Spinal case of the month with short perspective: How would you treat this L3-L4 synovial cyst?

BACKGROUND: In this new section, Case of the Month with Short Perspective from Surgical Neurology International, we want to see how various spine surgeons would approach different spinal pathologies. In this first case, an elderly male presented with 3 years of lower back pain and progressive neurogenic claudication with bilateral radiculopathy that had exacerbated over the prior 6 months. An outside physician performed a magnetic resonance (MR) study of the lumbar spine that showed a massive synovial cyst filling the spinal canal (e.g., large bilateral cysts) at the L3-L4 level with grade I spondylolisthesis. The MR and CT studies also both demonstrated moderate L2-L3, and severe L3-L4 stenosis. METHODS: Despite the massive synovial cyst filling the spinal canal at the L3-L4 level, pain management (anesthesia training) spent 3 months performing three successive epidural steroid injections accompanied by attempts at percutaneous synovial cyst aspiration/rupture. RESULTS: By the time the patient presented to neurosurgery, he had developed severe neurogenic claudication, radiculopathy, myelopathy, and a cauda equina syndrome. Dynamic X-rays revealed a mild grade I degenerative spondylolisthesis at the L3-L4 level without active motion, while both computed tomography (CT) and MR studies confirmed moderate stenosis stenosis/ossification of the yellow ligament at the L2-L3 level, severe stenosis at L3-L4 level with spondylolisthesis, and massive bilateral synovial cysts at the L3-L4 level filling the spinal canal. CONCLUSIONS: Following an L2-L4 decompressive laminectomy without fusion (note the absence of motion intraoperatively at the L3-L4 level), the patient's symptoms resolved, and he regained normal function. How would you have managed this patient?