AO Spine Clinical Practice Recommendations: Evidence-Based Surgical Strategies for Lumbar Synovial Cysts

Study DesignLiterature review with clinical recommendations.ObjectiveTo highlight key studies on the surgical management of lumbar spinal synovial cysts and to provide recommendations for practicing clinicians on the interpretation and use of the evidence presented in these studies.MethodsThe AO Spine Degenerative Knowledge Forum performed a focused narrative review and critical appraisal of recent literature addressing key management strategies for symptomatic LSCs. Three representative original studies evaluating percutaneous rupture, decompression with or without fusion, and full-endoscopic resection were selected based on relevance and methodological quality. Evidence was appraised using the GRADE methodology, and clinical recommendations were formulated and graded as strong or conditional.ResultsPercutaneous rupture may provide short-term symptom relief but demonstrates limited long-term efficacy, with over half of patients requiring surgery within one year. Surgical decompression alone is effective in stable segments but is associated with higher cyst recurrence rates. Decompression with fusion reduces recurrence and offers more durable axial back pain relief, particularly in the presence of mechanical instability or anticipated post-decompression instability. Endoscopic resection shows promising outcomes in carefully selected, stable patients, though evidence quality remains low and outcomes are dependent on surgeon experience.ConclusionsManagement of LSCs should be individualized based on clinical presentation and radiographic stability. Fusion is recommended when instability is present, while decompression alone or endoscopic techniques may be appropriate in stable segments. Higher-quality comparative studies are needed to refine treatment algorithms.