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Jover-Sánchez JJ, Cristóbal-Velasco L, Benza-Villarejo E, Maldonado-Morillo AA. Tarsal tunnel ganglion cyst: intraneural or extraneural site? RADIOLOGIA 2023; 65 Suppl 2:S74-S77. [PMID: 37858356 DOI: 10.1016/j.rxeng.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Intraneural ganglion cysts are very uncommon lesions, whose diagnosis has increased since the articular theory and the description of the MRI findings were established. We present a case report of a 59-year-old man with symptoms of tarsal tunnel syndrome. Foot and ankle MRI demonstrated the presence of an intraneural cystic lesion in the posterior tibial neve and its connection with the subtalar joint through an articular branch. The identification of the specific radiological signs like the «signet ring sign» allowed establishing an adequate preoperative diagnosis, differentiating it from an extraneural lesion and facilitating the articular disconnection of the nerve branch during surgery.
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Affiliation(s)
- J J Jover-Sánchez
- Servicio de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, Spain.
| | - L Cristóbal-Velasco
- Servicio de Cirugía Plástica, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - E Benza-Villarejo
- Servicio de Radiodiagnóstico, Hospital Universitario de Getafe, Getafe, Madrid, Spain
| | - A A Maldonado-Morillo
- Servicio de Cirugía Plástica, Hospital Universitario de Getafe, Getafe, Madrid, Spain
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2
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Debs P, Fayad LM, Ahlawat S. Magnetic Resonance Neurography of the Foot and Ankle. Foot Ankle Clin 2023; 28:567-587. [PMID: 37536819 DOI: 10.1016/j.fcl.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
Peripheral neuropathies of the foot and ankle can be challenging to diagnose clinically due to concomitant traumatic and nontraumatic or degenerative orthopedic conditions. Although clinical history, physical examination, and electrodiagnostic testing comprised of nerve conduction velocities and electromyography are used primarily for the identification and classification of peripheral nerve disorders, MR neurography (MRN) can be used to visualize the peripheral nerves as well as the skeletal muscles of the foot and ankle for primary neurogenic pathology and skeletal muscle denervation effect. Proper knowledge of the anatomy and pathophysiology of peripheral nerves is important for an MRN interpretation.
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Affiliation(s)
- Patrick Debs
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Laura M Fayad
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD 21287, USA
| | - Shivani Ahlawat
- The Russell H. Morgan Department of Radiology & Radiological Science, The Johns Hopkins Medical Institutions, 600 North Wolfe Street, Baltimore, MD 21287, USA.
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3
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Khodatars D, Gupta A, Welck M, Saifuddin A. An update on imaging of tarsal tunnel syndrome. Skeletal Radiol 2022; 51:2075-2095. [PMID: 35562562 DOI: 10.1007/s00256-022-04072-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 05/02/2022] [Accepted: 05/07/2022] [Indexed: 02/02/2023]
Abstract
Tarsal tunnel syndrome (TTS) is an entrapment neuropathy of the tibial nerve (TN) within the tarsal tunnel (TT) at the level of the tibio-talar and/or talo-calcaneal joints. Making a diagnosis of TTS can be challenging, especially when symptoms overlap with other conditions and electrophysiological studies lack specificity. Imaging, in particular MRI, can help identify causative factors in individuals with suspected TTS and help aid surgical management. In this article, we review the anatomy of the TT, the diagnosis of TTS, aetiological factors implicated in TTS and imaging findings, with an emphasis on MRI.
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Affiliation(s)
- Davoud Khodatars
- Radiology Department, Royal National Orthopaedic Hospital, Stanmore, UK.
| | - Ankur Gupta
- Foot and Ankle Orthopaedic Surgery Department, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Matthew Welck
- Foot and Ankle Orthopaedic Surgery Department, Royal National Orthopaedic Hospital, Stanmore, UK
| | - Asif Saifuddin
- Radiology Department, Royal National Orthopaedic Hospital, Stanmore, UK
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4
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Jover-Sánchez J, Cristóbal-Velasco L, Benza-Villarejo E, Maldonado-Morillo A. Ganglión en el túnel del tarso: ¿localización intra o extraneural? RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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5
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Lui TH, Chan SK. Endoscopic Ganglionectomy of the Tarsal Tunnel: A Medial Approach. Arthrosc Tech 2021; 10:e1615-e1619. [PMID: 34258212 PMCID: PMC8252809 DOI: 10.1016/j.eats.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/01/2021] [Indexed: 02/03/2023] Open
Abstract
A ganglion inside the tarsal tunnel can compress the tibial nerve, leading to posterior tarsal tunnel syndrome. Classically, the ganglion is resected with an open approach. This requires release of the flexor retinaculum and dissection around the tibial neurovascular bundle, which may induce fibrosis around the tibial nerve. Endoscopic resection of a tarsal tunnel ganglion via a posterior approach has been reported. The purpose of this Technical Note is to describe the medial approach of endoscopic ganglionectomy of the tarsal tunnel. This is indicated for tarsal tunnel ganglia compressing the tibial nerve and extending to the flexor retinaculum. It is contraindicated if there is other pathology of the tarsal tunnel that demands open surgery; the ganglion compresses the tibial nerve from its deep side and does not extend to the flexor retinaculum; or in the presence of intraneural ganglion of the tibial nerve.
