Lumbar Intraspinal Synovial and Ganglion Cysts (Facet Cysts)

©lyyi. J. li. Lippincott (-ompany
Lumbar Intraspinal Synovial and
Ganglion Cysts (Facet Cysts)
Ten-Year Experience in Evaluation and Treatment
Ken Y. Hsu, MD,* James F. Zucherman, MD,* William J. Shea, MD.t
and Robert A. Jeffrey, MDt
Study Design. This study analyzed the clinical his
tory, physical examination, diagnostic studies, and op
erative and histoiogic findings in 19 patients with lum
bar intraspinal synovial and ganglion facet cysts
evaluated and treated over a 10-year period.
relieving symptoms. |Key words; facet degeneration,
ganglion cysts, intraspinal facet cysts, lumbar spine, sy
novial cysts] Spine 1995;20.000-000*~
Objectives. The results were correlated to provide a
greater understanding of the nature of lumbar facet
cysts and rationale for conservative or surgical treat
Synovial and ganglion cysts may arise from periarcicular
ments.
knee, ankle, and foot. Juxta-articular cysts in the spine
are less common. Intraspinal "synovial cysts" and "gan
glion cysts" have been defined, althougli it is not clear
whether they are two completely separate entities. Histologicnily, a true synovia! cyst has a surrounding lining
of synovial-likc epithelial cells. A ganglion cyst does not
have synovia] lining. !r has a collagenous capsule or
Summary of Background Data. The 19 patients in
cluded 13 women and 6 men ranging in age from 38 to
70 years. 84,4% of the patients presented with radicular
pain. 26.3% had significant motor deficit. 68.4% of the
"T^ei cysts were found at L4-i'l^, 21.1% at L5-S1, 5.2%
at 1.1-L2, and 5.2% at L2-L3. Their clinical pictures, im
aging studies, and surgical and histoiogic findings
were correlated in a retrospective fashion.
Methods. The clinical history and findings on physi
cal examination, standard radiography, myelography,
computed tomography-myelography, facet anhrography, post-facet arthrography, magnetic resonance imag
ing with and without contrast, and computed tomogra
phy scans were reviewed.
Results. Bilobed cysts were found on both dorsal
and ventral lispecis of the involved facet joints within
and outside of the spinal canal on facet arthrography.
computed tomography, magnetic resonance imaging,
and at the time of surgery in more than 60% of the pa
tients. Significant facet degeneration was found in 75%
of standard radiographs, and in all of the magnetic res
onance imaging and computed tomography scans, in
six patients, syniptoms improved with rest, medication,
and bracing, Epidural corticosteroid injections provided
short-term relief in three out of four patients. Facet cor
ticosteroid injections provided good relief in one, par
tissues, most commonly in the extremities at the wrist,
fibrous wall surrounding myxoid material. Some au
thors have suggested that a synovial cyst may evolve into
a ganglion cyst, and others have proposed that a ganglion
cyst may develop a synovial lining over cime.'"'^ Histo
iogic studies have demonstrated the presence of both sy
novial and ganglion cysts within the spine,although
the term "intraspinal synovial cyst" is more frequently
used in the lircrarurc. because our patients had both syno
vial and ganglion cysts rhat were associated with the facet
joints, the term "intraspinal facet cysts" will be used in the
present report.
In general, the literature, which consists of mostly
case reports, has emphasized the rarity of this condition
in the spine, although wc were able to find more than 65
articles, representing at least 120 cases.The largest
tial relief in one, and no relief in one patient. Surgical
reported scries of himbar intraspinal cysts described 10
decompression in eight patients resulted in three excel
patients.^''
lent, four good, and one fair outcome.
Conclusions. Most of the lumbar intraspinal facet
cysts were associated with significantly degenerated
facet joints. Patients with intraspinal facet cysts may
respond to conservative treatments if there is no signifi
cant neurologic deficit. Surgical decompression and
removal of large facet cysts usually are successful in
l-roin ".St. .Vlary's .Spmc Center, San Franci.seo, Calilornia, .ind fDc-
partincnt of Kadiology and $Dcpartnicnt of I'atlioiogy, St. Mary".*;
Hospital and Medical Center, San Franci-scn.
Accepted for publication July 19, 1994.
