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SNI digital innovations in learning is pleased to present
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another in the SNI digital series of controversies in spine surgery
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with a lecture and discussion by Nancy Epstein. This talk is
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in publication in surgical neurology international in the next month or two.
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Nancy Epstein is a professor of clinical neurosurgery at the School of Medicine at the State University of New York at Stony Brook and she's the editor-in-chief of Surgical Neurology International.
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She's internationally and internationally known spine surgeon, has been in practice for 40 years and has one of the most extensive bibliographies of anybody in doing this work. So today I'm going to
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talk about, it's a perspective which means it's my viewpoint on this, my experience with this which has been extensive over about four years of operating, but it's operating on lumbar synovial
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cysts and how ineffective percutaneous techniques usually are My main intent in this lecture is to have everyone come away with a sense of how to read MRI scans. and CAT scans themselves so that you
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yourself can recognize the presence of a synovial cyst. And then the latter part is how to deal with it technically, surgically. So here's an illustration, a cross-section illustration. My father
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actually was a neurosurgeon and this is his drawing. But the multiple locations of synovial cysts, you have the central cysts, that may give you a quarter coin of syndrome. You have the lateral
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cysts, that may give you a nerve root deficit You have a proximal foraminal lesion, that's gonna give you an upper nerve root deficit at the four or five level, that's gonna be an L-5 root, an L-4
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root syndrome, where you might haveilius ous or quadriceps weakness. You may have distal foraminal disease also, affecting that L-4 root, and sometimes it's just far lateral. So these are the
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main locations for synovial cysts, and you're gonna have to differentiate these from other processes, in particular, disc herniations, but sometimes even tumors are other factors. I can ask you a
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question right here in this. Looking at that slide, if a synovial cyst is related to
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the joint, the lumbar joints there, how do you get a synovial cyst in the mid-light and how do you get it out in the foramen? I mean, it is, that's good. Good question. I think the more
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stenotic your patient, the more possible it is to get a paracentral or central synovial cyst extrusion to the point where you can't even figure out which side it arose from. In terms of the lateral
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and foramenal extension, I mean, these can just extrude into the canal and with Valsava maneuvers and everything else, these cysts can actually move in the spinal canal. I think that's really how
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they get to these different locations. So we're looking at it, if you look at the picture
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on our right now looking at it. The fissette joint actually, it's it's extensive. So you can have a cis coming out from, that's right. From all different locations, some can come out superiorly
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and say, and go to the framing and so forth and so on. I mean, here, superiorly, here's the proximal root. This is in the distal foramen, an extra foraminal is here. And
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lateral and inferior is the inferiorly exiting nerve root. And here's your dural tube, so you can get the whole quarter coin at the same time. And that's why you're looking for these different root
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syndromes. If you feel you have to do a full facetectomy, which you do at times, then you can decide whether or not these patients need a more exhaustive procedure like a fusion associated with it,
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but not in all cases. Can I ask you one more other question? Yeah. And that is, how common, what we're talking about the synovial cyst, If you have a hundred spine operations. or people with
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let's say a
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radiculopathy or myelopathy and lumbar disease. Right. Is this gonna be 5 or 10 or
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it's not 90 was in terms of a causative factor. I think it's at least 5
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and actually I'll show you later of a series of 336 lumbar laminectomies and non-instrumental fusions. And I looked at the incidence of CSF leaks and there were six synovial cysts that were
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responsible for those CSF leaks. But I'd say overall it's somewhere between 5 and 10. And I can't stress how often you get in there surgically and you say, wow, there is a synovial cystic
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extrusion here. It's not just hypertrophy of the yellow ligament. So it's more frequent than you think, but it's not as frequent as a disc herniation in some of the other pathology that you're
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gonna see stressing if you have a microscope, use it. Okay, terrific So here's a synovial cyst, you know, it evolves. The synovium is obviously the lining of a facet joint. So what you're
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looking at here is the disruption of the external capsule of that facet and then it can extrude into the spinal canal. By the way, I'll also show you some images where it can also extrude outside
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the spinal canal, but we're interested in the ones to become symptomatic neurologically because they're compressing on a nerve root or the quarter coin up. If pathology, if you look at the
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pathology of these synovial cysts, and this is one of my main points in this talk, these cysts have a very thick cyst wall. Oftentimes, the central liquid component is minimal. And therefore,
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that's why I'm saying that they're difficult to deal with and have to be dealt with because it is the thick fibrous capsule that compresses the nerve tissue and just aspirating or getting rid of the
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fluid is not going to decompress this spinal canal. So this is just some pathological specimens shown. Are those images of the cyst wall? That's the cyst, these are the cyst wall. Yes, some
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intermixed with some component of cyst and other factors of degeneration. But again, it's like having a tennis ball that's, I guess, filled with rubber bands and then just having a little bit of
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liquid on the side. And when you get in there, you realize that you can disrupt the posterior aspect of this cyst capsule, and then you can find this crankcase thick fluid on the inside, which is,
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by the way, extremely difficult to aspirate. It usually clogs up your syringes. And then you just have very thick fibrous tissue that you're dealing with. It's not just, you know, you stick in
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your thumb and you pull out a plumb. So actually what you just said is if it's very thick tissue, even if somebody was telling you they're gonna aspirate it, it's gonna be difficult. It's gonna be
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difficult And then the question is, what kind of problems do they create? trying to aspirate it, because they may try and try again. And what happens is you get in there surgically afterwards,
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and you find all these holes all over the dura. If you don't end up operating on these patients and obliterating those holes, these are candidates who eventually may develop but he's a rachnoditis.