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Affiliation(s)
- Tun Hing Lui
- Department of Orthopaedics and Traumatology, Sheung Shui, NT, Hong Kong SAR, China
- Address correspondence to Tun Hing Lui, M.B.B.S (H.K.), F.R.C.S. (Edin.), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Rd., Sheung Shui, NT, Hong Kong SAR, China.
| | - Sui Kit Chan
- North District Hospital, Sheung Shui, NT, Hong Kong SAR, China
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6
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Migonis A, Murano R, Stillman IE, Iorio M, Giurini JM. A Case Report and Literature Review: Intraneural Ganglion Cyst Causing Tarsal Tunnel Syndrome. J Foot Ankle Surg 2019; 58:795-801. [PMID: 31053383 DOI: 10.1053/j.jfas.2018.11.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Indexed: 02/03/2023]
Abstract
Intraneural ganglion cysts are benign mucinous lesions that form within joints and enter adjacent nerves via an articular branch. Despite being morphologically characterized as benign, they can demonstrate considerable intrafascicular destruction and expansion, resulting in worsening compressive neuropathies or nerve injury. There have been several suggested theories of pathogenesis, but the most widely accepted articular (synovial) theory describes a capsular defect in a neighboring joint that allows joint fluid to egress and track along the epineurium of the innervating articular branch. In this case report, we describe an intraneural ganglionic cyst located in the tarsal tunnel with extensive involvement of the tibial nerve. We describe the symptoms, diagnosis, and treatment as well as review the current literature on intraneural ganglionic cysts.
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Affiliation(s)
- Alison Migonis
- Attending, Central Vermont Medical Center, Department of Orthopedics, Berlin, VT
| | - Raymond Murano
- Chief Resident, Division of Podiatric Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Clinical Fellow in Surgery, Harvard Medical School, Boston, MA
| | - Isaac E Stillman
- Attending, Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA; Associate Professor in Pathology, Harvard Medical School, Boston, MA
| | - Matthew Iorio
- Co-Director, Extremity Microsurgical Reconstruction, University of Colorado, Anschutz Medical Campus, Aurora, CO; Associate Professor in Surgery, University of Colorado, Aurora, CO
| | - John M Giurini
- Associate Professor in Surgery, Harvard Medical School, Boston, MA; Chief, Division of Podiatric Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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Ibrahim IK, Medani SH, El-Hameed MMA, Imam MH, Shaaban MMA. Tarsal tunnel syndrome in patients with rheumatoid arthritis, electrophysiological and ultrasound study. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2012.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Affiliation(s)
- Ibrahim Khalil Ibrahim
- Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University , Egypt
| | - Sameh Hafez Medani
- Diagnostic Radiology, Faculty of Medicine , Alexandria University , Egypt
| | | | - Mohamed Hassan Imam
- Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University , Egypt
| | - Mohamed Magdy Aly Shaaban
- Physical Medicine, Rheumatology and Rehabilitation , Faculty of Medicine , Alexandria University , Egypt
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8
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Ultrasound facilitates the diagnosis of tarsal tunnel syndrome: intraneural ganglion cyst of the tibial nerve. J Ultrasound 2018; 22:95-98. [PMID: 30019288 DOI: 10.1007/s40477-018-0314-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/11/2018] [Indexed: 02/06/2023] Open
Abstract
The tibial nerve intraneural ganglion cyst-which presents with fluid accumulated inside the nerve epineurium-is a rare etiology of tarsal tunnel syndrome. We report a case with insidious onset of numbness over his left medial ankle. Ultrasound imaging revealed that the tibial nerve was encircled by crescent-shaped anechoic substances, spanning from the distal leg to the sole. Magnetic resonance imaging disclosed a thickened tibial nerve wrapped by hyperintense materials in the tarsal tunnel. Some effusion was observed besides the tibialis posterior and flexor digitorum tendons as well. The patient underwent a surgical treatment and an intraneural ganglion cyst was confirmed. This report elaborated the clinical and imaging presentations of a tibial nerve intraneural ganglion cyst and highlighted the usefulness of ultrasound in exploring the cause of compressive neuropathy at the ankle region.
