Clinical Context

Synovial cysts of the lumbar facet joints are:

• Degenerative in origin, arising from the facet capsule.
• Often associated with segmental instability or facet arthropathy.
• Most common at L4–L5, causing foraminal or lateral recess stenosis, compressing the exiting or traversing nerve root.

Symptoms include:

• Radiculopathy
• Neurogenic claudication
• Localized back pain

Endoscopic Surgical Solution

Indications

• Confirmed cyst on MRI compressing neural structures
• Refractory symptoms despite conservative management
• Positive correlation with facet degeneration
• Patient preference to avoid open surgery/fusion when instability is absent

Surgical Technique

• Approach: Transforaminal or interlaminar full-endoscopic route based on cyst location (foraminal vs medial)
• Anesthesia: Local with sedation or general anesthesia
• Navigation: Fluoroscopy and endoscopic visualization
• Steps:
  1. Access the facet joint capsule endoscopically
  2. Use RF ablation and micro-instruments to expose and decompress the cyst
  3. Perform cyst wall excision and evacuation of gelatinous contents
  4. Decompress adjacent neural elements
  5. Preserve surrounding bone and ligament when feasible
• Optional: Partial SAP resection if access is limited, especially in foraminal cysts.

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Advantages of Full-Endoscopic Approach

• Minimally invasive: <1 cm incision, no muscle stripping
• No destabilization: Preserves midline structures
• Direct visualization = precise cyst removal
• Avoids fusion in cases without gross instability
• Fast recovery and outpatient surgery

Outcomes

• Symptom resolution in most cases (80–95% in literature)
• Low recurrence when the capsule is fully removed
• Reduced operative time and hospital stay
• Lower morbidity than open decompression

Key Considerations

• Pre-op imaging: MRI + dynamic X-rays (to rule out instability)
• Recurrence: Rare if complete excision of the cyst wall is achieved
• Instability: In cases with gross facet degeneration or spondylolisthesis, fusion may be considered

Dr. Rami Hamed
Consultant Spine & Orthopedic Surgeon
Founder, DRHC – Dubai Healthcare City
📞 ‪+971 4 279 8800‬
🌐 www.drhc.ae
📍 Dubai Healthcare City, Building 52