Intraneural Ganglia of the Common Peroneal Nerve in Children: Case Report and Review of the Literature

Complete foot drop due to atypical peroneal ganglion in a 13 ½ year old boy

INTRODUCTION

Peroneal nerve palsy due to compression by an intraneural ganglion is an uncommon entity in the pediatric setting with a need for surgical treatment. Uniquely in this case, the ganglion presented as an elongated instead of a typical round cyst, delaying diagnosis and treatment.

CASE PRESENTATION

We present the case of a 13 ½ year old boy with increasing peroneal nerve palsy due to an atypically shaped intraneural ganglion. An MRI of the knee revealed an elongated peroneal ganglion compressing the nerve between the lateral insertion of the gastrocnemius muscle and fibular head over a length of 10 cm. After surgical decompression and physiotherapy the peroneal nerve recovered well, achieving M 4 - 5 one year after surgery.

CONCLUSION

The atypical shape of the present peroneal ganglion delayed diagnosis and correct treatment. Though rare in the pediatric setting, this entity must be specifically looked for during the diagnostic workup of peroneal palsy, for time to surgery determines neurological outcome.

The current trend of proximal tibiofibular ganglion cyst: A summary of 7 case series and 61 case reports

Purpose

To review the different types of ganglion cysts surrounding the proximal tibio-fibular joint, their management options, outcomes, and recurrence.

Design

Descriptive analytical review.

Results

7 case series consisting of a total of 159 patients and 61 case reports consisting of 80 patients (with three patients having bilateral pathology) were included in this review. (Total cysts 159 + 83 = 242). The mean age was 41 years, and 71 % of the patients were males. 96.5 % of the cases were managed operatively, out of which 98 % of patients felt improvement in local symptoms and 71.5 % had improvement in neurological symptoms. Complete excision of the cyst is the primary mode of operative management. Many added procedures with complete excision are to mitigate the risk of recurrence. The recurrence rate of aspiration, simple excision alone, simple excision with recurrent articular branch neurectomy, and simple excision with PTFJ procedures were 77 %, 56 %, 11.5 %, and 0 %, respectively. Outcomes beyond recurrence were poorly reported.

Conclusion

There is not enough literature regarding the topic from which any formal systematic review can be done. Our summary suggests that aspiration alone or with steroid injection is associated with the highest recurrence rates among all the procedures. Complete excision with recurrent articular branch neurectomy should be the primary management. Revision cyst excision in isolation is an inadequate treatment option, therefore should be done in conjunction with PTFJ arthrodesis, which reduces the recurrence rates. Better quality studies are needed that report patient-centered outcomes and morbidities following PTFJ procedures.

Acute Foot Drop Caused by Intraneural Ganglion Cyst of the Peroneal Nerve: Literature Review and Case Report

BACKGROUND

Foot drop (FD) is characterized by an inability to lift the foot against gravity because of dorsiflexor muscle weakness. The aim of the present study is to report a clinical case of acute non-traumatic FD in patients with peroneal intraneural ganglion, after performing a scoping review on the methodological management of this disease.

METHODS

We performed a review of the literature and reported the case of a 49-year-old man with acute FD caused by an intraneural ganglion cyst of the peroneal nerve.

RESULTS

Out of a total of 201 articles, 3 were suitable for our review beyond our case report. The acute FD caused by peroneal intraneural ganglion can be managed by a careful clinical-instrumental differential diagnosis. A targeted surgery with subsequent rehabilitation produced a satisfactory motor recovery.

CONCLUSIONS

Acute FD requires an appropriate diagnostic-therapeutic framework to identify and effectively treat the causes in order to promote complete recovery.

Intraneural or extraneural ganglion cysts as a cause of cubital tunnel syndrome: A retrospective observational study

Purpose

Cubital tunnel syndrome caused by ganglion cysts has rarely been reported. The purpose of this study was to evaluate the surgical treatment outcomes of a patient diagnosed with cubital tunnel syndrome caused by intraneural or extraneural cysts and to summarize our experience.