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Very good, mate. So you have a thick synovial capsule, a minimal central crankcase fluid that is difficult to aspirate. So here's your illustration of that synovial cyst, another illustration
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over here of that thick capsule, which is shown here in green. And finally, again, the anatomical specimen showing a thick capsule, essentially all the way around.
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Terrific. The synovial cyst can extrude into the canal, compress the duro or the thicosac or the quarter-coina, and it can extrude laterally, superiorly impinging on the nerve root and inferiorly
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as well. So here is figurative diagram of lumbar spinal, Here's your normal facet lining seen here, okay? But this is what it looks like when you develop an extrusion of that synovial system, the
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canal. You have inflammation of the facet joint. This results in the synovial cyst extruding into the spinal canal, and it results in your compression of the corticuina, centrally or paracentrally,
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and the lateral, ferramidal or far lateral nerve root
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By the way, when you're dealing with this surgically, you have to realize that that synovium capsule starts
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way underneath the facet joint here. So usually under a microscope from the contralateral side of the over table angled, you have to really get underneath that facet to do your, you know, medial
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facetectomy for aminotomy. If you're trying to preserve the facet, if you don't go after that, you often will leave that superiorly, pharaminally exiting nerve root.
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compressed. And it's very easy to leave pathology behind, so you don't want to leave that behind. Okay.
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For the extruded synovial cyst compressing the corticuina and the individual nerve roots, this is what you're going to see on your MRI. Here is the hyperintense fluid. In this case, it may look
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more so than in others, but the hyperintense
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hypogensity is the capsule around the cyst, the hyperintensity is the fluid in the central portion of the cyst, and here you can see a dorsolateral synovial cyst at L5S1, resulting in significant
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corticuina
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compression. So again, if you just try and aspirate the fluid, you do nothing about the capsule. Lots of times you're going to leave that neurological deficit intact. You're not going to
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decompress the nerve roots superiorly or inferiorly, and you're going to still end up with that patient with a corticuina
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So here are your MR locations of synovial cysts, which I showed you in the first slide. It can be on one side or both sides. It can be lateral or foraminal, in the proximal or the distal foramen.
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It can even extend far laterally. And you might have to differentiate it from a far lateral disc. In some instances, you'll say, Hey, is it tumor? We're not sure. It can be paracentral or
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central in location. So here is an example of a synovial cyst that's at the four or five level It's extended upward to the mid-petacle level, and here it is on your axial MRI scan.
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Here is a paracentral location where it's come out of your facet and here is your synovial cyst. It looks like it's come from the right sign of, right facet rather than the left. Here by the way is
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hypertrophy of your yellow ligament. So lots of times people will say, oh, it's just, you know, ossification or hypertrophy of the ligament, but look for the hyper intensity to tell you that
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there's a synovial cyst there. Look how compressed your coda coin is here. That's exactly what's under my arrow here Okay? And beware, fluid in both of the facet joints, okay? That has to be
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looked at very carefully. Make sure you get flexion extension films, how mobile is that segment, because you want to be on top of how to treat this. Can you go back to that for just a second? I
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guess it's on your next side too. The area, there's an area of hyper density, which is the cyst right here, hyper intensity
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And the hypodensity, is that the capsule or is that reaction or what is it? Hypo, hypo intensity is your capsule. Also, a lot of these capsules are partially calcified. So not only are they
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often hypo-intense, but they also often look very black if they're super calcified. Okay.
