ABORDAGEM DOS CISTOS SINOVIAIS

MANAGEMENT — Management of symptomatic cysts includes treatment of the underlying joint disorder (when present), arthrocentesis, and intraarticular injection of the affected joint with glucocorticoids. This approach is based upon multiple case series and clinical experience.
Asymptomatic cysts found incidentally do not require treatment. We advise patients with asymptomatic cysts that there is a small risk of future cyst rupture. Patients should return if a cyst becomes symptomatic and should promptly seek further medical attention if they develop signs or symptoms of the pseudothrombophlebitis syndrome.
GENERAL MEASURES — In all patients with symptomatic cysts, we treat any underlying joint disorder that may be present, such as osteoarthritis, rheumatoid arthritis, which is causing the increased synovial fluid and enlarged cyst.
INITIAL THERAPY — We suggest treating adult patients with symptomatic, painful cysts, with or without calf involvement, with arthrocentesis and intraarticular injection with glucocorticoids (eg, 40 mg triamcinolone acetonide) using the same approach as that for osteoarthritis or rheumatoid arthritis. A significant decrease in the size of the cyst and/or discomfort is observed in approximately two-thirds of patients within two days to a week from the time of injection in various case series, which is consistent with our experience. Glucocorticoid injections into the joint space can also be effective in patients with cysts but without joint effusion.
Control of inflammation by glucocorticoid injection can reduce the pressure gradient between the joint and the cyst, can lead to symptomatic improvement, and can reduce the risk of recurrence.
In patients with a torn or other internal derangement, we also perform arthrocentesis and a glucocorticoid injection, which may provide temporary relief until a more definitive procedure can be performed.
TREATMENT OF CYST COMPLICATIONS — In patients with possible cyst complications, such as pseudothrombophlebitis or syndromes related to the compression of adjacent vascular structures or nerves, we perform the appropriate studies needed to diagnose and treat such complications.
• Patients with features of pseudothrombophlebitis due to dissecting or ruptured cysts should be treated with rest, elevation, and analgesics. We also perform arthrocentesis and intraarticular glucocorticoid injection in patients with this condition.
• Patients with nerve entrapment caused by enlarged or ruptured cysts may respond to intraarticular glucocorticoid injections.
• Patients with acute compartment syndrome require immediate surgical evaluation.
CYSTS RESISTANT TO INITIAL TREATMENT — In patients who do not respond to an initial injection with intraarticular glucocorticoids, additional therapeutic measures may be necessary if the diagnosis is confirmed:
• Accuracy of the diagnosis of cyst — Imaging studies to assess the anatomy and confirm the diagnosis should be obtained. This includes ultrasonography (if not already performed) and magnetic resonance imaging in patients in whom the diagnosis remains uncertain after ultrasound alone.
• Thus, consultation with an orthopaedic surgeon should be obtained in patients with persistent symptoms or functional impairment who have no response to injection and in whom pathology in the knee cannot be identified.
DIRECT CYST INJECTION — In patients who do not respond to intraarticular injection, ultrasound-guided direct aspiration of cysts, followed by injection of glucocorticoids, can be performed by clinicians experienced in this procedure. However, we usually avoid this approach because of the significant risk of recurrence related to failure to address the underlying joint pathology, the thick gelatinous character of the fluid that makes it difficult to aspirate, and the proximity of neurovascular structures in the popliteal fossa. In patients found to have noncommunicating cysts, this approach can be attempted prior to surgical excision.
SURGERY — Surgical excision may very infrequently be required if the cyst remains symptomatic with pain and/or limited mobility attributable to the cyst despite treatment of the underlying disorder and administration of intraarticular glucocorticoids. Generally, surgical excision should be reserved only for those cases where more conservative interventions have failed and where there is significant functional impairment that can be ascribed to the cysts. Potential risks include recurrence. Arthroscopic approaches include repair of the intraarticular abnormality with either removal of the cyst or debridement of the connecting capsular opening.

REFERÊNCIA: http://www.uptodate.com/contents/popliteal-bakers-cyst?source=search_result&search=cysto+synovial+de+baker&selectedTitle=2~150