Device status category; 1,
Over the years, various diagnostic studies have been
used to identify intraspinal facet cysts. These include
myelography, computed tomography (CT), CT myelog
raphy, facet arthrography, post-facet CT arthrography,
and magnetic resonance imaging (MRI) with and with
out contrast agent. Treatment methods have ranged
from bed rest, bracing, percutaneous needle aspiration,
and facet corticosteroid injection to surgical removal of
rhc cysts.
In this report, we present our experience with 19
documented lumbar intraspinal facet cysrs evaluated
Figure 1. (A) Oblique projection of plain film series demonstrates severe degenerative changes at the right L4-L5 facet of a 57-year-oid
woman. (B) Computed tomography axial view demonstrates partially calcified cyst. Note the presence ofcystic massesventral anddorsal
to the degenerated facet joint. (C) Magnetic resonance imaging axial Tl-weighted image (TR 800/TE 30) reveals increased signal intensity
of inner rim with low signal emanating from the center ofthecyst. (D) Sagittal T2-weighted image (TR 2000/TE 65) shows uniform decrease
in signal intensity in this lesion. (E) Post-facet arthrogram CT scan demonstrates contiguity of the bilobed ventral and dorsal facet cyst.
u-\
V'
rreared over a 10-year period. Our methods have
C\
,-V- ,\n(
Nineteen patients were evaluated and created for lumbar in-
Nine patients had magnetic resonance examinations of the
lumbar spine. (Figures IC, D; 5C; 6B, C; 7B, C; 9A, B, C) and
two patients were injected with gadolinium dierhylcnetriamine
pcnta-aceric acid (Magnevist; Beriex Laboratories, Cedar
Knolls, New lersey;U'"igurcs lOA^ B.^.
craspiiiai facet cysc.>5 between Janii.nry 1982 and June 1992 at St.
Mary's HospirnI and Medical Center, San Fraticisco, California.
ures IE, 5D) and then CT scans were obtained. All CT scans
evolved with the development of new technologies.
•
Materials and Methods
The clinical history, physical examination, diagnostic studies,
and operative and iuscologic findings were reviewed. There were
1.3 women and 6 men in the study group. Their ages ranged from
.38 to 79 years, wirh an average age of .S8. Follow-up with
physical examination and diagnostic studies were performed in
14 pariLMUs, wirh a range of follow-up of 1.5 ro 8 years. In five
pacients, follow-up ranged from .? co i 1 months. Fifteen patients
were studied with standard radiogrnphj' of the lumbar spine,
inclutling oblititic projcction,s. (Figure.s lA, 2A)
Three of thc.se patients uiidcrwent lumbar myelography
followed by CF myclography of the involved areas. (C'Kurc.s.
1A;(3C;
b;^5.A, P>) Twelve pacients had routine CT scans
of the lumbar spine. Qugurcs IB; 2B, D, E; .3B;(6A;l7A;/'8A, B;
(9D, E)
'
^
In rhrec pacients, facet arthrograms were performed (Fig
were performed on either a General Electric 9800 (General
Electric, Milwaukee, WI) or a Technicarc 2060 (Solon, OH)
scanner. The magnetic resonance examinations were obtained
using a General Electric 1.5 Tcsla superconducting unit, a .03
Tcsla Fonar (Melville, New York) 500 permanent magnet, or
a Resonex (Sunnyvale, California) R4000. All magnetic reso
nance examinations included Tl-weighccd axial scans (TR
600-800, TE 20) and T2-wcighced (TR 2000, TE 80-100)
sagittal sequences. The slice thickness varied from 3 co 5 mm,
depending on machine and technique used. Additional T2wcighted axial scans were obtained in three (flip angle, 10°—
15°). All patients initially were treated with conservative mea
sures. Eight patients required surgical intervention. Epidural
corticosteroid injections were performed in four patients. In-
Figuru 2. (A) Lateral radiograph of a ^B-year-oid woman in September 1984 reveals mild degenerative changes at L4-L5. (B) Computed
tomography axial image in October 1986 demonstrates noncalcified cyst off right L4-L5. Patient was treated with corticosteroid injection
of facet joint and conservative management, (C) laiBrai radiograph in February 1991 reveals degenerative spondylolisthesis of 14 on 15.
