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Bret White
Ralph Kruse
Kurt Olding


Synovial Cyst, Low Back Pain, Flexion-Distraction Therapy


Objective: To describe the chiropractic treatment of a patient with a chronic, symptomatic L4-L5 synovial cyst using the Cox® flexion-distraction manipulation.

Clinical Features: A 75-year-old retired postal worker had lower back pain radiating into his right buttock, of non-traumatic onset. The pain was present for 4-5 months and was rated as severe when standing or walking. Magnetic resonance imaging documented a large synovial cyst at L4-L5.

Intervention and Outcomes: Treatment consisted of Cox® flexion-distraction to the lumbar spine for a total of 6 treatments over approximately 3 weeks. The initial numerical pain rating scale (NPR) was 3-4 at rest and was rated as severe when standing or walking. The Oswestry Disability Index (ODI) was 48%. The final NPR was rated as 0 at rest, and the ODI was 36%. This represents a 25% improvement in the ODI and a 100% improvement in resting pain.

Conclusion: The Cox® flexion-distraction manipulation may be an effective conservative option for symptomatic lumbar synovial cysts. This becomes important in a patient who has several co-morbidities which make surgery a riskier option.


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1. Wilby M, Fraser R, Vernon-Roberts B, Moore R. The prevalence and pathogenesis of synovial cysts within the ligamentum flavum in patients with lumbar spinal stenosis and radiculopathy. Spine J 2009;34:2518-2524. doi:10.1097/BRS.0b013e3181b22bd0
2. Gellhorn A, Katz J, Suri P. Osteoarthritis of the spine: The facet joints. Nat Rev Rheumatol 2013;9:216-224. doi:10.1038/nrrheum.2012,199
3. Kalichman L, Hunter D. Lumbar facet joint osteoarthritis: A review. Semin Arthritis Rheum 2007;37:69-80. doi:10.1016/j.semarthrit.2007.01.007
4. Cox JM, Cox JM II. Chiropractic treatment of lumbar spine synovial cysts: A report of two cases. J Manipulative Physiol Ther 2005;28:143-147. doi:10.1016/j.jmpt.2005.01.011
5. Howington J, Connolly E, Voorhies R. Intraspinal synovial cysts: 10-year experience at the Ochsner clinic. J Neurosurg 1999;91:193-199. doi:10.3171/spi.1999.91.2.0193
6. Charest D, Kenny B. Radicular pain caused by synovial cyst: An underdiagnosed entity in the elderly? J Neurosurg. 2000;92:57-60. doi:10.3171/spi.2000.92.1.0057
7. Bozzao A, Floris R, Fraioli C, Ticca L, Simonetti G. Relapsing-remitting bilateral synovial cysts of the lumbar spine. Neuroradiology 2001;43:1076-1078. doi:10.1007/s002340100642
8. Tillich M, Trummer M, Lindbichler F, Flaschka G. Symptomatic intraspinal synovial cysts of the lumbar spine: Correlation of MR and surgical findings. Neuroradiology 2001;43:1070-1075. doi:10.1007/s002340100682
9. Reust P, Wendling D, Lagier R, Pageaut G, Reverdin A, Jacquet G, et al. Degenerative spondylolisthesis, synovial cyst of the zygapophyseal joints, and sciatic syndrome: Report of two cases and review of the literature. Arthritis and Rheumatism 1988;31:288-294. doi:10.1002/art.1780310220
10. Khan A, Girardi F. Spinal lumbar synovial cysts: Diagnosis and management challenge. Eur Spine J 2006;15:1176-1182. doi:10.1007/s00586-005-0009-4
11. Mobbs R, Campbell R, Phan K. NeuroSpine surgery research group (NSURG) classification system for grading lumbar synovial cysts. Orthopaedic Surgery 2018;10:3-7. doi:10.1111/os.12363
12. Shah RV, Lutz GE. Lumbar intraspinal synovial cysts: Conservative management and review of the world's literature. Spine J 2003;3:479-488. doi:10.1016/S1529-9430(03)00148-7
13. Eshraghi Y, Desai V, Cajigal C, Tabbaa K. Outcome of percutaneous lumbar synovial cyst rupture in patients with lumbar radiculopathy. Pain Physician 2016;19:e1019-e1025.
14. Hatgis J, Granville M, Berti A, Jacobsen R. Targeted radiofrequency ablation as an adjunct in treatment of lumbar facet cysts. Cureus 2017;9:e1318. doi:10.7759/cureus.1318
15. Hazen L, Cox J. Lumbar intraspinal extradural synovial cyst: A case study. J Neuromusculoskeletal Syst 1993;1:167-169.
16. Taylor D. Spinal synovial cysts and intersegmental instability: A chiropractic case. J Manipulative Physiol Ther 2007;30:152-157. doi:10.1016/j.jmpt.2006.12.002
17. Cox JM Chiropractic management of a patient with lumbar spine pain due to synovial cyst: A case report. J Chiropr Med 2012;11:7–15. doi:10.1016/j.jcm.2011.08.007
