial cysts and parafacetal
pseudocysts.5
Patients with synovial cysts most commonly present with
chronic low back pain with or without radicular symptoms.
Synovial cysts can be associated with hypesthesia or dysesthesias.3
These symptoms can be secondary to mechanical compression of
adjacent structures or inflammation surrounding the cyst.11
Depending on their size and location, synovial cysts can contribute
to central canal stenosis or neural foraminal stenosis (see Figs. 75-8
to 75-11). Large synovial cysts can cause cauda equina syndrome
in the lumbar region or myelopathy if located in the thoracic or
cervical region. Synovial cysts occur less frequently in the thoracic
and cervical regions and in these locations tend to be relatively
small in size, but some thoracic synovial cysts can be quite large
and cause cord compression or radiculopathy.12
IMAGING FEATURES
There is nearly always degeneration of the adjacent facet joint in
patients with synovial cysts or juxtafacet (ganglion) cysts.13 Facet
joint degeneration is manifested on radiographs, computed tomog-
raphy (CT), or magnetic resonance (MR) imaging as articular
facet hypertrophy/overgrowth, commonly joint space narrowing
 CHAPTER 75: Synovial Cyst  575
 

Figure 75-1 ▶ Large Synovial Cyst, L4 Level. Right parasagittal T2-weighted Figure 75-2 ▶ Large Synovial Cyst, L4 Level. Same patient as in Figure 75-1.
MRI. A large fluid-filled synovial cyst (long arrow) is positioned above the L4-5 Corresponding right parasagittal T1-weighted MRI. The synovial cyst (long arrow) is
intervertebral disc level in the spinal canal posterior to the L4 vertebral body. Noted nearly isointense relative to intrathecal CSF. Noted is Schmorl’s node (short arrow) in
is a Schmorl’s node (short arrow) in L3 vertebral body inferiorly. L3 vertebral body inferiorly.

Figure 75-4 ▶ Large Synovial Cyst, L4 Level. Axial contrast-enhanced fat-

saturated T1-weighted MRI obtained just above L4-5 intervertebral disc level in same
patient as in Figures 75-1 to 75-3. The cyst margins (arrows) enhance with contrast,
but fluid in the cyst does not enhance. The cyst extends into the medial aspect of the
right L4-5 neural foramen (short arrow). A portion of the cyst is located in the spinal
canal (long arrow) where it displaces the thecal sac to the left.
Figure 75-3 ▶ Large Synovial Cyst, L4 Level. Same patient as in Figures 75-1
and 75-2. Right parasagittal contrast-enhanced fat-saturated T1-weighted MRI. The
synovial cyst contains fluid that is isointense relative to CSF. The margins of the cyst
enhances intensely (long arrow). The L3 Schmorl’s node (short arrow) enhances
intensely.
576  IMAGING PAINFUL SPINE DISORDERS

with subchondral cyst formation, intra-articular gas formation, and
occasionally facet joint widening secondary to facet joint effusions.
Synovial cysts are usually not visible on plain radiographs unless
calcified. Synovial cyst calcification, when it occurs, is usually
peripheral within the wall of the cyst and this is best shown with
CT (Fig. 75-12). More extensive calcification of the synovial cyst
may occur in cysts that arise in patients with CPPD.2 Synovial cysts
may not calcify at all. These are usually of nearly homogeneous
density and isodense or slightly hyperdense relative to the cerebro-
spinal fluid (CSF). The synovial cyst may contain gas if there is
gaseous degeneration of the adjacent facet joint, which is in com-
munication with the cyst.11
MR imaging is the modality of choice for detecting synovial
cysts and evaluating their relationship to adjacent structures.11,13,14
On MR images, most synovial cysts are T1 hypointense and T2
hyperintense centrally relative to CSF (see Figs. 75-1, 75-2, 75-5,
75-6, 75-8, and 75-10).11 If the cyst contains gas, blood, or inspis-
sated material, it is usually T2 hypointense.10 The cyst wall is T2
hypointense, composed of a fibrous capsule, often containing
hemosiderin.10 The cyst wall can be thin or thick (Fig. 75-13). The
wall of the cyst often enhances after IV contrast administration,
and this enhancement may be visible on enhanced CT or MR
images, but is more conspicuous on contrast enhanced MR (see
Figs. 75-3, 75-8, and 75-11). Occasionally, there is considerable
inflammatory tissue adjacent to the synovial cyst that enhances
with contrast (see Figs. 75-8 and 75-11). Occasionally, bilateral
synovial cysts occur at a given lumbar level, which can cause sig-
nificant side-to-side compression of the thecal sac and cauda
equina (Figs. 75-12 and 75-14).