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Laumonerie P, Lapègue F, Reina N, Tibbo M, Rongières M, Faruch M, Mansat P. Degenerative subtalar joints complicated by medial plantar intraneural cysts : cutting the cystic articular branch prevents recurrence. Bone Joint J 2018; 100-B:183-189. [PMID: 29437060 DOI: 10.1302/0301-620x.100b2.bjj-2017-0990.r1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS The pathogenesis of intraneural ganglion cysts is controversial. Recent reports in the literature described medial plantar intraneural ganglion cysts (mIGC) with articular branches to subtalar joints. The aim of the current study was to provide further support for the principles underlying the articular theory, and to explain the successes and failures of treatment of mICGs. PATIENTS AND METHODS Between 2006 and 2017, five patients with five mICGs were retrospectively reviewed. There were five men with a mean age of 50.2 years (33 to 68) and a mean follow-up of 3.8 years (0.8 to 6). Case history, physical examination, imaging, and intraoperative findings were reviewed. The outcomes of interest were ultrasound and/or MRI features of mICG, as well as the clinical outcomes. RESULTS The five intraneural cysts followed the principles of the unifying articular theory. Connection to the posterior subtalar joint (pSTJ) was identified or suspected in four patients. Re-evaluation of preoperative MRI demonstrated a degenerative pSTJ and denervation changes in the abductor hallucis in all patients. Cyst excision with resection of the articular branch (four), cyst incision and drainage (one), and percutaneous aspiration/steroid injection (two) were performed. Removing the connection to the pSTJ prevented recurrence of mIGC, whereas medial plantar nerves remained cystic and symptomatic when resection of the communicating articular branch was not performed. CONCLUSION Our findings support a standardized treatment algorithm for mIGC in the presence of degenerative disease at the pSTJ. By understanding the pathoanatomic mechanism for every cyst, we can improve treatment that must address the articular branch to avoid the recurrence of intraneural ganglion cysts, as well as the degenerative pSTJ to avoid extraneural cyst formation or recurrence. Cite this article: Bone Joint J 2018;100-B:183-9.
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Affiliation(s)
- P Laumonerie
- Institut Locomoteur, Hôpital Pierre-Paul Riquet, Allée Jean Dausset, Toulouse 31059, France and Anatomy Laboratory, Toulouse Rangueil Faculty of Medicine, 133 Route de Narbonne, Toulouse 31062, France
| | - F Lapègue
- Institut Locomoteur, Hôpital Pierre-Paul Riquet, Allée Jean Dausset, Toulouse, 31059, France
| | - N Reina
- Institut Locomoteur, Hôpital Pierre-Paul Riquet, Allée Jean Dausset, Toulouse, 31059, France
| | - M Tibbo
- Mayo Clinic, 200 First Street SW, Rochester, Minnesota 55905, USA
| | - M Rongières
- Institut Locomoteur, Hôpital Pierre-Paul Riquet, Allée Jean Dausset, Toulouse 31059, France and Anatomy Laboratory, Toulouse Rangueil Faculty of Medicine, 133 Route de Narbonne, Toulouse 31062, France
| | - M Faruch
- Institut Locomoteur, Hôpital Pierre-Paul Riquet, Allée Jean Dausset, Toulouse, 31059, France
| | - P Mansat
- Institut Locomoteur, Hôpital Pierre-Paul Riquet, Allée Jean Dausset, Toulouse, 31059, France
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Sillat T, Pivec C, Bernathova M, Moritz T, Bodner G. Unusual Cause of Anterior Tarsal Tunnel Syndrome: Ultrasound Findings. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:837-839. [PMID: 28039874 DOI: 10.7863/ultra.16.03092] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2016] [Accepted: 05/27/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Tarvo Sillat
- Department of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Radiology Department, North Estonia Medical Centre, Tallinn, Estonia
| | - Christopher Pivec
- Department of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Maria Bernathova
- Department of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Thomas Moritz
- Institute for Pediatric and Gynecologic Radiology, Kepler University Hospital, Linz, Austria
| | - Gerd Bodner
- Department of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
- Private Ultrasound Center Vienna, Vienna, Austria
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Kawakatsu M, Ishiko T, Sumiya M. Tarsal Tunnel Syndrome Due To Three Different Types of Ganglion During a 12-Year Period: A Case Report. J Foot Ankle Surg 2017; 56:379-384. [PMID: 28073652 DOI: 10.1053/j.jfas.2016.11.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Indexed: 02/03/2023]
Abstract
A 52-year-old male complained of numbness and radiating pain affecting the plantar region of his left foot. He was found to have recurrent tarsal tunnel syndrome due to posterior tibial nerve compression by 3 different types of ganglion during a 12-year period. To the best of our knowledge, a similar case has not been documented. At the first operation, flexor retinaculum release and simple excision of an epineural ganglion were performed without injuring the nerve fascicles; however, an intrafascicular ganglion developed approximately 2 years later. At the second operation, the ganglion cyst was resected completely to prevent recurrence, despite the risk of nerve fiber injury. The cyst originated from the subtalar joint; thus, the joint was closed, and a free fat graft was placed to prevent adhesion formation. However, an extraneural ganglion occurred about 3 years later. At the third operation, the cyst was resected completely, and a free periosteal graft was used to close the joint more effectively. No recurrence had developed at 6 years after the third operation. The findings of the present case show the need for long-term monitoring of patients with tarsal tunnel syndrome caused by a ganglion owing to the possibility of recurrence related to different ganglion types.