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Synovial cyst, they compress the nerve roots and the quarter-quina. Here's another example of a synovial cyst This is a lateral and foraminal cyst, and here is just an example of a central one that
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might give you quarter-quina compression. The central one has to squeeze out more medially in order to get there, is that right? That's true. But if you think about your patient with severe lumbar
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spinal stenosis, what I usually tell the medical students is you put your arms out like this and you are the vertebral body, The space in front of you is the spinal canal from your elbows. your
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wrists. That's the lamina in your hands of the Spanish processes. And I tell them, okay, that's a normal canal. But if you put your elbows together, that's a stenotic canal. And there's no room
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left in front of you. So there isn't that much room, especially the bigger the stenosis, the greater the chance that that synovial cyst may extrude centrally.
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Here are images of an increasing larger lateral and phyramidal synovial cysts. So you can see here is your typical axial view of a phyramidal synovial cyst
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and then here is an illustration where you start out with a smaller synovial cyst, dural compression, thicosac compression, somewhat larger, more dural and thicosac compression, and here the
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larger and the largest Now, operations that can be done a left L5 hemilaminectomy
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and laminotomy can decompress the synovial cyst and freeing up your dural sac and the S1 root. So here is your typical synovial cyst. I'm looking, you know, distal-deproximal. So that's why I'm
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calling this the left side because here on my illustration is a left L5 hemilaminectomy. The L5 hemilaminectomy
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is right here Medio-facetectomy for amanotomy for. but more extensive for abdominal decompression at 51. Here's your synovial cyst. We've decompressed it to see it. We're gonna try and
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differentiate it from the Dura. Remember, I said to you sometimes the adhesion to the Dura is really severe. So you wanna have adequate decompression. Otherwise you're gonna end up with a massive
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CSF leak. That's not necessary because you may want to just take out like, you know, 56
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of the synovial cyst and leave a portion adherent to the capsule But here's your dural sac here and then here's your inferiorly exiting, you know, S1 nerve root. And P is for pedicle, right?
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Excuse me? P is for pedicle. Yes, P is for pedicle, correct. Yes. Same.
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Here's an MR of a lumbar synovial cyst at 45 and here's directed to your question, Jim. Here's the hypo intensity of the capsule on the MRI, okay? MR, scan you, a thick outer capsule, it's hypo
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intense. The central fluid is hyperintense, and that's the green arrow pointing to that. And here's another example of it though. So the amount of fluid you may have in that synovial cyst can
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markedly vary because here's an example on an axial or cross-section view. The outer capsule, look how thick that is. That is all hypo-intense synovial cyst capsule. Look at the amount of dural
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compression that you have here. The nerve root is underneath here It's getting completely obliterated. And more likely than not, you're compressing the superiorly exiting nerve root that should be
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over there, okay? Look how minimal the amount of fluid is in that
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synovial cyst. So minimal fluid is present there. That's why here we spoke about the hypo-intense capsule, compressing everything, hyper-intense fluid. There may be minimal fluid and it may be so
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thick And so small in amount that it can be very difficult to aspirate. So you have radiologists going in all the time, 'cause I hear this at MM conferences and spine conferences, oh, let's
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have them try it, et cetera. Well, it's not always so benign because then once you get in there surgically, it can make a mess. First of all, the fact that you have any kind of invasive
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procedure, an epidural or an attempted
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aspiration increases the risk of an infection if it's been done within three months of an operation. That's number one And then number two, of course, is all the holes it can make, which can make
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your life in terms of trying to obliterate or sew up those holes much more difficult.
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In fact, that picture really illustrates why a percutaneous aspiration is fraught with difficulty and may result in no fault. And how often are they going to be coming in? And they're going to
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actually go right to and through the dura to get into the cyst.
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plus the fact, think about the dura that's underneath the cyst, and then if you get a hole in the ventral dura, then you've got a real problem in terms of how you're gonna treat that, because
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those can be very, very difficult to treat technically, surgically. So here's examples of L4, 5, and L5S1, synovial cysts in the presence of significant lateral recestinosis with compression of
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the corticuina and the various nerve roots. So here is an illustration, cross-section of view Look at this very hypertrophyte facet. This might be hypertrophy of the yellow ligament. The facet is
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in large lateral recestinosis. You can see how the root is already compromised in that lateral recess. You superimpose on that, you know, a nice synovial cyst and guess what? You've got stenosis.