DIFFERENTIAL DIAGNOSIS

1. Parafacetal pseudocyst: Also called a juxtafacet cyst or gan-

Figure 75-5 ▶ Large Synovial Cyst, L4 Level. Axial contrast-enhanced
T2-weighted MRI obtained just above L4-5 intervertebral disc level in same patient
as in Figure 75-4. The cyst (arrows) is lobulated and contains T2 hyperintense fluid.
The infrapedicular portion of the cyst (short arrow) extends into the medial aspect
of the right L4-5 neural foramen where it encroaches upon the right L4 nerve root
(L4). The portion of the cyst in the spinal canal (long allow) compresses and displaces
the thecal sac (T) toward the left.
glion cyst, these cysts are not lined by synovium and do not
communicate with the facet joint.1,5 Commonly, these cysts
arise adjacent to the ligamentum flavum (see Figs. 75-8, 75-9,
and 75-15). Juxtafacet cysts may also arise within the poste-
rior longitudinal ligament.1 It is usually not possible to differ-
entiate a parafacetal pseudocyst from a synovial cyst with MRI
or CT. If a parafacetal cyst opacifies when contrast is injected
into the adjacent facet joint, this is considered a synovial cyst.
Cysts that are located adjacent to the ligamentum flavum that
communicate with the joint space are considered synovial
cysts (see Fig. 75-7).
2. Epidural cyst: These may occur in the anterior or posterior
epidural space.1 The posteriorly located epidural cyst is usually
positioned between the leaves of the ligamentum flavum
within the posterior epidural fat pad.

A B
Figure 75-6 ▶ Large Synovial Cyst, L4 Level. Axial unenhanced T1-weighted image A and axial contrast-enhanced fat-saturated T1-weighted MR image B, obtained
at the L4-5 facet level, in same patient as in Figures 75-1 to 75-5. The synovial cyst (short arrow in A and B) obscures the fat in the medial aspect of the right L4-5
neural foramen. The facets (long arrows in image A) are hypertrophic secondary to osteoarthritis. The posterior facets and facet capsules (long arrows in B) enhance fol-
lowing IV contrast compatible with active inflammatory facet arthropathy. L4 = right L4 nerve root in lateral aspect of right L4-5 neural foramen.
 CHAPTER 75: Synovial Cyst  577
 

A B
Figure 75-7 ▶ L4-5 Subligamentous Synovial Cyst. Contiguous axial T2-weighted MR images A and B, obtained at the L4-5 intervertebral disc level. Demonstrated is
a synovial cyst arising along the medial margin of the right L4-5 facet joint. The cyst (arrow in images A and B) is positioned posterior to the right ligamentum flavum and
displaces the right ligamentum flavum anteriorly.

A B C
Figure 75-8 ▶ Large Parafacetal Pseudocyst (Juxtafacet Cyst) Arising from the Ligamentum Flavum. Sagittal T2-weighted MR image A. T1-weighted image B,
and contrast-enhanced fat-saturated T1-weighted MR image C. A large cyst (arrow) causes anterior displacement of the thecal sac and compresses the cauda equina. The cyst
(arrow) is T2 hyperintense centrally on image A and is T1 isointense relative to CSF on image B. In image C, the cyst fluid centrally does not enhance but the margins of the
cyst enhance intensely, including the ligamentum flavum (long arrow). The thecal sac is displaced anteriorly. Adjacent compressed cauda equina nerve roots also enhance (short
arrow in image C).