Method

In total, 34 patients were evaluated retrospectively from January 2011 to January 2020 with a follow-up of more than 24 months. Preoperative data, such as demographic data, clinical symptoms, physical examination findings, and laboratory tests, were all recorded and pre-operative and post-operative data were compared. The function was evaluated by the modified Bishop scoring system and the McGowan grade at the last follow-up.

Results

Improvement of interosseous muscle strength, the Visual Analog Scale (VAS), 2-point discrimination (2-PD), electromyogram (EMG) result, Wartenberg sign, claw hand, and weakness could be clearly observed in all patients. Extraneural cysts were completely removed and the pedicles of the cysts were ligated. Intraneural cysts were incised and drained, and part of their cyst walls were removed using a microsurgical technique. All patients underwent anterior subcutaneous transposition (AST). At the last follow-up, McGowan's (0-IIa) grade increased from seven patients (20.6%) preoperatively to 27 patients (79.4%); the excellent and good rate according to the modified Bishop scoring system was 82.4% (28 patients), and all patients had no symptoms of recurrence after surgery.

Conclusion

The treatment of cubital tunnel syndrome caused by intraneural or extraneural cysts achieved good long-term results through extraneural cyst resection or intraneural cyst incision and drainage combined with subcutaneous transposition. Early diagnosis and surgical treatment are essential for the patient's postoperative recovery.

Intraneural Ganglion of the Peroneal Nerve-A Rare Cause of Pediatric Peroneal Nerve Palsy: A Case Report

Intraneural ganglia are benign mucinous cysts located within the epineurium of a peripheral nerve. The pathogenesis and formation of intraneural ganglia are controversial. The main theories described in the literature are of degenerative, synovial or de novo occurrence. We present the case of a 14-year-old boy who presented in our outpatient clinic with a complaint of interdigital neuralgia between hallux and second toe, as well as left foot drop. MRI examination showed a hyperintense cystic distension of the common peroneal nerve measuring 130 mm × 5 mm extending from the poplitea to the anterior compartment of the leg. We performed microscopic decompression and neurolysis surgery. The cyst showed a sac-like distension at its distal end with connection to the tibiofibular joint and was resected. After 8 weeks, postoperatively, the boy claimed to be pain-free and slight recovery of the superficial peroneal nerve was noticed. At 6 months postoperative, the patient showed a continuous improvement of motor function, demonstrating foot eversion with 3/5 muscle strength and foot extension with 2/5 muscle strength. Intraneural ganglia reported for pediatric patients represent a very rare entity. To the best of our knowledge, less than 15 cases have been described within the English-speaking literature.

Treatment approach to isolated common peroneal nerve palsy by mechanism of injury: Systematic review and meta-analysis of individual participants' data

BACKGROUND

We reviewed the individual participant data of patients who sustained isolated common peroneal nerve (CPN) injuries resulting in foot drop. Functional results were compared between eight interventions for CPN palsies to determine step-wise treatment approaches for the underlying mechanisms of nerve injury.

METHODS

PubMed, Embase, Cochrane Library, Web of Science, Scopus, and CINAHL databases were searched. PRISMA-IPD and Cochrane guidelines were followed in the data search. Eligible patients sustained isolated CPN injuries resulting in their foot drop. Patients were stratified by mechanisms of nerve injury, ages, duration of motor symptoms, and nerve defect/zone of injury sizes, and were compared by functional results (poor = 0, fair = 1, good = 2, excellent = 3), using meta-regression between interventions. Interventions evaluated were primary neurorrhaphy, neurolysis, nerve grafts, partial nerve transfer, neuromusculotendinous transfer, tendon transfer, ankle-foot orthosis (AFO), and arthrodesis.