Computed tomography scan with (D) axial and (E| sagittal reconstructed images demonstrate severe facet degeneration and bony erosive
changes. The cyst disappeared spontaneously.
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Figure 3. (A) Myelogram localizing posterolateral extradural defect at L5-S1 on the riaht side in a 72-vpar niri wnmpn /ri rnmnMtoH
o°™mTpJtient
'arge cyst occupying approximately 50% of the spinal canal. (C) Post-myelogram CT scan-axial view
jcciions of corticosteroid into the involved facet joints were
performed in ihrcc pacient.s (|-igi,re 9I-). i-indings were inci
dental in three patients. Seven surgical specimens were histo-
logicaliy examined. Patients' clinical history, physical cxaminntion. imaging modalities, and operative and histologic
findings were correlated in a retrospective fashion.
a*.
r
iiiinimrnPrrmTm
®
41
contiguous with facet vacuum
5,.
>r *:
-
demonstrates development of a cyst with air in the central cavity that is
Figure 5. (A) Oblique projection
from lumbar rriYelogram in a 48-
tyoar-old woman reveals charactorisiic extradural posteroiatern!
defect on subarachnoid column
of dye. (B) Computed tomograpfiy
myelogram documents 14 mm
noncalcified cyst on the left at
L4-L5. (Cj Tl-weighted MR! (TR
1000/TE 30) reveals homogenous
increased signal intensity in this
cyst. This lesion was not identi
fied on T2-weighted sagittal se
quence. (D) Post-facet arthrogram CT scan with patient prone
clearly demonstrates communi
cation between cyst and facet
joint.
•
T
Results
Nineteen incraspinal facet cysts were identified in 19
patients. Thirteen of the involved facet cysts were iden
tified nt L4-L5, four at L5-S1, and one each at Ll-12
and L2-L3. Seven patients reported only radicuiar pain,
lasting 6 weeks to 29 months and averaging 8 months.
Nine patients complained of back and lower extremit)'
pain. Three patients had only back pain. In the above 12 •f'"
patients, the duration of back pain was 3 months to 20
years, with an average of 7 years.
B
/I
D
Figure 6. (A) Computed tomography axial scan through L4-L5 demonstrates typical cyst extending from the degenerative left L4-L5 facet
joint of a 62-year-old man. Note faint calcification in the rim of the cyst. (B) Magnetic resonance imaging axial Tl-weighted images (TR
833; TE 11) demonstrate cyst with increased signal intensity when compared with the cerebrospina! fluid and poorly defined rim. (C)
Magnetic resonance imaging sagittal T2-weighted images (TR 1000; TE 30/70) demonstrate the difficulty in identifying this cyst. Note
decreased signal of the cyst rim and T2 prolongation of cyst contents.
7k'7- 8
S-2-\-3o
- LI - i
*
Figure 7. (A) Axial image from CT scan of a 53-year-old woman in April 1991 demonstrates only degenerative changes at the right L4-L5
facet joint. No cyst is evident. (Bj Magnetic resonance imaging axial Tl-weighted image (TR 817/TE 11) obtained in September 1991
demonstrates increased signal intensity in the cyst compared with the cerebrospinal fluid. (C) Sagittal T2-weighted images (TR 2000/TE
30/80) from the same study fails to demonstrate this cyst. (D) Surgical specimen stained with indigo carmine. (E) Histologic examination
of the surgical specimen revealed that most of its wall contained fibrous connective tissue without synovial lining. (Hematoxylin-eosin,
original magnification x350.) (F) Histologic examination of the base of the cyst adjacent to the facet joint where the synovial cells were
evident. (Hematoxylin-eosin. original magnification xlBO)
Physical examination revealed tenderness over the
involved facet joints in 12 paticnt.s. Facet maneuvers
with lumbar extension and lateral bending to the side of
superior-medial aspects of the involved facet joints.
These bilobed or dumbbell shaped lesions were other
wise similar in their CT appearance (Figure IB).
the lesion increased the back pain or radicular pain in
five patients. In one patient, manual compression of the
involved facet joint caused reproduction of radicular
on Tl-weighted axial scans was characteristic. In all
pain. The straight leg raising test was positive in seven.
Femoral nerve stretch test was positive in five. Signifi
cant motor deficits were noted in five patients. Sensory
changes were found in eight patients.
