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Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region in recent years. Dorsal, volar, ulnar, and radial accessory portals are used to reach all points of the carpal and hand joints. The minimal tissue damage, lesser injury to the capsule and its mechanoreceptors, the assessment of injuries associated with the reason for surgery, and aesthetically more favorable scars have attracted many doctors and their patients. As a result, there has been an increase in publications and diversifications of arthroscopic techniques. The aim of this update article is to present the advances and the evidence available in the literature to assist readers in their decision on which technique to use in the treatment of wrist and hand conditions.

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Background: A synovial cyst is a herniation of synovial tissue through a joint capsule, often mistaken for a ganglion cyst. The key distinctions are that synovial cysts have a synovial cell lining, while a ganglion cyst is delineated by dense fibrous connective tissue. Typically found near joints, synovial cysts are associated with conditions like osteoarthritis, prevalent in females aged 20 to 50. We present a rare case of a synovial cyst in the extensor digitorum superficialis of the right hand. Case summary: A 53-year-old Hispanic female visited our hand clinic due to a 3-year history of pain on the back of her right hand. At exploration, a 3 × 3 cm soft tumor was identified. Surgery revealed a clear-yellowish mass within the extensor digitorum superficialis tendon. Following the surgery, synovial cyst was confirmed by pathology and the patient was discharged without complications. Conclusion: This case highlights the rare presentation of an intratendinous synovial cyst and emphasizes the importance of a comprehensive understanding of synovial cysts in the differential diagnosis of hand tumors.

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Abstract Wrist and hand arthroscopy, despite being an old tool, has gained popularity and advanced in assisting in the treatment of various injuries and conditions in the region in recent years. Dorsal, volar, ulnar, and radial accessory portals are used to reach all points of the carpal and hand joints. The minimal tissue damage, lesser injury to the capsule and its mechanoreceptors, the assessment of injuries associated with the reason for surgery, and aesthetically more favorable scars have attracted many doctors and their patients. As a result, there has been an increase in publications and diversifications of arthroscopic techniques. The aim of this update article is to present the advances and the evidence available in the literature to assist readers in their decision on which technique to use in the treatment of wrist and hand conditions.

Resumo A artroscopia de punho e mão, apesar de ser uma ferramenta antiga, tem ganhado popularidade e avançado no auxílio do tratamento das mais diversas lesões e doenças da região nos últimos anos. Utilizam-se portais acessórios dorsais, volares, ulnares e radiais para se alcançar todos os pontos das articulações do carpo e da mão. O menor dano tecidual, a menor lesão da cápsula e de seus mecanoceptores, a avaliação de lesões associadas ao motivo da cirurgia e as cicatrizes esteticamente mais favoráveis têm atraído muitos médicos e seus pacientes. Com isso, houve um aumento das publicações e diversificações de técnicas artroscópicas. O objetivo deste artigo de atualização é mostrar os avanços e o que temos de evidência na literatura para apoiar os leitores na sua decisão sobre qual técnica utilizar nos tratamentos das doenças do punho e da mão.

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Objective To evaluate the efficacy of hypertonic saline infiltration as a sclerosing agent in the dorsal synovial cyst of the wrist. Method Patients of both genders, aged 18 years or older, with clinical and ultrasound diagnosis of synovial cyst, and without any previous treatment were selected. Case series in which 50 patients underwent aspiration of the contents of the cyst and infiltration of the hypertonic saline solution (2 ml sodium chloride solution 20% and 1 ml of lidocaine 2%). The patients were followed up for 24 weeks, when the parameters pain, strength, range of motion, function (quickDASH and Brief Michigan question), recurrence, and complications were evaluated. Results A total of 46 patients were evaluated for 24 weeks, 18 (39.1%) cysts evolved to resolution, and 28 (60.9%) presented recurrence. There was no statistically significant difference in the effect force or in the range of motion. There was no clinically significant difference in the scores of the questionnaires. The most frequent complications were pain and edema. Conclusion Infiltration with hypertonic saline solution for the treatment of dorsal synovial cyst of the wrist showed a recurrence rate of 60.9%.