3. Tarlov cyst: A synovial cyst or parafacetal pseudocyst located
in the neural foramen can have an appearance similar to an
intraforaminal root sheath (Tarlov) cyst.
4. Post-inflammatory paraspinous cysts: Inflammation of the
interspinous ligaments (Baastrup’s disease) may result in
cystic dilation of paraspinous bursa.1 These bursae may com-
municate with the posterior facet joint capsules (see Chapter
39 for detailed description of interspinous bursitis).
5. Facet joint capsular/synovial proliferation: Thickened,
redundant T2 hypointense capsular or synovial tissue, which
does not contain fluid, may project into the spinal canal or
neural foramen. This redundant facet capsular tissue can con-
tribute to thecal sac deformity in the setting of central canal
stenosis.
6. Herniated disc: Disc extrusions are typically T2 hypointense
and slightly T1 hyperintense relative to the CSF. Proliferative
578  IMAGING PAINFUL SPINE DISORDERS
capsular/synovial tissue may be T2 hypointense. The poste-
rior margin of a chronic herniated disc fragment or seques-
tered disc fragment rarely contains a small T2 hyperintense
cystic region, which may represent cystic degeneration within
the disc fragment or liquefaction of a small paradiscal
hematoma.1
Figure 75-9 ▶ Parafacetal Pseudocyst (Juxtafacet Cyst). Axial T2-weighted
MRI in same patient as in Figure 75-8. A large cyst (C) is positioned between the
ligamentum flava. The cyst likely originates from the right ligamentum flavum where
a small notch (arrow) is seen in the ligamentum flavum. The thecal sac (TS) and
contained cauda equina nerve roots are compressed and displaced anteriorly along
the posterior margin of the L3-4 intervertebral disc.
A B
Figure 75-10 ▶ L5-S1 Foraminal Synovial Cyst. On left parasagittal T1-weighted MR image A, a T1 hypointense synovial cyst (arrow) in the left L5-S1 neural foramen
is located posterior to the left L5 dorsal root ganglion/nerve root (R). On fat-saturated T2-weighted image B, the cyst (arrow) is hyperintense relative to the slightly less intense
L5 nerve root (R).
TREATMENT
A minority of synovial cysts will involute spontaneously.15 Back
pain or radicular pain can be managed conservatively by adminis-
tering oral nonsteroidal anti-inflammatory agents or with short-
term systemic steroid therapy. Invasive therapy for treatment of
synovial cysts includes the following:
1. Epidural steroid injection: Interlaminar or transforaminal
steroid injections can provide temporary relief of pain for
symptomatic synovial cysts, but this is of limited long-term
benefit in our experience. This may reduce inflammation sur-
rounding the cyst but does not usually result in reduction in
cyst volume in our experience.
2. Facet joint steroid injection: Injection at the level adjacent
to the synovial cyst may provide temporary relief and some-
times long-term relief of symptoms.16,17 Without accompany-
ing cyst decompression, we have not found this technique to
provide long-term benefit in our patient population.
3. Direct synovial cyst puncture: This procedure is performed
by inserting a needle directly into the synovial cyst using fluo-
roscopic or CT guidance.18 Needle positioning is confirmed
by injecting a tiny amount of iodinated contrast agent into
the cyst. A mixture of anesthetic and steroid is then injected
directly into the cyst. This technique alone does not usually
result in lasting symptomatic relief unless the cyst wall rup-
tures. Furthermore, it is difficult to cause a sizeable rent in
the cyst by direct injection into the cyst alone, because the
facet joint acts to decompress the pressure when the cyst fills
with the injected contrast agent and/or anesthetic-steroid
mixture.
4. Synovial cyst injection and decompression via percutane-
ous facet joint injection. This procedure is readily performed
in an outpatient setting and not significantly more involved
than facet joint epidural injection alone. This can be performed
 CHAPTER 75: Synovial Cyst  579
 

A B C
Figure 75-11 ▶ L5-S1 Foraminal Synovial Cyst. Axial T2-weighted MR image A, T1-weighted image B, and contrast-enhanced fat-saturated T1-weighted MR image C,
in same patient as n Figure 75-10. The cyst is T2 hyperintense (arrow in A) and T1 hypointense (arrow in B) relative to the intraforaminal fat. In image C, the outer margin of
the cyst (arrow) enhances intensely. The cyst is positioned between the dorsal root ganglion (G) anteriorly and the hypertrophic superior articular facet (F) posteriorly. Note
enhancing tissue in subchondral erosions or tiny geodes within the facets.