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Affiliation(s)
- Motohisa Kawakatsu
- Chief, Department of Plastic and Reconstructive Surgery, Sumiya Orthopaedic Hospital, Wakayama, Japan.
| | - Toshihiro Ishiko
- Chief, Department of Plastic and Reconstructive Surgery, Otsu Red Cross Hospital, Shiga, Japan
| | - Masafumi Sumiya
- Chief Director, Department of Orthopaedic Surgery, Sumiya Orthopaedic Hospital, Wakayama, Japan
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The mechanism underlying combined medial and lateral plantar and tibial intraneural ganglia in the tarsal tunnel. Acta Neurochir (Wien) 2016; 158:2225-2229. [PMID: 27562681 DOI: 10.1007/s00701-016-2930-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/04/2016] [Indexed: 10/21/2022]
Abstract
Intraneural ganglion cysts in the tarsal tunnel are rare. We present a patient who had an intraneural ganglion cyst involving the medial and lateral plantar and distal tibial nerves. Magnetic resonance imaging revealed evidence to support the joint-related (i.e., subtalar) origin of the cyst. Careful reinterpretation of the imaging supported a phasic mechanism (i.e., cross-over) to explain the interrelated pathogenesis of the intraneural cyst within the three nerves. This mechanism is analogous to that described for the prototypes-the peroneal, tibial and sciatic nerves in the knee region-and can be generalized to other nerves in the foot and ankle region. We believe that understanding the pathogenesis sheds light on the effective treatment.
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Lui TH. Endoscopic Resection of the Tarsal Tunnel Ganglion. Arthrosc Tech 2016; 5:e1173-e1177. [PMID: 28224073 PMCID: PMC5310185 DOI: 10.1016/j.eats.2016.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 07/05/2016] [Indexed: 02/08/2023] Open
Abstract
The tarsal tunnel ganglion is a cause of posterior tarsal tunnel syndrome. Open resection of the ganglion calls for release of the flexor retinaculum and dissection around the tibial neurovascular bundle. This can induce fibrosis around the tibial nerve. We report the technique of endoscopic resection of the tarsal tunnel ganglion. It is indicated for tarsal tunnel ganglia arising from the adjacent joints or tendon sheaths and compressing the tibial nerve from its deep side. It is contraindicated if there is other pathology of the tarsal tunnel that demands open surgery; if the ganglion compresses the tibial nerve from its superficial side, which calls for a different endoscopic approach using the ganglion portal; or if an intraneural ganglion of the tibial nerve is present. The purpose of this technical note is to describe a minimally invasive approach for endoscopic resection of the tarsal tunnel ganglion.
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Affiliation(s)
- Tun Hing Lui
- Address correspondence to Tun Hing Lui, M.B.B.S.(HK), F.R.C.S.(Edin), F.H.K.A.M., F.H.K.C.O.S., Department of Orthopaedics and Traumatology, North District Hospital, 9 Po Kin Road, Sheung Shui, NT, Hong Kong SAR, China.Department of Orthopaedics and TraumatologyNorth District Hospital9 Po Kin RoadSheung ShuiNTHong Kong SARChina
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14
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Desy NM, Wang H, Elshiekh MAI, Tanaka S, Choi TW, Howe BM, Spinner RJ. Intraneural ganglion cysts: a systematic review and reinterpretation of the world's literature. J Neurosurg 2016; 125:615-30. [PMID: 26799306 DOI: 10.3171/2015.9.jns141368] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE The etiology of intraneural ganglion cysts has been controversial. In recent years, substantial evidence has been presented to support the articular (synovial) theory for their pathogenesis. The authors sought to 1) perform a systematic review of the world's literature on intraneural cysts, and 2) reinterpret available published MR images in articles by other authors to identify unrecognized joint connections. METHODS In Part 1, all cases were analyzed for demographic data, duration of symptoms, the presence of a history of trauma, whether electromyography or nerve conduction studies were performed, the type of imaging, surgical treatment, presence of a joint connection, intraneural cyst recurrence, and postoperative imaging. Two univariate analyses were completed: 1) to compare the proportion of intraneural ganglion cyst publications per decade and 2) to assess the number of recurrences from 1914 to 2003 compared with the years 2004-2015. Three multivariate regression models were used to identify risk factors for intraneural cyst recurrence. In Part 2, the authors analyzed all available published MR images and obtained MR images from selected cases in which joint connections were not identified by the original authors, specifically looking for unrecognized joint connections. Two univariate analyses were done: 1) to determine a possible association between the identification of a joint connection and obtaining an MRI and 2) to assess the number of joint connections reported from 1914 to 2003 compared with 2004 to 2015. RESULTS In Part 1, 417 articles (645 patients) were selected for analysis. Joint connections were identified in 313 intraneural cysts (48%). Both intraneural ganglion cyst cases and cyst recurrences were more frequently reported since 2004 (statistically significant difference for both). There was a statistically significant association between cyst recurrence and percutaneous aspiration as well as failure to disconnect the articular branch or address the joint. In Part 2, the authors identified 43 examples of joint connections that initially went unrecognized: 27 based on their retrospective MR image reinterpretation of published cases and 16 of 16 cases from their sampling of original MR images from published cases. Overall, joint connections were more commonly found in patients who received an MRI examination and were more frequently reported during the years 2004 to 2015 (statistically significant difference for both). CONCLUSIONS This comprehensive review of the world's literature and the MR images further supports the articular (synovial) theory and provides baseline data for future investigators.