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You've got the hypertrophyte facet joint and
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the synovial cyst all compressing the dura and the nerve roots If you try to do this minimally-invasively, a tube you're not going to be doing that patient any kind of service because you're going to
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end up with a CSF leak and probably destroying some of your neural tissues. Here's an example, another illustration. You see this is a laminotomy. A portion of the lamina above of L4 has been
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removed. A portion of the lamina of L5 has been removed here. Okay, so medial facetectomy for a monotomy, dural sac, L5 nerve root, L4-5 laminotomy decompresses the L5 root. You can call it an
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extended laminotomy. And here below it, a L5-S1 laminotomy decompresses the S1 nerve root. So, you don't have to do always complete laminectomies. If you have, in this example, patient is
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stenotic, then you're much better off doing a laminectomy. Because in the presence of stenosis, you are better off doing a laminectomy and a bilateral medial festectomy frame anatomy than you are.
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if you're just gonna go to one side and do a ham and laminectomy and completely knock off your facet joint. That's actually what's often done in T-lifts. And basically, you wanna try and preserve
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some of the stability of these levels than medial fast-sectomy for aminotomy is gonna be a better way to go if it's possible. Can I go back to that and wanna ask you a question? Well. Let's say,
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I've got my studies that don't have an MR. If I do, I'm not really sure what it really shows I know there's compression on the root, it fits with the clinical symptoms. I wanna go in there. And
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so I do, I go ahead and I wanna do a hemiliminectomy or at least that. Let's say in the process, I don't know about it. I get into the cyst
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accidentally. And now I've got the medial facet off. What do I do? Do I have to take more facet off, do I destabilize them? I wasn't prepared for that idea. Well, how do I deal with that? Yeah,
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I think really the safest thing under those circumstances is, you know, you can do what's called a coronal hemulaminectomy. Take off a portion of the Spanish process above and below, take off a
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portion of the lamina above and below. See if you can then get a margin around and define the extent of that synovial cyst. Make sure you have your microscope, and then try and define the limits of
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that synovial cyst Also, try and find where there is normal dura. Try and delineate if you can find it where the nerve root happens to be, the inferior nerve root, as well as the superior nerve
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root. If you can't see any of these structures, clearly the better thing to do is to continue to take off more bone until you can identify normal structures above, below, medial, and lateral,
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because otherwise you're going to destroy something in your meanderings and you don't want to really nearly take a stab at something. or take a kerosene and take a bite and then really regret the
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bite that you've taken. Okay, terrific.
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The axial MR scans that I'm going to show you are going to be two cases of L45 synovial cysts. And they're going to be a little different. Here is a synovial cyst. And you're going to see the this
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is the The cyst is extruded superiorly. And then here's your coda coin and down here inferiorly. This is the sagittal image, by the way. And here, again, is your synovial cyst seen on your AP
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and lateral views on your axial lateral views. Here, the L4 nerve root above may be compressed. So that patient may haveilius ous or quadriceps weakness. That's why that deficit may be appearing.
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On the other hand, in the next case here Let's say we're also at L4-5. Here is your synovial cyst sitting right here. it's going to be exactly where your L5 nerve root should be sitting. So very
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likely this patient has a foot drop. And then you notice that your quarter coin has been completely moved over towards the contralateral side. So you're going to have right L5 root as well as an
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extent of quarter coin and compression in this patient. You're also going to see, in this case, there was fluid in both facet joints. So on the MR, you're going to see that very nicely. On the
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CAT scan, it's going to be more difficult to delineate CAT scans are just really going to show you as a calcified or not, and give you a better idea as to how severe the stenosis is in that patient.
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The more severe the stenosis, the bigger the operation should be to safely decompress these. What do you do, Nancy, if you're - you see this, yes, do you want to take it out? Hold to begin with,
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you take it out piecemeal. Is it going to be stuck to the nerve? Well, you take it out piece by piece by piece, but only after you delineate. as you're decompressing, you know, you use your
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cottonoid to basically mark out that limit between the nerve tissue and the dura, nerve tissue and dura. So you creep your way along with the microscope, you may get to a point where you see there
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is no plane between this synovial cyst and the dura. So then your best bet is to make sure you've done enough of a decompression around the residual cyst wall so that it's no longer compressing the
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neural tissues. But yes, you try to delineate that demarcation, that plane between them. Lots of cases you're gonna find that plane, but about 16 of the time you're not gonna find that plane.
