Klessinger Stephan
Department of Neurosurgery, Nova Clinic Biberach, Eichendorffweg 5, 88400 Biberach, Germany; Department of Neurosurgery, University of Ulm, Albert-Einstein-Allee 23, 89081 Ulm, Germany.
Clin Neurol Neurosurg. 2016 May;144:14-9. doi: 10.1016/j.clineuro.2016.02.038. Epub 2016 Mar 2.
Synovial cysts in the lumbar spine are uncommon causes of radicular pain. In cases where conservative treatment fails, surgical resection is recommended. Dural adhesions are common intraoperative findings; therefore, the removal of the cyst may sometimes result in dural tears. The frequency of dural tears is greater with synovial cysts than in other lumbar surgeries. Clinical parameters and characteristics seen on magnetic resonance imaging were assessed to investigate the correlation between the outcome after surgery of lumbar synovial cysts and dural tears.
This study was designed as a retrospective practice audit. Patient data were drawn from an electronic medical record system. Included were consecutive patients after microsurgical resection of symptomatic lumbar synovial cysts between May 2013 and November 2015. The surgical report was evaluated retrospectively regarding the extent of decompression and cyst resection as well as surgery-related complications. Pre-operative magnet resonance imaging was assessed concerning the reason for compression of the neural structures, the dimension of the cyst, and the signal of the cyst content in T2 images. In a follow-up examination about four weeks after surgery, the patient satisfaction index was evaluated.
Forty-four consecutive patients after resection of a lumbar synovial cyst met the inclusion criteria. The mean patient satisfaction index was 2.0±1.0. Twenty-nine patients of the 38 patients with follow-up (76.3%) with a satisfaction index of 1 or 2 were rated as favorable. One revision surgery was necessary because of a cerebrospinal fluid fistula. Furthermore, in 4 patients an incidental durotomy occurred without any symptoms after surgery. Accordingly, the rate of dural tears was 11.4%. Dural tears were significantly more common in patients with a satisfaction index of 3 or 4 (P=0.04). Sixty percent of the patients with dural tears were operated on in level L5/S1 compared to 3 patients without a dural tear (P=0.008). There was no statistically significant difference between the different patient subgroups in any other analyzed parameter.
Dural tears were found significantly more often in patients without a good outcome; they appear to portend a poorer prognosis. The level L5/S1 was significantly more often affected. During surgery, it should be considered whether to remove the cyst completely and risk a dural tear, or to leave residuals of the cyst wall if otherwise a good decompression is achieved.
腰椎滑膜囊肿是神经根性疼痛的罕见病因。在保守治疗失败的情况下，建议进行手术切除。硬膜粘连是常见的术中发现；因此，切除囊肿有时可能导致硬脑膜撕裂。与其他腰椎手术相比，滑膜囊肿导致硬脑膜撕裂的频率更高。评估磁共振成像上的临床参数和特征，以研究腰椎滑膜囊肿手术后的结果与硬脑膜撕裂之间的相关性。
本研究设计为一项回顾性实践审计。患者数据来自电子病历系统。纳入2013年5月至2015年11月间接受有症状腰椎滑膜囊肿显微手术切除的连续患者。对手术报告进行回顾性评估，内容包括减压和囊肿切除的范围以及手术相关并发症。术前磁共振成像评估神经结构受压的原因、囊肿大小以及T2图像中囊肿内容物的信号。在术后约四周的随访检查中，评估患者满意度指数。
44例连续接受腰椎滑膜囊肿切除的患者符合纳入标准。患者满意度指数的平均值为2.0±1.0。38例有随访的患者中，29例（76.3%）满意度指数为1或2的患者被评为良好。因脑脊液漏需进行1次翻修手术。此外，4例患者术后发生意外硬脑膜切开但无任何症状。因此，硬脑膜撕裂率为11.4%。满意度指数为3或4的患者中硬脑膜撕裂明显更常见（P=0.04）。与3例无硬脑膜撕裂的患者相比，60%发生硬脑膜撕裂的患者在L5/S1节段接受手术（P=0.008）。在任何其他分析参数中，不同患者亚组之间均无统计学显著差异。
结果不佳的患者中硬脑膜撕裂明显更常见；它们似乎预示着预后较差。L5/S1节段受影响明显更频繁。手术过程中，应考虑是完全切除囊肿并冒硬脑膜撕裂的风险，还是在减压良好的情况下留下囊肿壁残余部分。