In 10 of the 15 patients, standard radiographs dem
onstrated degenerative changes at the involved facet
joints manifested by joint space narrowing and bony
overgrowth (Figure lA). Facet subliixation and degen
erative spondylolisthesis were identified in three. Three
myelograms demonstrated posterolaceral extradural fill
ing defects in three patients (Figure .3A).
On CT scan, the density of tlie facet cysts varied
significantly. In five ofthe patients, the scan appeared to
be completely cystic. In two of tiic patients, a rim of
calcification was identified, suggesting ossification
within the capsule (Figure 6A). Diffuse calcification was
scattered throughout the cyst in three patients (Figures
IB; 9D, E). In two patients, a focal globular area of
calcification was identified within the contents of the
cyst itself. The cysts varied in size from 5 to 16 mm.
Erosion of the cortical bone in the adjacent articulating
facets was identified in one patient, and in another, air
wa,s identified witliin the cy.sr and communicated with
air within die facet joint. All of the facet cysts were
identified as extradural masses adjacent to the facet
iigamcntum flavum within the spinal canal. Compres
sion of the dura] sac or nerve roots was identified in all
patients. In eight patients, the soft tissue mass appeared
to involve both the dorsal mferolatcral and the ventral
The magnetic resonance appearance of the facet cysts
instances, independent of CT density, the facet cysts
were of increased signal intensity compared with the
cerebral spinal fluid on Tl-weighted axial scans (Figure
6B). Signal intensity was nearly the same or slightly
increased when compared with the adjacent iigamcntum
flavuin. The cysts were of variable signal intensity on all
T2-wcighted sequences (Figures 9B, IOC). At times, the
facet cysts were extremely difficult to identify on sagittal
T2-weightcd sequences because of partial volume aver
aging and their variable signal intensity (Figures 6C,
7C). The capsule of the cyst had a well-defined, low
signal intensity on Tl- and T2-weighced sequences in
only two patients. These patients had densely calcified
rims on CT scans.
injection of contrast material in the facet joints of
three patients followed by CT scanning confirmed the
continuity of the cysts with the involved facet joints
(Figures IE, 5D). In these three patients, similar findings
were noted at the time of surgery. They were found to
have dorsal involvement of the cyst at the facet joint
(i^MgureJJ). As the paraspinal musculature was elevated,
cystic material was found emerging from the facet joint
before the spinal canal was exposed. Indigo carmine
solution injected into the dorsal component of the cystic
mass subsequently was found within the ventral com
ponent in the spinal canal. In our experience, indigo
carmine localization of the synovial cyst facilitated com
plete surgical resection (Figure 7D).
Significant calcification noted within the cystic mass
on CT was confirmed intraoperativeiy in two patients. A
chalk-like substancewas found along with gelatinous or
Of the 19 patients, 11 received nonsurgical treat
ments. Because the facet cysts were incidental findings in
mucinous material within the mass at the time of sur
gery. In the others, no apparent calcification was visu
alized during surgery. Degenerated mucinous material
was found ro be enclosed in the fibrous cyst wall. The
three, no treatment was directed to this condition in
cystic ma.ss compressed the diiral snc or the nerve root in
these patients. In six patients, symptoms improved with
conservative treatment, including rest, medication, and
bracing. Two patients were not included in follow-up.
all cases. The dural sac had adhered to the cyst wail in
Epidurai corticosteroid injections in four patients pro
three cases.
vided significant but short-term relief lasting 3 weeks to
2 months. One patient had no relief of symptoms. Facet
corticosteroid injections were performed in three pa
tients, with one having good relief, one partial relief,
Histologic examination of the surgical specimens in
four patients revealed that the cyst wall contained fi
brous connective tissue without synovial lining. In one
cyst, most of its wall was fibrous and devoid of synovial
lining cells, except at the base adjacent to the facet joint
and one no relief. A 48-year-oid woman received a facet
injection for an L4-L5 facet cyst documented on CT
where the synovial cells were evident (Figures 7E, F). In
scan (Figure 2B). After the injection, her symptoms im
proved for 5 months. However, more back pain subse
quently developed. Repeat CT scan 4.3 years later re
vealed the disappearance of the cysr and development of
the others, the internal surface of the fibrous wall was
lined with a layer of synovial-type cells. Amorphous
protcinaceous substance was found in the cyst interior.
