Spine Surgery for Synovial Cysts

Surgery may be considered for a lumbar synovial cyst if symptoms have not been relieved by nonsurgical treatments and the symptoms are severe, such as:

• Severe and/or progressive neurological issues, such as difficulty walking
• Severe pain, especially leg pain
• Spinal cord compression

The most common kinds of spine surgery for synovial cysts can be either a decompression alone or a decompression with a spine fusion.  A newer surgery called a TOPS system is also available for certain patients.

Surgery is mainly recommended for patients that would like to do more activity with less pain. The surgery is very effective for treatment of this condition.

While rare, immediate surgery may be needed if the cyst causes a dangerous condition called cauda equina syndrome.

Microdecompression Spine Surgery

If there is no associated instability with the cyst (e.g. no degenerative spondylolisthesis as seen on flexion/extension x-rays), then a microdecompression of the nerve root with removal of the cyst is reasonable. 

Basically, this is the same approach as would be used for a microdiscectomy, and is a minimally invasive surgery with a relatively quick recovery.

However, since the joint pathology that caused the original synovial cyst is still present, the cyst can re-form at a later date.

Microsurgical surgery for a synovial cyst typically has good results, especially in relieving leg pain and symptoms.

This type of surgery is usually done as an outpatient surgery, meaning that the patient returns home the same day as the surgery. The recovery time for a microdecompression without fusion is relatively short, requiring a few days to weeks of relative rest and return to almost all activities after about 6 weeks.

Decompression with Spine Fusion Surgery

The most reliable treatment method for a synovial cyst is to remove the cyst and then fuse the joint. Fusing the joint stops all the motion at that level of the spine, and without any motion, the cyst should not regenerate.

However, the spinal fusion is an extensive surgery, and there is a longer spinal fusion recovery period. 

The spinal fusion changes the biomechanics in the back because one of the joints in the motion segment will no longer function. The L4-L5 level has the most motion, and fusing it creates more stress on the other non-fused levels of the lower spine.

Also, the recovery period for lumbar spinal fusion surgery is longer, and it takes about six to nine months or more for the fusion to fully heal into a solid bone.

Watch Lumbar Spinal Fusion Surgery Animation

The decompression and fusion are done as part of the same operative procedure.

Decision-Making Factors for Patients

When deciding which treatment to pursue, patients need to base their decisions on three primary factors:

• The amount of pain they are having
• The length of time of their symptoms
• The amount of dysfunction it causes in their life

If the pain is relatively acute and tolerable, it is probably reasonable for the patient to modify his or her activities. If the pain is severe, then an injection might be more reasonable. If the pain is severe and has been going on for a while (e.g. years), or if the injections and physical therapy have not worked, then surgery is more reasonable.

For younger, more active patients, a trial of a microdecompression is probably a reasonable consideration provided there is no gross instability of the joints.

A microdecompression surgery is done with the knowledge that a fusion may be necessary in the future. 

For more elderly or less active patients, it may be more reasonable to jump to the definitive procedure of a fusion, since the stress transfer the fusion creates to the other joints is not as great in these patients and only one procedure would then be necessary.

See Microdiscectomy Spine Surgery: Risks, Complications, and Success Rates

TOPS System

A newer option is available for select patients, called TOPS.  This surgery is commonly done for patients with lumbar spinal stenosis and spondylolisthesis and may also be done for patients with a lumbar synovial cyst.

A TOPS system surgery is also a decompression surgery, and involves a spinal implant attached to the back of the spine and secured with pedicle screws.  The device provides structure and support to the back of the spine while still allowing motion at the L4-L5 motion segment.

Synovial Cyst Surgery Success Rates

The most successful surgery tends to be a decompression with a fusion. (approximately a 90-95% success rate should be expected, which means a significant reduction in pain, not necessarily pain free). However, this type of surgery is also the treatment that is the hardest to go through, and changes the biomechanics of the spine. It should be considered for people with moderate to severe activity limitations that have joint instability along with the cyst, and who have failed non-surgical treatments such as injections.

Recovery Time for Synovial Cyst Surgery

The recovery time and postoperative instructions vary depending on factors such as the type of surgery performed, the severity of the cyst, and the patient’s individual health factors.

In general:

• Recovery for a microdecompression without a fusion is relatively fast, with the patient returning home the same day as the surgery and a 4 to 6 week overall recovery time.
• For a decompression with fusion, the patient is more likely to stay overnight in the hospital and have a longer recovery time.  It takes 6 to 9 months or more for the fusion to fully set up and heal into one stable bone.

All the approaches have good success rates in terms of pain reduction, especially for leg pain, and is a reasonable approach for people who have not had meaningful symptom relief with nonsurgical treatments and who have with moderate to severe activity limitations and pain.