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Abstract Objective To evaluate the efficacy of hypertonic saline infiltration as a sclerosing agent in the dorsal synovial cyst of the wrist. Method Patients of both genders, aged 18 years or older, with clinical and ultrasound diagnosis of synovial cyst, and without any previous treatment were selected. Case series in which 50 patients underwent aspiration of the contents of the cyst and infiltration of the hypertonic saline solution (2 ml sodium chloride solution 20% and 1 ml of lidocaine 2%). The patients were followed up for 24 weeks, when the parameters pain, strength, range of motion, function (quickDASH and Brief Michigan question), recurrence, and complications were evaluated. Results A total of 46 patients were evaluated for 24 weeks, 18 (39.1%) cysts evolved to resolution, and 28 (60.9%) presented recurrence. There was no statistically significant difference in the effect force or in the range of motion. There was no clinically significant difference in the scores of the questionnaires. The most frequent complications were pain and edema. Conclusion Infiltration with hypertonic saline solution for the treatment of dorsal synovial cyst of the wrist showed a recurrence rate of 60.9%.

Resumo Objetivo Avaliar a eficácia da infiltração da solução salina hipertônica como agente esclerosante no cisto sinovial dorsal do punho. Método Pacientes de ambos os sexos, com 18 anos ou mais, com diagnóstico clínico e ultrassonográfico de cisto sinovial, e sem nenhum tratamento prévio foram selectionados. Série de casos em que 50 pacientes foram submetidos a aspiração do conteúdo do cisto e infiltração da solução salina hipertônica (2 ml solução de cloreto de sódio 20% e 1 ml de lidocaína 2%). Seguimento realizado por 24 semanas, durante as quais foram avaliados os parâmetros dor, força, arco de movimento, função (questionários quick disabilities of the arm, hand, and shoulder [quickDASH] e brief Michigan), recorrência e complicações. ResultadoForam avaliados 46 pacientes por 24 semanas, 18 (39,1%) cistos evoluíram para cura e 28 (60,9%) cistos apresentaram recorrência. Não houve diferença estatisticamente significante nos quesitos força e arco de movimento. Não houve diferença clinicamente significante nos escores dos questionários. As complicações mais frequentes foram dor e edema. Conclusão A infiltração com solução salina hipertônica para tratamento do cisto sinovial dorsal do punho mostrou taxa de recorrência de 60,9%.

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ABSTRACT Facet joint ganglia are benign cystic lesions located adjacent to a facet joint. The majority is asymptomatic. However, can cause important low-back pain and radiculopathy. Neurogenic deficit, claudication, and cauda equina syndrome have also been reported. The authors report two cases of acute low back pain with bilateral sciatica, dorsal foot dysesthesia, and hallux dorsiflexion/extension deficit, due to the presence of encapsulated cysts adjacent to the facet joints causing a significant reduction of the spinal canal. Urgent surgical decompression was performed in both patients with an uneventful recovery. Symptomatic facet joint ganglia is a highly unusual cause of back pain, although it can present with acute onset of bilateral sciatica and canal stenosis requiring urgent surgical decompression. This paper highlights facet joint synovial as a differential diagnosis of lumbar pain and describes two different surgical approaches with good outcomes. Level of Evidence IV; Case Series.

RESUMO: Os quistos facetários são lesões císticas benignas localizadas adjacentes a uma articulação facetária. A maioria é assintomática. No entanto, podem ser causa de importante dor lombar e radiculopatia. Estão ainda relatados casos de déficit neurogénico, claudicação e síndrome de cauda equina. Os autores apresentam dois casos de dor lombar aguda com ciatalgia bilateral, disestesia do dorso do pé e défice na dorsiflexão/extensão do hálux, causados por uma redução significativa do canal medular devido à presença de quistos encapsulados adjacentes às articulações facetarias. Os doentes foram submetidos a descompressão cirúrgica urgente com uma excelente recuperação. Os quistos facetários sintomáticas são uma causa rara de lombalgia, porém podem apresentar-se inicialmente com um quadro agudo de ciatalgia bilateral e estenose canalar com necessidade de descompressão cirúrgica urgente. Este artigo realça os quistos facetários como diagnóstico diferencial de lombalgia e descreve duas abordagens cirúrgicas diferentes com bons resultados. Nível de Evidência IV; Série de Casos.

