Is Surgery for Lumbar Facet Cysts a Thing of the Past? Evaluating the Efficacy of Percutaneous Facet Cyst Rupture as a Primary Treatment Modality

Article information

J Minim Invasive Spine Surg Tech. 2025;10(Suppl 2):S171-S176

Publication date (electronic) : 2025 July 31

doi : https://doi.org/10.21182/jmisst.2025.02257

Nishant Dineshkumar Juva, Abhay M. Nene, Priyank Patel

Wearespine, Mumbai, India

Corresponding Author: Nishant Dineshkumar Juva Wearespine, Mumbai, Godhra/Gujarat, India Email: n1juva@gmail.com

Received 2025 April 16; Revised 2025 June 14; Accepted 2025 June 15.

Abstract

INTRODUCTION

Lumbar facet cysts, also known as juxtafacet cysts (Figure 1), are fluid-filled sacs that arise from the facet joints of the spine, often in association with degenerative changes. These cysts can exert pressure on adjacent neural structures, leading to symptoms such as low back pain, neurogenic claudication, and more significantly, acute radiculopathy due to nerve root compression. While they are most commonly seen in older adults with degenerative lumbar spine disease, they can also appear in patients with subtle or even asymptomatic spinal pathology until a sudden onset of symptoms.

Figure 1.

Lumbar facet cyst on magnetic resonance imaging. (A) Sagittal cut. (B) Axial cut (arrow pointing towards cyst).

Traditionally, symptomatic lumbar facet cysts have been managed with surgical decompression (Figure 2), typically via laminectomy without [1,2] or with fusion [3,4]. While effective, surgery carries inherent risks including blood loss, infection, dural tears, and prolonged recovery, particularly in elderly patients or those with multiple comorbidities such as diabetes, cardiovascular disease, or poor functional reserve. For such patients, the invasiveness of surgery may outweigh the benefits, leading to the exploration of less aggressive alternatives.

Figure 2.

Excised lumbar facet cyst in decompression surgery (clinical image).

Percutaneous facet cyst rupture (PFCR) has emerged as a promising minimally invasive option that involves accessing the cyst via a spinal needle under imaging guidance, injecting contrast and steroid, and achieving decompression by rupturing the cyst. This technique can often be performed under local anesthesia, significantly reducing perioperative risk and recovery time. Despite being a relatively underutilized technique, growing clinical experience suggests that PFCR can provide immediate symptom relief in many patients and may delay or even eliminate the need for surgical intervention in selected cases.

This study aims to evaluate the efficacy of PFCR in a real-world clinical setting over a 10-year period, with a particular focus on the role of facet orientation as a predictor of treatment outcome. By identifying factors that influence the success of PFCR, we aim to refine patient selection criteria and expand the utility of this procedure in modern spine care.

MATERIALS AND METHODS

4. Patient Demographics

A total of 55 patients were included in the study: 27 males and 28 females, aged between 44 and 87 years. The cohort was divided based on facet joint orientation [5,6] (Figure 3) into 2 groups: favorable orientation group (24 patients) and unfavorable orientation group (31 patients).

Figure 3.

Schematic representation of lumbar facet orientation. (A) Coronal orientation (favorable). (B) Facet tropism (unfavorable). (C) Sagittal orientation (unfavorable).

5. Procedure Technique

All procedures were performed under computed tomography guidance using 1 of 2 approaches: (1) translaminar approach: needle insertion through the lamina; (2) transfacetal approach: direct access through the facet joint (Figure 4).

Figure 4.

Axial computed tomography (CT) cuts of the transfacetal cyst rupture technique. (A) Facet access (computed tomography-guided needle insertion). (B) Contrast to outline the facet and cyst margins. (C) Perineural leakage from the facet capsular rupture. (D) Transfacet needle tip along L4. (E) Epidural contrast leakage from the facet capsular rupture (showing circumferential dye spread).

Under local anesthesia, a 22-gauge spinal needle was used to access the affected facet joint. Iodinated contrast was injected to distend the cyst and confirm communication with the epidural space. A perineural injection comprising 20 mg of triamcinolone acetonide and 0.5 mL of 0.5% ropivacaine was administered along the nerve root sleeve.