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Affiliation(s)
| | | | | | - Shota Tanaka
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Japan; and
| | - Tae Woong Choi
- Department of Physical Medicine and Rehabilitation, Korea University Anam Hospital, Seoul, Republic of Korea
| | | | - Robert J Spinner
- Departments of 2 Neurologic Surgery.,Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota
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15
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Ganglion cyst versus synovial cyst? Ultrasound characteristics through a review of the literature. Rheumatol Int 2014; 35:597-605. [DOI: 10.1007/s00296-014-3120-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2014] [Accepted: 08/22/2014] [Indexed: 12/18/2022]
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Abstract
We describe the treatment of a ganglion within the ulnar nerve at the elbow and apply the concept that an intraneural ganglion arises from the joint adjacent to the nerve in which the ganglion is located. Successful treatment of nerve compression and prevention of recurrence of the ganglion require disconnection of the nerve from the joint and deflation, not excision, of the ganglion.
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Peripheral neuropathy caused by joint-related cysts: a review of 17 cases. Acta Neurochir (Wien) 2012; 154:1741-53. [PMID: 22941422 DOI: 10.1007/s00701-012-1444-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Accepted: 06/28/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND Clinical compression neuropathy caused by para-articular cysts is rare. Only recently, the unifying articular theory was proposed to clarify its true etiologic nature. The authors attribute 17 cases to this theory in order to illustrate the shift in the diagnostic and treatment protocol, and the possible impact on patient outcome. METHODS Eight intraneural and nine extraneural cysts were included. The proposed diagnostic protocol includes electromyography and ultrasound, followed by magnetic resonance imaging to characterize the cyst. The proposed treatment protocol consists of (1) ligation of the pedicle connecting the cyst with the afflicted joint, (2) decompression of the nerve and, when needed and (3) disarticulation of the superior tibiofibular joint (in case of peroneal nerve involvement). RESULTS Outcome was good to excellent in all patients, with recovery of sensory and motor function. Cyst recurrence was observed in three intraneural cases (18 %). Analysis of our own diagnostic protocol showed that atypical compression neuropathies should follow a strict diagnostic protocol to exclude missing the presence of a cyst. Ultrasound needs to play a crucial role, with MRI for cyst characterization and pedicle identification. CONCLUSIONS Retrospective proof in favor of the articular theory was found in all cases. An explanation for the cyst recurrences was formed based on the articular theory. In addition, a diagnostic and therapeutic protocol is proposed for all atypical peripheral compression neuropathies with the ultimate goal to achieve optimal patient outcome.
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Chalian M, Soldatos T, Faridian-Aragh N, Andreisek G, McFarland EG, Carrino JA, Chhabra A. MR evaluation of synovial injury in shoulder trauma. Emerg Radiol 2011; 18:395-402. [DOI: 10.1007/s10140-011-0973-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 06/22/2011] [Indexed: 11/30/2022]
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19
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Galloway KM, Lester ME, Evans RK. Clinical utility of tibial motor and sensory nerve conduction studies with motor recording from the flexor hallucis brevis: a methodological and reliability study. J Foot Ankle Res 2011; 4:14. [PMID: 21609432 PMCID: PMC3125324 DOI: 10.1186/1757-1146-4-14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 05/24/2011] [Indexed: 11/30/2022] Open
Abstract
Background Standard tibial motor nerve conduction measures are established with recording from the abductor hallucis. This technique is often technically challenging and clinicians have difficulty interpreting the information particularly in the short segment needed to assess focal tibial nerve entrapment at the medial ankle as occurs in posterior tarsal tunnel syndrome. The flexor hallucis brevis (FHB) has been described as an alternative site for recording tibial nerve function in those with posterior tarsal tunnel syndrome. Normative data has not been established for this technique. This pilot study describes the technique in detail. In addition we provide reference values for medial and lateral plantar orthodromic sensory measures and assessed intrarater reliability for all measures. Methods Eighty healthy female participants took part, and 39 returned for serial testing at 4 time points. Mean values ± SD were recorded for nerve conduction measures, and coefficient of variation as well as intraclass correlation coefficients (ICC) were calculated. Results Motor latency, amplitude and velocity values for the FHB were 4.1 ± 0.9 msec, 8.0 ± 3.0 mV and 45.6 ± 3.4 m/s, respectively. Sensory latencies, amplitudes, and velocities, respectively, were 2.8 ± 0.3 msec, 26.7 ± 10.1 μV, and 41.4 ± 3.5 m/s for the medial plantar nerve and 3.2 ± 0.5 msec, 13.3 ± 4.7 μV, and 44.3 ± 4.0 msec for the lateral plantar nerve. All values demonstrated significant ICC values (P ≤ 0.007). Conclusion Motor recording from the FHB provides technically clear waveforms that allow for an improved ability to assess tibial nerve function in the short segments used to assess tarsal tunnel syndrome. The reported means will begin to establish normal values for this technique.