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And as I said, we'll get to it. Six out of 333 lumbars that I had done for stenosis, the source of the CSF leak was a synovial cyst. So if you encounter the synovial cyst, Slow down, make sure
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you're using the microscope. and try and avoid getting a CSF leak in those patients because believe me, it's better to have a bigger operation and not have that CSF leak than it is to have a smaller
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operation and that have the repeated CSF leaks and all the complications that go along with it.
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Okay, here's an MR of an L4-5 superior synovial cyst extrusion. So, here's your L4-5 level, there's your dorsal lateral synovial cyst, look at how compressed your quarter-quina happens to be in
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this image. Okay, so again, you want to be able to recognize this. It's dorsal. This should not be a disc herniation. You should not confuse this for a disc. Okay? Here's a CT of a partially
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calcified synovial cyst at the L3-4 level, you know. As I've been saying, synovial cyst are better seen on their NMR, but a CAT scan is great if you're looking for a partially or fully calcified
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capsule. This is a partially calcified capsule. Look over here. Nothing. Over here, nothing And here is my little arrow that's pointing to your partially calcified capsule. And we're going to
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see that again.
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This is a much more calcified synovial capsule. By the way, this is at the L45 level. Look at the grade one slip that you have here. Grade one slip may be an indication that you have disruption of
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your facet joint and you may have a synovial cyst at that level. But here is your calcified. On a CAT scan, you're gonna call it a hyperdense synovial cyst capsule seen here. It's compressing your
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dura and the roots and look how thick that is. So if you complete the circle, you're gonna see very, very small amounts of fluid in the middle So you have your hyperdense calcified capsule, thick
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fibers compressing the nerve tissue and the center is hypodense, minimal fluid
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and you often cannot manage to aspirate that. Certainly not without creating some problems. And the fact that it's calcified may mean that the entire capsule is gonna bounce out of your way.
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Here's an axial CAT scan of a calcified synovial cyst scene on the right side, okay? And you can see how this is where the nerve root should be exiting. So you're going to compress your L5 root,
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if you're at the four or five level, and you're compressing, here's your quarter coin. You see that? All compressed. This is probably, there's a grade one slip, which is why you're seeing the
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partial disc phenomenon here. That's not really a disc extrusion or herniation, but you probably have a grade one slip So again, the calcified hyperdense capsule, minimal hyperdense central fluid,
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it's almost nil. And again, an example where you're attempted percutaneous aspiration, often it's going to fail, but you can create some problems trying to do it
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I wrote a review article and I've read multiple articles, they will vary. They'll tell you that the failure rates for attempted percutaneous aspiration and other procedures for
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lumbar synovial cysts may fail. And here's, I couldn't, attempts often fail. Now, why are they failing? Multiple dural tears. So they make multiple stabs trying to get into these synovial cysts,
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trying to get that fluid. You know, if they're going to go in, they should have one try and back out if they can't do it on that first try, because you know that they're going to create a problem
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with the multiple attempts. Some of these patients end up with resultant intracranial hypotension. With the brain basically sags down through the frame and magnum, you can get in the brain on MRI
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scans, you can get dural enhancement. You can get the low-pressure headaches. Patients can develop neurological deficits, corticoidis syndrome, sexual dysplexia. all kinds of nasty things
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resulting from intracranial hypotension. There's always the risk of infection going in and out.
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The worst thing is you can get some fluid out of it maybe but you still have compression of the neural tissues, the nerves or the quarter-pointer because you have that thick capsule that's still
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sitting on the nerve tissue and you're risking nerve damage. Arachnoiditis, if you've gone in and you've attempted to aspirate, well a
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lot of these times you're going to get a CSF leak, which means that any of the blood and other fluids, the crankcase fluid from your synovial cysts, that gets inside the dura, it's going to create
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havoc, it's going to create a lot of inflammatory reaction and patients like this can end up with an adhesive arachnoiditis, which is not a good syndrome to find. So this high failure rate,
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various attempts, and this is the summary of some of the articles that I've read and are part of the summary that we just published in SNI. So here's your four or five synovial cysts. This is your
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sagittal image, your axial image. And then here is your cross sectional image.
