Tarsal tunnel syndrome secondary to intraneural ganglion

Tarsal Tunnel Syndrome Due To Three Different Types of Ganglion During a 12-Year Period: A Case Report

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.

Intraneural ganglion of the superficial peroneal nerve: a case report

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.

A posttraumatic, joint-connected sural intraneural ganglion cyst-with a new mechanism of intraneural recurrence: a case report

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.

Tibial intraneural ganglia in the tarsal tunnel: Is there a joint connection?

Intraneural ganglia are rare entities, and, as such, their pathogenesis has been extremely controversial. Recent evidence from intraneural ganglia occurring at more proximal sites-the peroneal nerve at the fibular neck (the most common site) and the tibial nerve at the knee-has suggested an articular origin rather than de novo formation. To our knowledge, of the 10 previous reports of tibial intraneural ganglia within the tarsal tunnel by others, a joint connection to the ankle joint was only identified in 2 cases. To support a hypothesis that tibial intraneural ganglia occurring within the tarsal tunnel region arise from neighboring joints, we analyzed 3 patients retrospectively, all of whom had magnetic resonance (MR) imaging and operative intervention. One of these patients was treated by a peripheral nerve surgeon specializing in foot and ankle surgery. The other 2 patients were the only ones previously published in the literature who had MR images available for reinterpretation. In none of these cases was a joint communication appreciated by radiologists interpreting the MR images preoperatively or by surgeons intraoperatively. Our review of these same cases demonstrated radiographic evidence of joint communications with the subtalar joints. Based on our findings in this article and our knowledge of intraneural ganglia occurring at more proximal sites, we believe that tibial intraneural ganglia within the tarsal tunnel originate from neighboring joints and that their connections to the joints (pedicles) are through articular branches. The importance of these connections is 2-fold: first, for their role in the pathogenesis of this entity, and second, for their potential therapeutic implications. As is highlighted by the clinical and radiographic follow-up in the 1 patient in this article and in many previously reported at other sites, intraneural cyst recurrence can occur if surgeons do not specifically address the articular connection.

Tarsal tunnel syndrome caused by epineural ganglion of the posterior tibial nerve: report of 2 cases and review of the literature

Ganglia within the posterior tibial nerve is a rare condition. The authors report 2 cases of epineural ganglion of the posterior tibial nerve, causing tarsal tunnel syndrome. Both cases presented with numbness on the plantar surface of the foot. Magnetic resonance imaging showed the presence of the cyst within the tarsal tunnel. During surgery, these cysts were found within the epineurium of the posterior tibial nerve and were successfully removed without damage to nerve fibers. Both patients were free of symptoms after surgery. Ganglion cysts in the peripheral nerve are either intrafascicular or epineural. Intrafascicular ganglia present beneath the epineurium and involve the nerve fibers, whereas epineural ganglia are located in the epineurium and do not involve the nerve fibers. A review of the literature discusses these concepts. The authors suggest that epineural ganglion should be clinically distinctive from an intrafascicular ganglion because of the differences in surgical treatment, postoperative nerve function, and the recurrence rate.

Synovial cysts and ganglia: the value of magnetic resonance imaging

Synovial and ganglion cysts commonly present in close proximity to joints and skeletal structures in rheumatic disorders. Familiarity with the presentation of these soft tissue masses can facilitate timely diagnosis and effective management, thus avoiding costly and potentially high-risk procedures to patients. Management usually consists of local, nonsurgical approaches. A patient with chronic joint deformities and clinical features primarily consistent with mixed connective tissue disease is described. Multiple localized masses developed at her right elbow and were identified on T2-weighted magnetic resonance imaging as multiloculated cysts that dissected from the elbow joint. The cysts were treated successfully by needle aspiration and intraarticular corticosteroid injection. The clinical associations, diagnosis, treatment, and management of synovial cysts and ganglions are reviewed.

Intraneural ganglion of the sciatic nerve: detection by ultrasound

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Bilateral tarsal tunnel syndrome

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Hereditary multiple exostosis with spinal cord compression in a 13-year-old boy

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