18. Ngo T, Decina P, Hsu W. Spontaneous resolution of symptoms associated with a facet synovial cyst in an adult female: A case report. J Can Chiro Assoc 2013;57:87-92.
19. Firth R. Lumbar intraspinal synovial cyst containing gas as a cause for low-back pain. J Manipulative Physiol Ther 2000;23:276-278. doi:10.1067/mmt.2000.106096
20. Arthur B, Lewkonia P, Quon J, Street J, Bishop P. Acute sciatica and progressive neurological deficit secondary to facet synovial cysts: A report of two cases. J Can Chiropr Assoc 2012;56:173-178.
21. Timchur M, McCarthy P. Lumbar radiculopathy and synovial cyst in the elderly, with re-imaging following long term conservative intervention: A case report. Chiropr J Aust 2016;44.
22. Khan A, Synnot K, Cammisa F, Girardi F. Lumbar synovial cysts of the spine: An evaluation of surgical outcome. J Spinal Disord Tech 2005;18:127-131. doi:10.1097/01.bsd.0000156830.68431.70
23. Supe A, Badole C, Babhulkar S, Wandile K. Spinal synovial cyst. J of Mahatma Gandhi Institute of Medical Sciences 2015;20:82-84. doi:10.4103/0971-9903.151745
24. Epstein N. Spinal case of the month with short perspective: How would you treat this L3-L4 synovial cyst? Surg Neurol Int 2018;9:56. doi:10.4103/sni.sni_27_18
25. Rhee J, Anaizi A, Sandhu F, Voyadzis JM. Minimally invasive resection of lumbar synovial cysts from a contralateral approach. J Neurosurg Spine 2012;17:453-458. doi:10.3171/2012.8.SPINE12101
26. Boviatsis E, Staurinou L, Kouyialis A, Gavra M, Stavrinou P, Themistokleous M, et al. Spinal synovial cysts: Pathogenesis, diagnosis and surgical treatment in a series of seven cases and literature review. Eur Spine J 2008;17:831-837. doi:10.1007/s00586-007-0563-z
27. Kratz B, Buck T, Cramer D. Improvement in radicular symptoms but continued facet arthropathy and axial back pain following rupture of a facet joint synovial cyst. Neuroscience & Medicine 2018;9:46-52. doi:10.4236/nm.2018.91006
28. Shah,V, von Fischer N, Chin C, Yuh E, Amans M, Dillon, W, et al. Long-term effectiveness of direct CT-guided aspiration and fenestration of symptomatic lumbar facet synovial cysts. American J of Neuroradiology 2018;39:193-198. doi:10.3174/ajnr.A5428
29. Wang D, Lownie S, Pelz D. A novel approach to symptomatic lumbar facet joint synovial cyst injection and rupture using iGuide navigational software: A case report and review. Interventional Neuroradiology 2016;22:596-599. doi:10.1177/1591019916653253
30. Domenicucci M, Ramieri A, Marruzzo D, Missori P, Miscusi M, Tarantino R, et al. Lumbar ganglion cyst: Nosology, surgical management and proposal of a new classification based on 34 personal cases and literature review. World J Orthop 2017;8:697-704. doi:10.5312/wjo.v8.i9.697
31. Amato V, Giannachi L, Irace C, Corona C. Lumbar synovial cysts: Microsurgical treatment and outcome in 40 cases: Review and critical analysis of the literature. J of Spine and Neurosurgery 2014;3. doi:10.4172/2325-9701.1000139
32. Scholz C, Hubbe U, Kogias E, Klingler JH. Incomplete resection of lumbar synovial cysts: Evaluating the risk of recurrence. Clin Neurology and Neurosurgery 2015;136:29-32. doi:10.1016/j.clineuro.2015.05.028
33. Bruder M, Cattani A, Gessler F, Droste C, Setzer M, Seifert V, et al. Synovial cysts of the spine: Long-term follow-up after surgical treatment of 141 cases in a single-center series and comprehensive literature review of 2900 degenerative spinal cysts. J Neurosurgical Spine 2017;27:256-267. doi:10.3171/2016.12.SPINE16756
34. Denis D, Hirt D, Shah S, Lu D, Holly L. Minimally invasive surgery for lumbar synovial cysts with coexisting degenerative spondylolisthesis. Int J of Spine Surgery 2016;10. doi:10.1444/3037
35. Epstein N. Lumbar synovial cysts: A review of diagnosis, surgical management, and outcome assessment. J Spinal Disord Tech 2004;17;321-325. doi:10.1097/01.bsd.0000096267.75190.eb
36. Bruder M, Gessler F, Cattani A, Droste C, Seifert V, Setzer M, Marquardt G. Surgical treatment of spinal synovial cysts in elderly patients: Symptoms, treatment course, and outcome in patients >75 years of age. World Neurosurgery 2018;110:e520-e525. doi:10.1016/j.wneu.2017.11.031
37. Epstein NE. Avoiding inappropriate spine surgery in a patient with major cardiac comorbidities. Surg Neurol Int 2019;10:44. doi:10.25259/SNI-57-2019