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This is after you've injected, or you've tempted an aspiration and you're injecting to see if you actually ruptured the cyst. And here they ruptured the synovial cyst, but they also got a massive
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dural tear. So they also found some intradural dye because they made some various holes into the dural at the time that they were trying to aspirate the cyst. So here's a study from 2001. They
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failed to inject steroids into the cyst. That's one of the things they try to do, arguing the steroids will cause it to shrink. Here's the study that I said, you know, CT guided fluoro, you're
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trying to aspirate it. You're trying to dilate it and rupture it. And here's a more recent one from Pain 2016 Physician
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This is your interventional radiologist. And it failed to rupture. The synovial cyst in about 30 of cases and six of those patients had to have re-operations or had to have surgery in order to deal
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with the resultant complications.
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Here's a CT example of a very calcified hyperdense synovial cyst filling the right L23 foramen. And here I'm showing you the hyperdense synovial cyst filling the foramen and down below here is, you
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see how open this is, that's the open foramen, normal, calcified, abnormal. This is also a normal foramen above. So you have to figure out if these are super calcified synovial cysts, you're
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gonna have a really hard time aspirating these things. Here's an illustration, yeah, fair. You're making a very strong case about the, I mean, once you look at the slides and what you're doing,
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The case for aspirating these really becomes very limited. I mean, it probably shouldn't do it at all, but I could see a patient saying, Well, I'm not so sure about surgery. The guy referring
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him to interventionists and he wants to do as best he can. He makes multiple attempts to get this thing out. He obviously punctures the dura and creates some blood in the area and scar in the area.
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It makes it worse. It's obviously gonna come back and the patient comes back for the more complicated problem. I mean, looking at these films as you describe it with the AP and lateral, it's
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pretty obvious. That's
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really a wish that you can fulfill. Right, but the problem too is that the neurologists and a lot of our friends, the neuro radiologists or the interventionalists have it so set in their heads that
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they're gonna get these and they try and they even bring them back for a second and third tries in which case by the time they come to surgery, pretty sick, and the pathology has been significantly
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altered.
32:20
So here's just an illustration, again, of our central, you know, synovial cyst, central synovial cyst extrusion there. And here is a central synovial cyst fluid in both facettes. Here's your
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hypertrophy gel ligament, by the way. You're looking at this. You can't tell which side this came from So the large central cyst, you've got a patient that has a codercoinis syndrome, and they
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can't present acutely with a codercoinis syndrome, and you can't tell where it's come from. You try and aspirate that. You're not going to resolve their codercoinis syndrome. You really need to
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operate on those patients. And again, my uncle was a neuro radiologist, Bernie Epstein, and he used to say, if you can put a circle around each of these facettes and those circles kiss in the
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mid-line, you've got significant stenosis the more severe your stenosis, the more possible it is. to get these large central synovial cysts. That image is really impressive. You see how the canal
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is occupied by the cysts, the ligamentum flavum, and you see they cut a coin and it just squeezed down at the bottom there. And it just emphasizes how little room there is. And you can see, if
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you were trying with the minimally invasive approach through a tube on one side, look at this. This is your facet. This is your spinous process You've got a few millimeters of a lamina here. It
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doesn't give you much room to work in. So it's almost impossible to do that unless you knock off the facet on that side. So you've got to think about which operation is worth it. In a case like
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this you wind up doing a laminaectomy? Yes, yes. And then you can angle with the microscope underneath both sides and try to do your medial vasectomy and frame anotomy So here's an MR scans of.
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Massive sinuses at three, four, and four, five. This one is over here at three, four, and seen over here, and then here, another one at three, four.
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Dorsal, again, that hypo intensity is the capsule. There's some fluid in that cyst, and it's here's your disc space level, and it's going downward. It's not gonna be a disc herniation because
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it's dorsal Here is your axial images of L23 synovial cysts. Here's axial, here's your sagittal, and here's two, three on the sagittal, and there, sorry, was on the axial. I wanted to get back
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to that. Look at this one. That synovial cyst is really filling your spinal canal. Here, it's filling the spinal canal over to the left. Here, it's just filling your spinal canal centrally.
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Here's, I'm. Again, I'm in rural America, and I can do spine surgery, but we have a CT scan, maybe I have an MR down the street or something, or maybe I've got one in there, but I don't get
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images like you're showing here. And so I'm not getting the data. So in the patient's clinically symptomatic, it all fits. There is something there. You can see the compression, at least I'd be
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able to see that. And I can't get better imaging, what do I do?