RESUMEN: Los quistes facetarios son lesiones quísticas benignas situadas junto a una articulación facetaria. La mayoría es asintomática. Pero pueden causar dolor lumbar y radiculopatía importantes. También se han descrito déficit neurogénico, claudicación y síndrome de cauda equina. Los autores presentan dos casos de lumbalgia aguda con dolor ciático bilateral, disestesia del dorso del pie y déficit en la dorsiflexión/extensión del hallux, causados por una reducción significativa del canal medular debido a la presencia de quistes encapsulados adyacentes a las articulaciones facetarias. Los pacientes fueron sometidos a descompresión quirúrgica urgente con una excelente recuperación. Los quistes facetarios sintomáticos son una causa poco frecuente de lumbalgia, aunque pueden presentarse inicialmente con un cuadro agudo de dolor ciático bilateral y estenosis del canal que requiere descompresión quirúrgica urgente. Este artículo destaca los quistes facetarios como diagnóstico diferencial de la lumbalgia y describe dos abordajes quirúrgicos diferentes con buenos resultados. Nivel de Evidencia IV; Serie de Casos.

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BACKGROUND: Synovial cysts are commonly associated with instability. Whether to fuse patients is a matter of controversy. Simple resection may offer favorable clinical outcomes but may come at the expense of recurrence rate. We describe our experience with the minimally invasive management of these lesions using microsurgical dissection through a tubular retractor system. MATERIALS: A retrospective cohort study of symptomatic patients with synovial cysts treated by a minimally invasive tubular approach from 2001 to 2018 was performed. We evaluated variables such as preexisting spinal pathology, previous surgery, radiological findings, comorbidities, and secondary surgery requiring fusion. We used the visual analog scale (VAS), the Oswestry disability index (ODI), and the Macnab scale for clinical evaluation. RESULTS: There were 35 patients with a mean age of 63 years. The mean duration of symptoms before surgery was 195 weeks. Axial pain was present in 77.1% of cases; radiculopathy was the main symptom in 94.3% of cases. The most frequent site was L4-L5 (62.8%). Presenting comorbidities were lumbar stenosis (28.6% of patients), spondylolisthesis (8.6%), and facet hypertrophy (31.4%). Mean surgical time was 143 minutes (range, 55-360 minutes). The mean hospital stay was 2 days, ranging from 1 to 5 days. No complications were encountered as a consequence of the surgical procedure. All patients showed neurophysiological improvement after surgical intervention. A total of 34 patients (97.14%) showed clinical improvement at the end of follow-up, averaging 17 months and ranging from 1 to 60 months, 28 patients (80%) had good to excellent Macnab outcomes, 6 patients (17.14%) were rated as fair, and 1 (2.86%) patient had a poor Macnab outcome. Radicular VAS significantly changed (P < .05) from a preoperative mean of 8.23 ± 1.24 to a postoperative mean of 2.23 ± 1.94. ODI significantly decreased (P < .05) from a preoperative of mean of 41.02 ± 12.56 to a postoperative of mean of 11.82 ± 10.56. We performed fusion at initial surgery in 37.1% of cases; however, 3 more patients required secondary fusion at follow-up. CONCLUSION: Our series corroborates the prior literature with a low incidence of synovial cysts in the cervical spine and none in the thoracic spine. The present work shows the efficacy of minimally invasive surgery in the treatment of these lesions. Synovial cysts were associated with instability, ultimately requiring fusion in the majority of patients. The authors' study includes a large patient series with minimally invasive microsurgical decompression performed through a tubular retractor to date. LEVEL OF EVIDENCE: 3.