Occasionally, hcmosidcrin deposits, small fragments of
calcified structure, bone, or cartilage were found.
progressive degenerative changes with erosion of sub-
chondral bone and formation of cavities (Figures 2D, E).
Serial radiographs over 6 years demonstrated a gradual
Other significant spinal pathologies were found in the
lumbar spine of eight patients. Those included severe
developmentof degenerative spondylolisthesisatL4-L5
spinal stenosis in two, stenosis and disc herniation in
two, multilevel disc degeneration and herniations in
three, and tumor metastasis in one.
(Figure 2C).
Surgical decompression with removal of the facet
cysts was performed in eight patients. We rated the
results as follows.
Excellent: complete resolution of symptoms.
Good: marked improvement, occasional pain, occa
sional use of pain medication.
Fair: some improvement, need for pain medications,
significant functional restrictions.
Poor: no change in symptoms, or worse.
There were three excellent results, four good results,
and one fair result. The patients with excellent results
S
had predominantly lower extremity pain of less than 1
t
year duration. The patient with a fair result had an
8-year history of low back pain and a 16-month history
of lower extremity pain with associated severe degener
ative disc disease and spinal .stenosis.
•
Discussion
A literature review showed chat most intraspinal syno
via! or ganglion cysts in the lumbar spine occur at
L4-L5 and occasionally ar L5-S1 and L3-L4.'~^'^ In the
present study, 68.4% were at L4-L5, 21.1% at L5-S1,
5.2% at L1-L2, and 5.2% at L2—L3. Increased joint
morion may predispose ro facet joint osreoartliritis, de
generative spondylolisthesis, and cyst formation at the
L4-L5 level, which generally has the most motion
within the lumbar spine.
Degenerative arthritic changes and increased joint
motion may lead ro proliferation or herniation of artic
ular tissue through a joinr capsule defect, resulting in
figure 8. (A, B) Soft tissue and bone windows from CT study of a
cyst formation.^" Altliough the term "intra.spinal syno
70-year-old man demonstrate calcification botii within the cyst
vial cyst" is commonly used in the literature, previous
and along its rim.
studies have demonstrated the presence of lumbar juxta-
which may accoun, fo. .he .agae.ic raaonan^Vsig'arcto^^
articular cysts with and without synovial lining ceils
i.nularly, our series iuid hoth types „i cysts Notably
one cyst sliowcd boti, features with most of its wall'
liurely fibrous, except for the base of the cyst which
c ntnined synovia! lining cells. It was not clear t'virc^er
ticatiMi, residual synovium. Ycc, the /indine of both
^ai"c;:':„d"'"the s::
arc
not entirer"'''""''
entirely separate entities
nenot
'S-'-'Slio"
or fibrous cyst)
PilnabkiT"'"''"'""
>1 betenderness over the involved facet joints. With
ta'L'eT"
ration. In eight patients, the bilobed configuration of the
cysts was documented on MRI, CT, post-facet CT ar-
wcr"^"
Cystic
masses
vcrc foundJi' on"u'i'"
the dorsal and ventral aspects
of severely
(Ic.gcncrated and hypcrtrophied facet joints, liven con
ventional radiographs showed marked degenerative
acct arthritis m75% of those who had standard radio
graphs. Serial radiographs in one patient over aS-year
period also documented the gradual development of
(cgenerative spondylohstlicsis in the involved level
These findings suggest that cysts may be one manifesta
tion n, the progression and spectrum of facet degenera-
mI a coniptcssion. rntlicninr j.ain cot,Id be teprodiiccd ,n one patient with CT scan, and MRI docu
five changes.
v
via cyst.