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Affiliation(s)
- Kathleen M Galloway
- United States Army Research Institute of Environmental Medicine, Natick, MA, USA.,Oakland University, Rochester, MI, USA
| | - Mark E Lester
- United States Army Research Institute of Environmental Medicine, Natick, MA, USA
| | - Rachel K Evans
- United States Army Research Institute of Environmental Medicine, Natick, MA, USA
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Spinner RJ, Amrami KK. Superficial peroneal intraneural ganglion cyst originating from the inferior tibiofibular joint: the latest chapter in the book. J Foot Ankle Surg 2010; 49:575-8. [PMID: 21035042 DOI: 10.1053/j.jfas.2010.08.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2010] [Indexed: 02/03/2023]
Affiliation(s)
- Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Stamatis ED, Manidakis NE, Patouras PP. Intraneural ganglion of the superficial peroneal nerve: a case report. J Foot Ankle Surg 2010; 49:400.e1-4. [PMID: 20510632 DOI: 10.1053/j.jfas.2010.04.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Indexed: 02/03/2023]
Abstract
Ganglia affecting the peripheral nerves of the foot and ankle are rare. The most frequent location of occurrence is the common peroneal nerve at the level of the fibular neck. We report the case of an intraneural ganglion of the superficial peroneal nerve and its branches. Although there have been many previous reports of intraneural ganglion involvement with the common peroneal nerve, deep peroneal nerve, sural nerve, and the posterior tibial nerve, to our knowledge, this is the first reported occurrence of an intraneural ganglion distinctly localized to the superficial peroneal nerve and its branches. The presumptive diagnosis was made preoperatively using magnetic resonance imaging, and then confirmed postoperatively by pathologic examination. Despite the use of operative magnification, it was impossible to remove all of the cyst elements within the nerve trunk, because the nerve fascicles were intimately intertwined. Therefore, complete resection of the common trunk of the superficial peroneal nerve and its terminal branches was performed, and the proximal stump was buried in a hole in the distal fibula. Two years after the surgery, the patient was pain free and asymptomatic except for cutaneous anesthesia in the distribution of the superficial peroneal nerve.
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Davis GA, Cox IH. Tibial intraneural ganglia at the ankle and knee: incorporating the unified (articular) theory in adults and children. J Neurosurg 2010; 114:236-9. [PMID: 20415523 DOI: 10.3171/2010.3.jns10427] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The etiology of intraneural ganglia has been debated for centuries, and only recently a unifying theory has been proposed. The incidence of tibial nerve intraneural ganglia is restricted to the occasional case report, and there are no reported cases of these lesions in children. While evidence of the unifying theory for intraneural ganglia of the common peroneal nerve is strong, there are only a few reports describing the application of the theory in the tibial nerve. In this report the authors examine tibial nerve intraneural ganglia at the ankle and knee in an adult and a child, respectively, and describe the clinical utility of incorporating the unifying (articular) theory in the management of tibial intraneural ganglia in adults and children. METHODS Cases of tibial intraneural ganglion cysts were examined clinically, radiologically, operatively, and histologically to demonstrate the application of the unified (articular) theory for the development of these cysts in adults and children. RESULTS Two patients with intraneural ganglion cysts of the tibial nerve were identified: an adult with an intraneural ganglion cyst of the tibial nerve at the tarsal tunnel and a child with an intraneural ganglion cyst of the tibial nerve at the knee. In each case, preoperative MR imaging demonstrated the intraneural cyst and its connection to the adjacent joint via the articular branch to the subtalar joint and superior tibiofibular joint. At surgery the articular branch was identified and resected, thus disconnecting the tibial nerve intraneural cyst from the joint of origin. CONCLUSIONS These cases detail the important features of intraneural ganglion cysts of the tibial nerve and document the clinical utility of incorporating the unifying (articular) theory for the surgical management of tibial intraneural ganglia in adults and children.
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Affiliation(s)
- Gavin A Davis
- Department of Neurosurgery, Cabrini Hospital, Malvern, Victoria, Australia.
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Value of computed tomography arthrography with delayed acquisitions in the work-up of ganglion cysts of the tarsal tunnel: report of three cases. Skeletal Radiol 2010; 39:381-6. [PMID: 20112106 DOI: 10.1007/s00256-009-0864-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Revised: 12/11/2009] [Accepted: 12/14/2009] [Indexed: 02/02/2023]
Abstract
Ganglion cysts are a common cause of tarsal tunnel syndrome. As in other locations, these cysts are believed to communicate with neighboring joints. The positive diagnosis and preoperative work-up of these cysts require identification and location of the cyst pedicles so that they may be excised and the risk of recurrence decreased. This can be challenging with ultrasonography and magnetic resonance (MR) imaging. We present three cases of symptomatic ganglion cysts of the tarsal tunnel, diagnosed by MR imaging, where computed tomography (CT) arthrography with delayed acquisitions helped to confirm the diagnosis and identify precisely the topography of the communication with the subtalar joint. These cases provide new evidence of the articular origin of ganglion cysts developing in the tarsal tunnel.