Figure 75-13 ▶ Thick-Walled Synovial Cyst on Right at L4-5 Level. Axial

Figure 75-12 ▶ Bilateral Synovial Cysts in L4 Lateral Recesses. Axial CT T2-weighted MR image. The synovial cyst (arrow) contains a small amount of T2
image at L4 level shows bilateral peripherally calcified synovial cysts (arrows) within hyperintense fluid. Note small facet joint effusion on right and severe facet hypertro-
both lateral recesses of L4. The cysts arise from bilateral osteoarthritic L4-5 facet phy on left.
joints and cause bilateral compression of the thecal sac.

under CT or fluoroscopic guidance.19 This is the initial proce-
dure of choice for treating symptomatic synovial cysts at our
institution, where we routinely perform this procedure using
fluoroscopic guidance. The goal of the procedure is to decom-
press the cyst by producing a defect or rent in the cyst wall. A
facet joint injection is first performed by inserting a needle
into the facet joint communicating with the synovial cyst. A
syringe filled with iodinated contrast agent is attached to
the needle via a connecting tube. Under fluoroscopic visualiza-
tion, the contrast agent is rapidly and forcibly injected by hand
injection into the facet joint with the goal of distending and
rupturing the cyst (Fig. 75-16). The patient usually experi-
ences an accentuation of the usual pain as the cyst distends,
and then immediate pain relief occurs when the cyst wall rup-
tures. As the cyst ruptures, the contrast agent will be seen
extending into the epidural space. A mixture of normal saline,
steroid, and anesthetic agent is then injected into the facet
joint, filling the facet joint as well as the ruptured synovial cyst,
and extending into the epidural space. A high percentage of
patients experience pain relief with or without cyst regression
using this technique.19 Approximately 50% to 60% of patients,
who undergo “successful” percutaneous cyst decompression,
using this technique, will reaccumulate liquid in the cyst after
3 to 4 months. These patients may be treated with repeat per-
cutaneous synovial cyst decompression using this same tech-
nique. If this procedure fails to reduce the size of the cyst and
symptoms do not improve or recur after three percutaneous
cyst injection procedures, surgical excision of the synovial cyst
should be considered.
5. Combined percutaneous approach: If the cyst cannot be
ruptured by percutaneous injection into the facet joint, we
have found a combined approach often is successful. With the
needle in the facet joint, as described above in treatment 4, a
second needle is inserted directly into the synovial cyst, using
580  IMAGING PAINFUL SPINE DISORDERS

Figure 75-14 ▶ Bilateral L4-5 Synovial Cysts. Bilateral “kissing” synovial cysts
(arrows) shown on axial T2-weighted MRI. The cysts arise from the medial aspect of
the L4-5 facet joint bilaterally. The cysts cause marked side to side compression of
the thecal sac and required decompressive laminectomy and bilateral facetectomies
for treatment.
Figure 75-15 ▶ Parafacetal Pseudocyst (Juxtafacet Cyst). The cyst likely
originates from ligamentum flavum at L3-4 level. The cyst (arrow) is hyperintense on
this axial T2-weighted MR image. The fluid-filled cyst (arrow) does not communicate
with the facet joints. The cyst causes compression and anterior displacement of the
thecal sac.

A B
Figure 75-16 ▶ Percutaneous Synovial Cyst Decompression. Procedure performed at L4-5 level on patient shown in Figure 75-13. Left anterior oblique (LAO) radio-
graphic images A and B. In image A, the facet joint capsule is distended with contrast agent just prior to rupture. The small fluid filled portion of the synovial cyst is indicated
by the arrow in image A. In image B, obtained immediately following rupture of the cyst, the contrast agent has extended from the ruptured cyst into the epidural space
(arrows). L4 = L4 vertebral body. L5 = L5 vertebral body.

fluoroscopic or CT guidance. A contrast-filled syringe is then
connected via a connecting tube to each needle and the cyst
is distended by simultaneous forcible hand injection of each
syringe. This causes rapid distention of the cyst and usually
results in rupture of the cyst wall. When the contrast agent is
seen in the epidural space, a mixture of normal saline, anes-
thetic, and steroid is injected into the facet joint, which passes
into the cyst and then into the epidural space.
6. Surgical excision of synovial cyst: Surgical excision has the
highest success rate for treatment of synovial cysts.
Laminectomy, removal of the ligamentum flavum, and surgical
excision of the synovial cyst is the definitive therapy for treat-
ing symptomatic synovial cysts if other treatment methods fail
to provide long-term relief.4 Sometimes medial facetectomy is
performed to prevent recurrence of the cyst. However, exten-
sive surgery carries the risk of developing spinal instability.
Microsurgical cyst excision with limited decompression can
be effective.20
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