^Compression
Tcy
of s
the dorsal
t'c
aspect
»ofthethesyno
cvst
inrm'r' l7
probably cansed transmission of dnid pre sure to the
vcnttal portion of the cyst, testilting mnerve root ittn
diagnosis of
facet
" erarth
arthrogram-CT
" Tt scan, and '"MRI.
yelography,
Magnetic
CT scan,
reso-
"ancc imaging appears to offer the best means of visu-
ahrmg the cyst, especially with the use of contrast agent.
faLt joint. The^cysTrim is^bTacfo'^n
enhancement centrally within the cyst of the left L4-L5
Yiih ec
reported five cases of intraspinal synovial
cysts evaluated with noncontrast MRI and MRI using
gadolmium dicthyienctriaminc pcnta-acctic acid. They
demonstrated early enhancement of the solid compo
fibrous connective tissue, which showed immediate and
persistent enhancement.
nent and cyst periphery, delayed enhancement of the
Although synovia! cysts are fairly characteristic, ap
pearance of similar soft tissue mass in the epidural space
requires consideration in the differential diagnosis of
cyst cap.siilc, enhancement of the facet joint, and recog
extruded or sequestered disc fragment, metastatic tu
mor, meningioma, schwannoma, ncurofibroma with
loint space. Yuh er nl speculated chat the MRI solid
dcrmoid cyst. Kao et al'^' classified cxtradural intraspi
cysr, persi.ycnt enhancement of the .solid component and
nition of possible connection between the cyst and the
component represented the isolated dense hypervascular
cystic degeneration, arachnoid cyst, perineural cyst, and
nal cysts into the following three groups.
1. l^erineural cysts (arising from dorsal root gangli
on).
2. Arachnoid cysts (pedicle attachment to spinal dura
near nerve root).
3. juxta-facec cysts (ganglion and synovial cysts at
tached to periarticiilar connective ris.sue of facet
joints).
Not all intraspinal synovial cysts are symptomatic, as
shown by incidenrni findings in three of our patients.
Spontaneous reduction or resolution of the cyst may
occur with rest or bracing. Facet injection or a.spiration
K.HsCC
may be attempted if the cyst is not calcified. Adminis
tration ofcorticosteroids with orwithout local anesthet
ics into the adjacent facet joint may improve or resolve
Figure 11_ Illustration of lumbar facet cyst visualized at the time of
ciic problem. Computed tomography scans pre- and
lli ilIS emerging
emprnfn ffrom the same facet joint.
(11)
post-facet injection in one patient in our series demon
strated the disappearance of the cysr after the intranriiciilar corticosteroid injection. Epidural corticosre-
dorsal portion
roid injections provided symptomatic relief of up to 2
months in three of four patients in our study.
Such response to epidurai injections may lead the
physician astray regarding the actual diagnosis. When
the cyst is partially or completely calcified, there is less
likelihood ofspontaneous shrinkage with aspiration or
corticosteroid injection. Surgical decompression is indi
cated in the face of intractable pain and especially with
significant neurologic deficit orcaudn eqiiina syndrome.
Surgical decompression generally produces good relief
ftom the radiciilar pain. Ifthere also is significant insta
bility with spondyloiisthesis, fusion in addition to de
compression may be necessary.
17. Eggert H, Agnoli A, Mennel H. Lumbar intraspinal gan
glion cysts: Case reports. Acta Neurochir (Wein) 1981;59:
263-6.
18. Pardon DF, Simmons JD. Gas filled intraspinal synovial /
cyst: A case report. Spine 1989;14:127-79.
19. Franck, J, King R, Petro G, Kanzer M. A posttraumatic ^
lumbar spinal synovial cyst. J Neurosurg 1987;66:293-6.
20. Gortavi P. Extradural cysts of the spinal canal. J Neurol
Neurosurg Psychiatry 26:223-230, 1963.
21. Gritzka T, Taylor T. A ganglion arising from a lumbar
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22. Haase J. Extradural cyst of ligamentum flavum L4—A
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2.5. Hemniati M, Thomas C, Patel DV. Symptomatic intraspi
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Address reprint requests to:
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Ken Y. Hsu, MD
St. Mary's Spine Center
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One Shrader Street
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San Francisco, CA 94117
AJR Am J Roentgeno! 1984;143:875-6.
AQ-1 AL): abstract had to be shortened to fit journal format.
AQ-2 AU: figures have been renumbered to preserve proper numerical citation in the text. NOTE: this is a
requirement of this journal.
AQ-3 AU: 'scanner' OK to describe machines.'
AQ-4 AU: R4000 what.'
AQ-5 AU: 12 patients mentioned in this paragraph.' Clarify.
AQ-6 AU: inferohucral OK.'
AQ-7 AU: signal intensity of what? Sentence is unclear.
;