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Well, number one, what's the clinical exam like, in terms of correlating the clinical exam with your non-contrast CT scan? The other thing is, if you have a CT scanner and you can't get an MR and
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you feel that you really need better definition, there's always still the myelogram CAT scan option. And that is too often forgotten.
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Obviously, it's always a great idea to get that MRI scan, but sometimes, you know, the cardiac pacemaker, the inaccessible alternative institution, et cetera, the most important thing is don't
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just turn around and say, oh, well, we'll get the MR in the morning and we'll send them to the next door, especially if they're sitting there with a quarter coin of syndrome and paraporetic or
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paraplegic. So if you have a CAT scan and you've got some, at least some definition, then you can do an operation based on that CAT scan or put in some dye and do a Milo CT. Is there a, again, I
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can get dye, we do it with some other procedures and so forth and putting some dye in there. Is that easy to do? I go above the lesion and put the dye in or how do I do this? In this case, I
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would definitely go above the lesion because if you go below, you don't want the patient to decompensate further. Right looks like it could be very nearly a complete block. And the radiologist
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should know amount of dye we use. And obviously, it goes away more quickly than the other lipid-based dyes that we use to help themselves. And then they have typically like 25 gauge needles and
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smaller needles that they can use in order to get that done. So there is another way you can use to define it. If you don't know it, I could do it almost virtually anywhere. I just have to slip
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some dye in there and take some images, right? That's right, yes. Terrific But be careful about going below the lesion, because if there is a complete block, you can precipitate worsening. Okay.
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Just as you were mentioning, you wanna go above the
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lesion. Yeah, okay. Okay, it's sometimes difficult to tell a lumbar disc apart from a synovial cyst on MR and CAT scan studies. Here is a clear cut dysmigration at the L4O5 level. It arose here,
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moving downward This is a sequestrated extruded fragment. Here is a paracentral L4-5 disc coming right out of the disc space itself. And here is a foraminal disc seen here. It's a little fuzzy,
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but in this case, that's what that happened to have been.
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Synovial SIS may look like discs on an MR, so this is what you're sometimes going to see. Here, this is synovial SIS at the L3-4 level, it moved upward, and that's your synovial SIS that's
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extruded upward. It's at the mid-pedical level of L3. Here
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is an extruded disc fragment, a rose at 3-4, moved upward. So you always have to figure out where is it gone, where is it going, and these have to be the differentials, because especially if you
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go in there, and you don't find the pathology that you think you're going to find at that disc space, and that patient has a significant neurological deficit.
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You have to look above. You've got to look below. You've got to go look pharaminally. Because too many cases where people go in, they say, Well, I don't think what I was doing. I didn't see
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anything there. There's nothing there. And then the patient ends up with a permanent deficit because you didn't look around. You have to know what that exam showed and correlate it with your
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findings to know what you're looking for. Here is an example where you have a synovial cyst and a disc. Synovial cyst is extruding from the facet joint directly. Good. Okay. That's pretty easy to
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delineate. But what about this? And this over here, this is your disc fragment. And this happens to be your dorsal root ganglion right here. But that's your disc fragment. So you have two
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pathologies there and you'll have to deal with those both at the same time.
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On the right hand side, on the other hand, this is a synovial cyst alone. It mimics a disc So this is all a synovial cyst here. That's your foraminal nerve root, by the way. And then here's your
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dural sac that's sitting over here, and here you can see the nerve roots sitting by gravity.
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If I only have a CT, I'm not gonna see that, right? You're not going to see that. The non-contrast CT is not gonna show you a great deal of detail. If you need to do it, do a Milo CT, if you
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can't get an MRI. Okay, fair enough. Some synovial cystic strew dorsally outside this spinal canal So here's an illustration of lumbar stenosis. And here is a dorsal extrusion of your synovial
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cyst. And here you can see, I just threw it in figuratively. And here is an MRI skin. It shows you bilateral dorsal extrusions of synovial cysts. The one on this side, the small one, and here
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on the other side, is the large one, okay? So, basically, we've gone through. Part one, which is the perspective on lumbar synovial cysts, my aim here was to show you what they look like on
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MRIs and CAT scans and to give you an idea of how extensive they are, how to recognize them and then to come up with a plan of formulation as to how to treat them and to just emphasize that these
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aspiration techniques, the neuro-radiological alternatives, aspirate, dilate, fenestrate, et cetera, often don't work.
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