When it comes to chiropractic care, and health care in general across the lifespan, reasonable questions may be asked pertaining to the role we can play in reasonably reducing the need for surgery in the aging and frail populations. While certainly some surgeries are necessary (cancer removal and other lifesaving interventions for example), other surgeries are often recommended to restore movement, mobility and comfort as is the case with synovial cysts.
Is it therefore reasonable to try chiropractic care as a first resort rather than the more invasive surgical option? This case report comes with the usual disclaimer: We can’t rule anything in or out based on one case report, but this one certainly is an interesting read!
But first the background. Synovial cysts are relatively harmless growths that can develop throughout the spine, but most commonly in the lumbar region. The fluid filled sacs often form due to degeneration of the spine, whether that be driven by arthritis or simply older age. The synovium is an important feature of joints that facilitates smooth movement within the joint. Without the synovium, movements would be rough, sticky, and most likely painful due to the inevitable inflammation. Individuals with arthritis have a sense of the importance of this feature, as the synovium is often inflamed and degraded in the arthritic process, and movement of key joints becomes difficult and painful.
It follows that lumbar synovial cysts are more frequently observed in the 50+ age bracket, and while not inherently dangerous, they often cause discomfort and subsequently a reduced range of motion in the lower back.
So if one develops, how do we get rid of it?
Everyone’s spine experiences some degradation over time but due to our incomplete understanding of how and why these cysts develop, none of us can count ourselves ‘safe’ from a little fluid-filled friend emerging one day (of course, a healthy lifestyle can be nothing but protective against all ailments!)
There are multiple surgical interventions available that can effectively resolve synovial cysts. One option is surgically removing the cyst and fusing the joint to prevent the cyst returning. While this option is common and effective at preventing recurring issues, it is very invasive, requires a long recovery period (up to months), and permanently prevents the fused joint from moving. In the chiropractic world, this means a marked and permanent step away from the body’s natural adaptive state.
Considering lumbar synovial cysts are more common in older populations, surgical interventions with long recovery periods are not always suitable. As such, the hunt for an equally effective conservative approach is on. The current study cites literature involving the existing conservative approaches, such as cyst aspiration and steroid injection. While cyst aspiration (removing the fluid via a needle) provided significant immediate relief, most patients proceeded to undergo surgery. When radiofrequency ablation followed the cyst aspiration procedure the was a decrease in the recurrence of synovial cysts.
The study also cites previous case reports that describe the management of synovial cysts using the Cox® flexion-distraction technique protocol with good results. The case at hand was published in the Journal of Contemporary Chiropractic, and is referenced below if you’d like a thorough and complete explanation of the chiropractic protocols utilised.
The Case
A 75-year-old retired mailperson presented for care with primary concerns of lower back and right buttock pain. He had a history for Merkel Cell Carcinoma (neuroendocrine carcinoma) of the skin of his left leg, with chronic lymphedema in the left leg as a residual effect from the radiation therapy. He also had controlled hypertension, controlled atrial fibrillation, and a lumbar synovial cyst that was newly diagnosed by his neurologist. He reported that the pain in his lower back had been worsening with the pain beginning to radiate into the right buttock (4-5 month progression). It was now described as a sharp stabbing pain that was worse when standing, walking downstairs, and particularly at the right-foot heel-strike. Sitting did alleviate some pain, but it remained present to a degree. When rating the pain during his first consultation, he rated it a 3-4/10 while at rest and ‘fairly severe’ when standing or walking [1]. Additionally;
- Postural analysis revealed a left head tilt, high left shoulder, high right iliac crest and right rib humping. There was significant swelling in the left leg, and he wore a compression stocking.
- He had a limping gait.
- Active lumbar spine ranges of motion were all decreased, with a particularly painful right lateral flexion. The straight leg raise test elicited pain in the low back on the right side, at about 45 degrees of elevation.
- The Cox® tolerance test was performed to ensure there was no contraindication to using the flexion-distraction technique with this patient. (it was negative and okay for that treatment)
- An MRI was performed prior to presentation and revealed the large synovial cyst at the L4-L5 level
Based on the clinical experience of the treating chiropractor determined that a low-force flexion-distraction manipulation would be better tolerated and provide the best overall outcome for the patient, even though there was no specific contraindication to HVLA in this case.
The treatment plan involved 3 sessions a week of the Cox® flexion-distraction technique Protocol II, applied to the lumbar spine, for 2-4 weeks. In line with the Cox® protocol, one of the aims of care was to see a 50% relief in pain, measured subjectively by the patient.
While undergoing chiropractic care, the patient also remained under the care of his primary care physician, neurologist, and cardiologist. At home he performed the Cox® Lower Back Home Exercise daily. These included pelvic tilts, pelvic lifts, knee-chest, and hamstring stretch.
Outcomes
The patient received 6 sessions over 2.5 weeks. Despite the slightly infrequent care, the patient reported he felt markedly better following his fourth visit. The final revaluation on the 6th visit revealed a high left shoulder and high right pelvis. The active ROM of the lumbar spine remained slightly reduced but there was no pain. Flexion of the lumbar spine increased by 3%, right lateral flexion increased by 4%, and extension and left lateral flexion both increased by 8%. Notably, the patient rated his pain at rest as a 0 out of 10 and a 1-2 out of 10 when standing and walking. This was a significant decrease in subjective pain when compared to initial rating of 3-4 at rest and ‘fairly severe’ when standing.
His ODI score had improved by 24% following treatment. The patient noted improvements in the ‘personal care’ and ‘social life’ categories, and a significant improvement with ‘lifting’ and ‘changing degree of pain’.
The patient reported his condition was the best it had been in many months. He decided not to continue with further care. The treating chiropractor advised the patient that he had not reached maximum medical improvement, and further could be achieved. Follow-up conversations at 3-weeks and 22-months post-discharge revealed the patient was still feeling well and had not experienced any exacerbations of his symptoms.
While certainly it would have been desirable to have the patient continue under care, the importance of this case can’t be overstated, especially given the paucity of information on synovial cysts and chiropractic care and the profound comorbidities of the case. The latter would have made surgery more risky and recovery (potentially) more difficult.
While the limitations of this case mean there is more work to be done, it is interesting in that it supports the potential for successful management of lumbar synovial cysts as even a short course of care yielded a significant result – at least in the eyes of the patient.
We know surgery isn’t suitable for everyone, and not everyone wants to pursue that medical pathway, so more research on the how and why and backing up the efficacy of alternative/conservative management is needed. In future, it would be interesting to see if there was a change to the cyst at all (MRI) or even if there was a change pre-post in inflammatory markers. But we can dream.
REFERENCES
White, B., Kruse, R., & Olding, K. (2022). COX FLEXION-DISTRACTION UTILIZED IN THE MANAGEMENT OF A LOWER BACK PAIN IN A PATIENT WITH AN L4-L5 SYNOVIAL CYST: A CASE REPORT. Journal of Contemporary Chiropractic, 5(1), 50–56. Retrieved from https://journal.parker.edu/index.php/jcc/article/view/192