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Pseudotumoral ganglion cyst of a finger with unexpected remote origin: multimodality imaging. Skeletal Radiol 2010; 39:375-9. [PMID: 19894046 DOI: 10.1007/s00256-009-0816-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2009] [Revised: 09/22/2009] [Accepted: 10/01/2009] [Indexed: 02/02/2023]
Abstract
The case of a ganglion cyst in the pulp of a fifth finger in an elderly woman initially mimicking a soft tissue tumor is described. Most typical sites of ganglion cysts are well documented at the wrist and in the vicinity of inter-phalangeal and metacarpo-phalangeal joints. In this case, ultrasonography (US) and magnetic resonance imaging (MRI) demonstrated a cystic lesion within the pulp of the fifth finger and indicated carpal osteoarthritis as the distant-and unexpected-origin of the lesion. The suggested diagnosis of ganglion cyst was confirmed by computed tomography arthrography (CT arthrography) of the wrist, which showed opacification of the cyst on delayed acquisitions after intra-articular injection into the mid-carpal joint, through the fifth flexor digitorum tendon sheath. The communications between the degenerative carpal joint, the radio-ulnar bursa, the fifth flexor digitorum tendon sheath and the pedicle of the cyst were well demonstrated.
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Hébert-Blouin MN, Amrami KK, Wang H, Skinner JA, Spinner RJ. Tibialis anterior branch involvement in fibular intraneural ganglia. Muscle Nerve 2009; 41:524-32. [DOI: 10.1002/mus.21522] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Spinner RJ, Scheithauer BW, Amrami KK. THE UNIFYING ARTICULAR (SYNOVIAL) ORIGIN OF INTRANEURAL GANGLIA. Neurosurgery 2009; 65:A115-24. [DOI: 10.1227/01.neu.0000346259.84604.d4] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
THE PATHOGENESIS OF intraneural ganglia has been an issue of curiosity, controversy, and contention for 200 years. Three major theories have been proposed to explain their existence, namely, 1) degenerative, 2) synovial (articular), and 3) tumoral theories, each of which only partially explains the observations made by a number of investigators. As a result, differing operative strategies have been described; these generally meet with incomplete neurological recoveries and high rates of recurrence. Recent advances in magnetic resonance imaging and critical analysis of the literature have clarified the mechanisms underlying the formation and propagation of these cysts, thereby confirming the unifying articular (synovial) theory. By identifying the shared features of the typical cases and explaining atypical examples or clinical outliers, several fundamental principles have been described. These include: 1) a joint origin; 2) dissection of fluid from that joint along an articular nerve branch, extension occurring via a path of least resistance; and 3) cyst size, extent, and directionality being influenced by pressures and pressure fluxes. We believe that understanding the pathogenesis of these cysts will be reflected in optimal surgical approaches, improved outcomes, and decreased frequency, if not elimination, of recurrences. This article describes the ongoing process of critically analyzing and challenging previous observations and evidence in an effort to prove a concept and a theory.
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Affiliation(s)
- Robert J. Spinner
- Departments of Neurologic Surgery, Orthopedics, and Anatomy, Mayo Clinic, Rochester, Minnesota
| | | | - Kimberly K. Amrami
- Departments of Neurologic Surgery and Radiology, Mayo Clinic, Rochester, Minnesota
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Abstract
MRI has become the modality of choice for imaging the peripheral nervous system. When technically optimized and customized for individual clinical problems, MRI can provide insight into the underlying causes of neoplastic, inflammatory, and other diseases affecting peripheral nerves with a high degree of accuracy and effectively distinguish benign from malignant processes. With high-resolution imaging techniques targeted fascicular biopsy can be planned to improve diagnostic yield and decrease the risk of surgically sampling primary nerve pathology.
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Affiliation(s)
- Kimberly K Amrami
- Department of Radiology, Mayo Clinic, 200 1st Street SW, Rochester, MN 55905, USA.