Subsequently, the facet joint was flushed with additional saline until a "give" sensation indicated rupture of the cyst. This was visually confirmed by circumferential leakage of contrast into the epidural space. A second injection of 40-mg triamcinolone with 0.5-mL ropivacaine was administered into the facet joint postrupture.

RESULTS

1. Immediate Outcomes

Postprocedure, 49 of 55 patients (90.9%) reported immediate relief in radicular symptoms (Figure 5). Six patients experienced partial relief but noted improvement in functionality.

Figure 5.

Immediate postprocedure pain relief.

Average preprocedure VAS is 8.4 and average postprocedure VAS (first follow-up) is 2.2

There were no reported complications such as infection, bleeding, or neurological deterioration related to the procedure.

2. 1-Year Follow-up

Out of 54 patients available for 1-year follow-up (1 lost), 43 (79.6%) maintained significant pain relief without need for further intervention. One patient experienced cyst recurrence requiring revision PFCR. Two patients required surgery due to persistent symptoms. Eight patients presented with ongoing symptoms suggestive of lumbar canal stenosis, though not all required surgical treatment (Figure 6).

Figure 6.

One-year follow-up, with 1 patient lost to follow-up; 79.6% experienced pain relief at 1 year, 18.81% had lumbar canal stenosis, 3.7% opted for surgery, and 1.85% had recurrence.

3. Final Follow-up (≥2 years)

At the final follow-up (Table 1), 38 of 53 patients (71.6%) had sustained relief with no significant complaints; 23 of these had favorable facet orientation; 15 had unfavorable orientation; 10 patients continued to have symptoms suggestive of lumbar canal stenosis; 2 patients underwent revision PFCR due to recurrence; 3 patients ultimately required surgical intervention (1 underwent decompression alone, 2 underwent decompression with instrumented fusion); 2 patients were lost to follow-up after the 1-year mark.

Table 1.

Patient demographics and outcomes (n=55)

DISCUSSION

This study reinforces the clinical utility of PFCR as a first-line treatment for patients with acute radiculopathy secondary to lumbar facet cysts. The overall immediate response rate of over 90% and sustained relief in over 70% of cases at long-term follow-up reflect the efficacy of this minimally invasive technique. Similar findings of 98% immediate relief and significant long-term relief was published by Shah et al. [7] in 2018. And also by Cambron et al. [8] 87% success rate by PFCR was reported in 2013. They also mentioned that cyst rupture was very successful in high and intermediate signal intensity cysts as they are easier to rupture, perhaps because the cysts contain a higher proportion of fluid and are less gelatinous or calcified than T2 hypointense cysts and so patients with T2 hyperintense LFSCs are less likely to need surgery. Thus, this supports the findings obtained in this study that acute cyst ruptures are very successful.

A key finding of this analysis is the predictive value of facet joint orientation. Patients with favorable orientation not only had better outcomes but also demonstrated significantly lower recurrence rates and a reduced need for further surgical intervention. This may be due to improved access and more effective rupture in anatomically conducive orientations. Also, the shear stresses are more in the unfavorable facet orientations [9].

PFCR offers a distinct advantage in elderly and high-risk patients who may not tolerate open decompression surgery. It allows for symptom resolution without the morbidity associated with general anesthesia, hospital stay, or spinal instrumentation. Furthermore, patients who failed PFCR did not suffer procedural complications and were able to transition to surgery without delay or complication. Allen et al. [10] had published similar findings in 2009. The authors also emphasized that if even half of a highly-selected patient group can truly avoid surgery without undue morbidity, controlled trials appear warranted.

The technique's low complication rate and repeatability further support its use, particularly in patients needing short-term relief before a scheduled event or surgery, or in those with high surgical risk. Amoretti et al. [11] also published that they had no complications of PFCR in their study which is the finding of our study as well. They also suggested to consider PFCR as the first line of treatment.

CONCLUSION

PFCR is a safe, effective, and repeatable outpatient procedure that provides significant and often long-term pain relief in patients with symptomatic lumbar facet cysts.

Facet joint orientation is a strong predictor of outcome, with favorable anatomy associated with superior results and lower recurrence. PFCR should be considered a primary treatment modality, particularly in elderly, comorbid, or surgery-averse patients.

When unsuccessful, PFCR does not preclude future surgical options, making it a low-risk, high-reward intervention in the spectrum of spinal care.

Article information Continued