RESULTS

One hundred and forty-four studies included 1284 patients published from 1985 through 2020. Transection/Cut: Excellent functional results following tendon transfer (OR: 126, 95%CI: 6.9, 2279.7, p=0.001), compared to AFO. Rupture/Avulsion: Excellent functional results following tendon transfer (OR: 73985359, 95%CI: 73985359, 73985359, p<0.001), nerve graft (OR: 4465917, 95%CI: 1288542, 15478276, p<0.001), and neuromusculotendinous transfer (OR: 42277348, 95%CI: 3001397, 595514030, p<0.001), compared to AFO. Traction/Stretch: Good functional results following tendon transfer (OR: 4.1, 95%CI: 1.17, 14.38, p=0.028), compared to AFO. Entrapment: Excellent functional results following neurolysis (OR: 4.6, 95%CI: 1.3, 16.6, p=0.019), compared to AFO.

CONCLUSIONS

Functional results may be optimized for treatments by the mechanism of nerve injury. Transection/Cut and Traction/Stretch had the best functional results following tendon transfer. Rupture/Avulsion had the best functional results following tendon transfer, nerve graft, or neuromusculotendinous transfer. Entrapment had the best functional results following neurolysis.

Intraneural ganglion cyst of the common peroneal nerve causing foot drop in a 12-year old child

OBJECTIVES

Intraneural ganglia are benign fluid-filled cysts contained within the subepineurial space of peripheral nerves. The common peroneal nerve at the fibular neck is by far the most frequently involved, although other nerves can be affected as well. Although the differential diagnosis of foot drop in adults and children show some differences, clinical presentation, diagnostic workup, treatment and follow-up of intraneural ganglia are quite similar in both groups. The primary objective was to create an overview of intraneural ganglia in children, with an emphasis on diagnostic workup and potential pitfalls during neurosurgical intervention, based on all available literature concerning this topic and own center experiences. As a secondary objective, we tried to raise the awareness concerning this unique cause of foot drop in childhood.

PATIENTS AND METHODS

We performed a review of the literature, in which children who developed foot drop secondary to an intraneural ganglion cyst of the common peroneal nerve were examined. A total of eleven articles obtained from MEDLINE were included. Search terms included: "pediatric", "children", "child", "intraneural ganglia", "intraneural ganglion cysts", "foot drop", "peroneal nerve" and "fibular nerve". Additional studies were identified by checking reference lists. Furthermore, we present the case of a 12-year old girl with foot drop caused by an intraneural ganglion cyst. She underwent cyst decompression with evacuation of intraneural cyst fluid and articular branch disconnection. PRISMA and CARE statement guidelines were followed.

RESULTS

We hypothesize that minor injury caused a breach in the joint capsule, resulting in synovial fluid egression along the articular nerve branch, corroborating the unifying articular theory and emphasizing the need for ligation of said branch. Foot drop is a predominant characteristic, explained by the proximity of the anterior tibial muscle motor branch near the articular branch nerve. In children, satisfactory motor recovery after surgical decompression is to be expected.

CONCLUSION

Sudden or progressive foot drop in children warrants an exhaustive neurophysiological and radiological workup. The management of intraneural ganglia is specific, consisting of nerve decompression, articular branch ligation and joint disarticulation, if deemed necessary. Our surgical results support the unifying articular theory and emphasize the importance of ligation and transection of the articular branch nerve, distally from the anterior tibial muscle branch, in order to prevent intraneural ganglia recurrence. This well-documented case adds depth to the current literature on this sparsely reported entity.

Intraneural Peroneal Ganglion Cyst Excision in a Pediatric Patient: A Case Report

CASE

A 14-year-old female presented with a profound foot drop after trauma to the right leg. Clinical examination and electrodiagnostic studies demonstrated a dense palsy of the common peroneal nerve. Magnetic resonance imaging revealed an intraneural peroneal ganglion cyst at the fibular neck. Surgical treatment included decompression and transection of the articular branch to the proximal tibiofibular joint. At the 1-year follow-up, the patient demonstrated complete recovery of peroneal nerve function.