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Background: Extradural synovial cysts (ESC) originate from an extrusion of the synovium in unstable or degeneratedjoints. In the spine, this condition can cause neurological signs such as hyperesthesia, proprioceptive ataxia and paresis.Since extradural presentations of synovial cysts are unusual in dogs, the aim of this manuscript is to report a case ofextradural synovial cyst of the cervical spine, as well as the clinical findings, diagnosis, surgical treatment and clinicalevolution after therapy.Case: A 3-year-old spayed Saint Bernard weighing 60 kg was presented to a Veterinary Medical Teaching Hospital with ahistory of acute paraparesis that evolved to non-ambulatory tetraparesis five days after the appearance of the first clinicalsigns. Neurological examination revealed non-ambulatory tetraparesis, normal muscle tone and segmental spinal reflexesin the thoracic and pelvic limbs, as well as cervical pain associated with limited neck movement. According to the neurological examination, the likely lesion location was the C1-C5 spinal cord segment. The differential diagnosis list includedintervertebral disc disease, caudal cervical spondylomyelopathy, neoplasm, infectious or noninfectious inflammatorydisease, and cystic diseases. Complete blood (cell) count and serum biochemistry tests were within reference limits. Thecerebrospinal fluid analysis revealed 35 mg/dL of protein (< 30 mg/dL) and 27 cells (up to 5 cells/mm3) with a predominance of lymphocytes. In plain radiography, bone proliferations of the C4 (caudal) C5 (cranial) articular processes wereobserved and, in myelography, extradural spinal cord compression was evident between C4-C5 on the right side. The animal underwent dorsal laminectomy for spinal cord decompression. An extradural synovial cyst and proliferated articularprocesses were removed. At 1,281 days after surgery, the dog was clinically normal and presented no neurological deficits...(AU)

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Background: Extradural synovial cysts (ESC) originate from an extrusion of the synovium in unstable or degeneratedjoints. In the spine, this condition can cause neurological signs such as hyperesthesia, proprioceptive ataxia and paresis.Since extradural presentations of synovial cysts are unusual in dogs, the aim of this manuscript is to report a case ofextradural synovial cyst of the cervical spine, as well as the clinical findings, diagnosis, surgical treatment and clinicalevolution after therapy.Case: A 3-year-old spayed Saint Bernard weighing 60 kg was presented to a Veterinary Medical Teaching Hospital with ahistory of acute paraparesis that evolved to non-ambulatory tetraparesis five days after the appearance of the first clinicalsigns. Neurological examination revealed non-ambulatory tetraparesis, normal muscle tone and segmental spinal reflexesin the thoracic and pelvic limbs, as well as cervical pain associated with limited neck movement. According to the neurological examination, the likely lesion location was the C1-C5 spinal cord segment. The differential diagnosis list includedintervertebral disc disease, caudal cervical spondylomyelopathy, neoplasm, infectious or noninfectious inflammatorydisease, and cystic diseases. Complete blood (cell) count and serum biochemistry tests were within reference limits. Thecerebrospinal fluid analysis revealed 35 mg/dL of protein (< 30 mg/dL) and 27 cells (up to 5 cells/mm3) with a predominance of lymphocytes. In plain radiography, bone proliferations of the C4 (caudal) C5 (cranial) articular processes wereobserved and, in myelography, extradural spinal cord compression was evident between C4-C5 on the right side. The animal underwent dorsal laminectomy for spinal cord decompression. An extradural synovial cyst and proliferated articularprocesses were removed. At 1,281 days after surgery, the dog was clinically normal and presented no neurological deficits...