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Blitz NM, Amrami KK, Spinner RJ. Magnetic resonance imaging of a deep peroneal intraneural ganglion cyst originating from the second metatarsophalangeal joint: a pattern of propagation supporting the unified articular (synovial) theory for the formation of intraneural ganglia. J Foot Ankle Surg 2009; 48:80-4. [PMID: 19110165 DOI: 10.1053/j.jfas.2008.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2008] [Indexed: 02/03/2023]
Abstract
UNLABELLED A deep peroneal intraneural cyst of the first web space of the foot is presented. Analysis of the magnetic resonance image scans revealed not only a connection with the medial aspect of the second metatarsophalangeal joint, but also the presence of an interconnected cyst within the lateral digital branch of the hallux. These characteristic magnetic resonance image findings are consistent with those previously described for a peroneal intraneural ganglion cyst that arose from the superior tibiofibular joint, and include (1) origin (ascent) from the second metatarsophalangeal joint with propagation along the articular branch and into the dorsal digital branch of the second toe, (2) cross-over within the shared epineurial sheath of the deep peroneal nerve, and (3) further propagation (descent) within the dorsal digital branch of the hallux. The analogous features between intraneural ganglion cysts affecting small and large-caliber nerves support the fundamental principles of the unified articular (synovial) theory for the formation of intraneural ganglia, including (1) a connection to a synovial joint, (2) dissection of joint fluid through a capsular rent along the articular branch into the parent nerve, and (3) intra-epineurial, pressure-dependent propagation of cyst fluid along paths of least resistance. LEVEL OF CLINICAL EVIDENCE 4.
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Affiliation(s)
- Neal M Blitz
- Department of Orthopaedic Surgery, Bronx-Lebanon Hospital Center, Bronx, NY, USA
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Spinner RJ, Amrami KK. What's New in the Management of Benign Peripheral Nerve Lesions? Neurosurg Clin N Am 2008; 19:517-31, v. [DOI: 10.1016/j.nec.2008.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Dellon AL. The Four Medial Ankle Tunnels: A Critical Review of Perceptions of Tarsal Tunnel Syndrome and Neuropathy. Neurosurg Clin N Am 2008; 19:629-48, vii. [PMID: 19010287 DOI: 10.1016/j.nec.2008.07.003] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- A Lee Dellon
- Plastic Surgery and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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Blitz NM, Prestridge J, Amrami KK, Spinner RJ. A posttraumatic, joint-connected sural intraneural ganglion cyst-with a new mechanism of intraneural recurrence: a case report. J Foot Ankle Surg 2008; 47:199-205. [PMID: 18455665 DOI: 10.1053/j.jfas.2008.01.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Indexed: 02/03/2023]
Abstract
UNLABELLED Intraneural ganglion cysts are rare in occurrence and most commonly involve the peroneal nerve at the fibular neck. We present a case of a traumatically induced intraneural ganglion cyst of the sural nerve that developed after a nondisplaced posterior malleolus ankle fracture. The intraneural ganglion cyst was connected to the subtalar joint by its articular branch and ascended several centimeters into the distal fourth of the leg. It was resected from the sural nerve proper and the posterior branch of the lateral calcaneal nerve, and the articular trunk was ligated. The patient developed subclinical intraneural recurrence, which was detected on a postoperative magnetic resonance imaging (MRI). Retrospective reinterpretation of the preoperative and postoperative MRIs revealed that ligation of the articular trunk proximal to a major branch (ie, the anterior branch of the lateral calcaneal nerve) led to increased intraneural cyst propagation distally: within the blind stump of the articular trunk and within several anterior branches of the lateral calcaneal nerve but not within the parent sural nerve or its continuation, the lateral dorsal cutaneous nerve. This mode of intraneural, but extraparental nerve recurrence can be easily understood by considering the altered fluid dynamics, particularly the increased resistance. This case report provides further evidence not only supporting the articular theory of intraneural ganglion formation but also highlighting the importance of searching for, identifying, and treating the pathologic articular branch connection near its joint connection in all cases. LEVEL OF CLINICAL EVIDENCE 4.
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Affiliation(s)
- Neal M Blitz
- Kaiser North Bay Consortium Residency Program, Department of Orthopedics and Foot & Ankle Surgery, Kaiser Permanente Medical Center, Santa Rosa, CA 95403, USA.
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Spinner RJ, Desy NM, Rock MG, Amrami KK. Peroneal intraneural ganglia. Part I. Techniques for successful diagnosis and treatment. Neurosurg Focus 2007. [PMID: 17613207 DOI: 10.3171/foc.2007.22.6.17] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The common peroneal nerve is the peripheral nerve most often affected by intraneural ganglion cysts. Although the pathogenesis of these cysts has been the subject of controversy in the literature, it is becoming increasingly evident that they are of articular origin. Recent recognition of this fact has proven to be significant in reducing recurrences and improving treatment outcomes for patients. The authors present a stepwise method of assessing and treating peroneal intraneural ganglion cysts.
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Affiliation(s)
- Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Abstract
✓The authors describe common modes of failure in the diagnosis and treatment of patients with peroneal intraneural ganglia. Illustrated examples correlate the modes of failure and the diagnostic or surgical errors. Understanding these pitfalls reinforces the rationale behind current treatment recommendations as outlined in the companion article. Avoiding these pitfalls will ultimately improve outcomes.
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Affiliation(s)
| | - Nicholas M. Desy
- 1Departments of Neurologic Surgery
- 4McGill University School of Medicine, Montreal, Quebec, Canada
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