CONCLUSIONS

This case demonstrates a rare finding of a pediatric intraneural peroneal ganglion cyst. The presentation and treatment is well-documented and adds depth to the literature on a sparsely reported condition.

Bilateral peroneal nerve palsy secondary to prolonged sitting in an adolescent patient

Peroneal nerve palsy most commonly occurs due to focal compression of the peroneal nerve at the level of the fibular head and causes foot drop and variable sensory loss. Mononeuropathies infrequently occur in childhood, bilateral peroneal palsy is very rare. In this article, we report the case of a 14-year-old boy with bilateral peroneal nerve entrapment which developed secondary to a prolonged sitting posture. We discuss the clinical assessment, diagnosis, and treatment of this rare case of bilateral peroneal palsy following prolonged immobility in light of the current literature.

Compressive peroneal neuropathy by an intraneural ganglion cyst combined with L5 radiculopathy: A case report

RATIONALE

Most cases of foot drop are known to result from lower motor neuron pathologies, particularly lumbar radiculopathy and peripheral neuropathy, including common peroneal neuropathy. To improve the prognosis of foot drop, it is important to quickly and accurately diagnose the etiology and provide appropriate treatment.

PATIENT CONCERNS

A 65-year-old female patient with a history of L4-5 intervertebral disc herniation presented with right foot drop that had developed 1 month previously.

DIAGNOSIS

Electrodiagnostic examination revealed common peroneal neuropathy combined with L5 radiculopathy, with the former being the main cause of the foot drop. MRI of the right knee was performed to identify the cause of the peroneal nerve lesion, which revealed an intraneural ganglion cyst in the common peroneal nerve.

INTERVENTIONS

The patient was treated by ultrasound-guided percutaneous cyst aspiration and corticosteroid injection into the decompressed ganglion, followed by strengthening exercise, electrical stimulation therapy, and prescription of an ankle foot orthosis.

OUTCOMES

We confirmed regeneration of the injured peroneal nerve at the follow-up electrodiagnostic examination 12 weeks after the intervention. In addition, the manual motor power test demonstrated an increase in the ankle dorsiflexor function score by one grade.

LESSONS

Diagnosing the cause of foot drop can be difficult with multiple co-existing pathologies, and consideration of various possible etiologies is the key for appropriate diagnosis and treatment. In addition to imaging modalities such as MRI, electrodiagnostic examination can help to improve diagnostic accuracy. Intraneural ganglion cyst of the common peroneal nerve is rare, but should be considered as a possible cause of foot drop.

Long-Term Functional Outcome After Surgical Treatment of Peroneal Intraneural Ganglion Cyst

BACKGROUND

Intraneural ganglia are benign mucinous cystic formations that originate within the epineurium of peripheral nerves. Different treatments have been recommended, with an overall satisfactory outcome. In this paper, we aim to evaluate the long-term outcomes of surgical treatment of peroneal intraneural ganglia by reviewing our local institutional experience.

METHODS

We performed a case series review of peroneal intraneural ganglia surgical treatment performed by the senior author. Demographic and surgical details were abstracted from the medical record for each patient. Electrodiagnostic studies and magnetic resonance imaging (MRI) were performed in all patients pre- and postoperatively.

RESULTS

Eight men were enrolled, with an average age at time of surgery of 47.5 years (range 28-68 years). Motor testing revealed a preoperative deficit of dorsiflexion, eversion, and toe extension in 7 patients, with a median preoperative Medical Research Council (MRC) score of 0/5. Sensory loss in the distribution of the common peroneal nerve was present in 7 patients. Mean clinical follow-up time was 113 months (range 32-189 months). Significant pain relief was achieved in all patients. Overall neurologic function was improved, more so for motor function. The median postoperative dorsiflexion, eversion, and toe extension at last follow-up were MRC score of 5/5. No complications occurred postoperatively. There was no clinical evidence of intraneural recurrence, as confirmed in postoperative MRI. In 2 patients, an extraneural cystic formation was visible in the anterior muscular compartment.