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Introducción: Los quistes artrosinoviales espinales son lesiones infrecuentes que se originan principalmente en la región lumbar. Aunque el tratamiento conservador es posible, la resección quirúrgica es considerada el tratamiento de elección en pacientes sintomáticos. La inestabilidad postoperatoria es una preocupación. Las técnicas mínimamente invasivas (MISS) demostraron ser una alternativa válida que podría disminuir el riesgo de inestabilidad postoperatoria. Objetivo: Describir la importancia de la orientación facetaria en la elección del lado del abordaje (ipsilateral o contralateral) y la conservación de la unión articular en una serie de pacientes operados de quistes sinoviales lumbares por técnica tubular mínimamente invasiva. Material y métodos: Se evaluaron 8 pacientes con quistes sinoviales lumbares operados con técnica tubular mínimamente invasiva. Se analizó en RMN la relación entre la orientación de las facetas articulares y la vía de abordaje seleccionada, se evaluó además la resección de los quistes sinoviales y el grado de preservación facetaria postoperatoria. Información demográfica e intraoperatoria fue detallada. El resultado clínico fue valorado usando la Escala Visual Analógica (VAS) y los criterios de Macnab modificados para medir la satisfacción postoperatoria de los pacientes. El seguimiento mínimo fue de 6 meses. Resultados: Ocho quistes sinoviales fueron operados y resecados completamente. Cinco pacientes presentaron orientación facetaria coronal y 3 sagital los cuales fueron abordados del lado ipsilateral y contralateral respectivamente. En todos los casos se logró preservar al menos 2/3 de la unión facetaria del nivel comprometido. El tiempo promedio de cirugía fue de 110 minutos. Todos los pacientes fueron dados de alta dentro de las 24 hs. Se observó una mejoría de 6 puntos en el VAS. Según la escala de Macnab; 6 pacientes refirieron resultados excelentes, 1 bueno y 1 regular. No se registraron fístulas ni infecciones. Conclusión: La orientación de las facetas articulares definió el lado del abordaje. En facetas articulares con orientación coronal recomendamos el abordaje tubular ipsilateral y en facetas articulares con orientación sagital el abordaje contralateral. Esto permite una excelente exposición del quiste sinovial y la preservación de la articulación facetaria. Ensayos prospectivos con mayor tiempo de seguimiento y cohortes más grandes serían de utilidad para avalar nuestras recomendaciones.

Background: Spinal arthro-synovial cysts are uncommon lesions that largely originate in the lumbar area. Although conservative management is an option, surgical resection is considered the treatment of choice in symptomatic patients. Post-operative instability is of concern, however. Minimally-invasive surgery techniques have proven a valid option which might reduce post-surgical instability. The aim of this paper is to describe the importance of facet orientation in side selection for the surgical approach (ipsilateral or contralateral) and facet joint sparing in a series of patients undergoing minimally-invasive tubular surgery (MITS) for lumbar synovial cysts. Methods: Eight patients with lumbar synovial cysts undergoing MITS were assessed. Pre-operatively, magnetic resonance imaging (MRI) was performed to identify facet joint orientation and aid in surgical approach selection. Post-operatively, MRI was repeated to confirm resection of the synovial cysts and the level of post-surgical facet sparing. Demographic and intraoperative data were recorded, with post- versus pre-operative pain compared using a visual analog scale (VAS), and the modified Macnab criteria used to measure patients' post-operative satisfaction. Minimum post-operative follow-up was six months. Results: Eight synovial cysts were resected completely. Five patients had a coronal and three a sagittal orientation of their facet and were managed with an ipsilateral versus contralateral approach, respectively. In all cases, at least 2/3 of the involved facet joint was spared. Average surgical time was 110 minutes, and all patients were discharged within 24 hours. A mean 6-point improvement was observed in VAS pain severity. Using the Macnab scale, six patients reported excellent results, one a good result and one a fair result. No spinal leaks or infections were reported. Conclusions: Facet-joint orientation determines which side is used for the surgical approach. For facet joints with a coronal orientation, we recommend the ipsilateral tubular approach; while for joint facets with a sagittal orientation, the contralateral approach. This enables both excellent exposure of the synovial cyst and facet-joint sparing. Prospective trials with longer follow-up and larger cohorts are needed to validate our recommendations.

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