Pigmented villonodular synovitis originating from the lumbar facet joint: a case report
- First Online:
- Cite this article as:
- Oe, K., Sasai, K., Yoshida, Y. et al. Eur Spine J (2007) 16: 301. doi:10.1007/s00586-007-0403-1
- 71 Views
The authors successfully treated a rare case of pigmented villonodular synovitis (PVNS) that originated from the lumbar facet joint (L4-5). A 43-year-old man presented with a complaint of left severe sciatica causing difficulty in walking. Magnetic resonance imaging (MRI) demonstrated an extradural mass on the left side at L4 and the mass compressed the dural tube and was continuous with the left L4-5 facet joint. A computed tomography myelogram revealed an extradural defect of contrast medium at the L4 level and an erosion of the L4 lamina. A total synovectomy with unilateral osteoplastic laminectomy was performed. The histological findings were a diagnosis of PVNS. The patient’s symptoms resolved completely and the MRI at postoperative 3 years demonstrated no recurrence of PVNS. It is important to totally remove the synovium, which is the origin of PVNS in order to prevent the recurrence. We think that our procedure is reasonable and adequate for lumbar PVNS.
KeywordsPigmented villonodular synovitisLumbar spineSynovectomyJuxtafacet cystLaminoplasty
Pigmented villonodular synovitis (PVNS) is a slowly progressive mass lesion that arises in association with villous or nodular overgrowth in the synovial membranes of tendon sheaths, joints and bursae [12, 14, 31]. The etiology of PVNS remains controversial but degenerative change and trauma have been implicated [1, 2, 6, 9, 11–14, 20, 31]. It is well known that PVNS occurs in young individuals and affects the appendicular skeleton, particularly the knee and hip joints [2, 9, 16, 18, 19, 22, 23, 28]. The occurrence of PVNS in the axial skeleton is quite rare and there have been few reports of PVNS of the lumbar spine; specifically, only 18 cases are found in the English literature [4, 7, 8, 10, 16, 21, 23, 24, 26, 27, 30, 31]. There have been no reports focusing on surgical treatment for PVNS although it is important that the synovium is totally removed to prevent the recurrence . We successfully treated a case of PVNS that originated from the lumbar facet joint (L4-5) using total synovectomy with unilateral osteoplastic laminectomy.
In 1980, Kleinman et al.  reported the first case of spinal PVNS and thereafter 48 cases were reported in the English literature. However, there have only been 18 reported cases of PVNS of the lumbar spine. The pathologic findings of spinal PVNS are similar to those seen in lesions of the appendicular skeleton . In addition, imaged-based diagnoses can be readily made when spinal PVNS exists. CT findings in spinal PVNS usually demonstrate bone involvement (including erosion, scalloping and destruction) and increased attenuation, presumably related to iron within hemosiderin [25, 29]. Calcification is not a feature of PVNS. Involvement of the facet joint and discontinuity from the vertebral space should suggest the diagnosis and warrant an evaluation of PVNS. In general, on MRI, the intensity of the fluid in the mass is variably altered due to the process of hemorrhage. Moreover, synovial tissue, scar and hemorrhage can be confused within the mass of PVNS. On MRI, the intensity of PVNS is not definite, but the demonstration of continuity between the mass and the facet joint helps support the diagnosis of PVNS.
The management options for spinal PVNS include surgery, radiation therapy, and radioisotope infusion . The role of radiation therapy has not been clearly defined. Surgical resection is the primary treatment for this lesion. However, the rate of local recurrence for spinal PVNS has been reported from17 to 46%, such that it is relatively common occurrence [10, 22, 31]. In recent years, research has suggested that deoxyribonucletic acid ploidy status and proliferative index might be related to the potential for recurrence . There have been no reports focused strictly on the value of various surgical procedures (some authors recommend wide synovectomy and/or laminectomy), although it is important to totally remove the synovium in order to prevent the recurrence . In our case, a total synovectomy with a unilateral osteoplastic laminectomy was performed. In 1980, Kawai et al.  introduced osteoplastic laminectomy as a decompression procedure for lumbar spinal canal stenosis. We applied this procedure in a unilateral way to this patient. Using unilateral osteoplastic laminectomy, we were able to not only excise the mass under direct observation but also complete the total synovectomy. Consequently, we experienced no recurrence of PVNS as of 3 years following surgery. We think that this procedure is reasonable and adequate for PVNS of the lumbar spine.