CONCLUSIONS

The data from our series support excellent long-term postoperative motor outcomes with a low recurrence rate. To avoid extraneural recurrence, resection of the superior tibiofibular joint is necessary.

Intraneural Synovial Cyst of the Common Peroneal Nerve: An Unusual Cause of Foot Drop with Four-Year Follow-Up

In our case report, we describe a 55-year-old male patient with isolated foot drop due to an intraneural synovial ganglion. We successfully treated the lesion with decompression via epineurotomy combined with primary division of the recurrent articular branch of the common peroneal nerve (CPN). Compression neuropathies of the common peroneal nerve arise from a variety of causes. Intrinsic compression due to intraneural ganglion cysts of the CPN is rare. Previous reports of simple decompression of the cystic fluid have resulted in recurrence. The unified articular theory describes a pathway for fluid to fill from the proximal tibiofibular joint into the CPN via a recurrent articular branch. In our case, we divide this articular branch which we feel prevents recurrence.

Peripheral nerve injuries in the pediatric population: a review of the literature. Part III: peripheral nerve tumors in children

INTRODUCTION

Peripheral nerve tumors type, inciedence and treatment in the pediatric population should be analyzed.

METHODS

We have performed an extense literature review of this subject.

RESULTS

incidence and distribution are similar to those observed in adults. The most common peripheral nerve tumors in children are neurofibromas and schwannomas. Malignant peripheral nerve sheath tumors are also observed, specially associated with genetic syndromes, like neurofibromatosis and Carney complex.

CONCLUSION

In this review, peripheral nerve tumors have been divided into three categories to aid with understanding: reactive and hyperplastic lesions, benign tumors, and malignant tumors. The most frequent lesions have been described.

Immediate Nerve Transfer for Treatment of Peroneal Nerve Palsy Secondary to an Intraneural Ganglion: Case Report and Review

Intraneural ganglion cysts, which occur within the common peroneal nerve, are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presented with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to flexor hallucis longus to a motor branch of anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, no evidence of recurrence and was able to bear weight without the need for orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.

The cubital tunnel syndrome caused by the intraneural or extraneural ganglion cysts: Case report and review of the literature

Cubital tunnel syndrome is the second most common nerve compression syndrome in peripheral nerve compression disease. Although potential ulnar nerve entrapment can occur at multiple points along its course, such as the arcade of struthers, the medial intermuscular septum, the medial epicondyle, the cubital tunnel, and the deep flexor pronator aponeurosis, the most common site of entrapment is the cubital tunnel. However, cubital tunnel syndrome could also be caused by the occupying masses along the course of ulnar nerve, such as intraneural or extraneural ganglia. The cubital tunnel syndrome caused by intraneural or extraneural ganglion cysts has been rarely reported. In our hospital, there were 184 patients with cubital tunnel syndrome who underwent surgical treatment from January 2010 to January 2014. Of these patients, 16 had extraneural cysts and 3 had intraneural ganglion cysts. The incidence rate of cysts in the cubital tunnel was 10.33%. Electromyography was used as routine examination. Ultrasound was used only in some patients in whom elbow mass was suspected. In the surgery of the cubital tunnel syndrome combined with cyst, if any other cysts were found, we should be remove completely the cyts and decompress the ulnar nerve thoroughly with the ulnar nerve being anterior transposition. These cysts were confirmed by histopathological examination. Finally, we compared the clinical features of patients who had a medial elbow ganglion with those of patients who had only cubital tunnel syndrome. B ultrasound can significantly improve the diagnosis. All patients were followed up for 4 months to 2 years, and the curative effect was good.

Immediate Nerve Transfer for the Treatment of Peroneal Nerve Palsy Secondary to an Intraneural Ganglion: Case Report and Review

Intraneural ganglion cysts that occur within the common peroneal nerve are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presents with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to the flexor hallucis longus to a motor branch of the anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, and no evidence of recurrence and was able to weight bare without the need of orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.