Ganglion cyst of temporomandibular joint - A systematic review

Ganglion cyst of the temporomandibular joint (TMJ) is an uncommon pathology with uncertain etiology. There is no consensus on their management. The current systematic review aimed to discuss the clinical and histopathological features of ganglion cysts of TMJ, to aid in appropriate treatment. A literature search was done and a total of 20 cases were retrieved from published databases such as PubMed, SCOPUS, and Google Scholar. The cyst presented with swelling in all the cases followed by pain (50 %) and trismus (35 %) as other common symptoms. Though CT and MRI proved helpful in determining the location of the cyst, a histopathological examination was essential in concluding its final diagnosis. It is a pseudocyst lined by dense fibro-connective tissue with myxoid tissue degeneration. Histologically, it is essential to distinguish them from the clinically and radiographically similar true cyst of TMJ, synovial cyst. The lining of ganglion cyst is devoid of epithelium and synovial cells. Surgical excision was found to be the treatment of choice with minimal recurrence (10 %) being reported.

Arthroscopic Dorsal Ligamentocapsulodesis in the Treatment of Occult Dorsal Wrist Ganglion Cysts Associated with Scapholunate Instability: Surgical Technique and Preliminary Clinical Results

Background: This study aimed to evaluate our preliminary results and experience with the arthroscopic dorsal ligamentocapsulodesis in managing occult dorsal wrist ganglion cysts (ODGCs) associated with scapholunate (SL) instability. Methods: All patients who underwent arthroscopic dorsal ligamentocapsulodesis due to an ODGC with concomitant SL ligament tear were retrospectively reviewed. In addition to demographic data and length of follow-up, outcomes data that included range of motion, grip strength, modified Mayo wrist score (MMWS), complications and radiographs were collected. Results: The study included 18 patients (18 wrists; 10 female and 8 male). The mean age was 32 years (range: 19-48) and the mean follow-up was 34 months (range: 24-48). The mean preoperative extension deficit decreased from 5.5° (range: 0°-20°) to 2.7° (range: 0°-15°) at the final follow-up (p = 0.004). The mean preoperative flexion deficits decreased from 4.4° (range: 0°-15°) to 2.2° (range: 0°-10°) postoperatively (p = 0.003). The mean hand grip strength significantly increased from 27.7 kg (range: 22-36) to 38.3 kg (range: 31-46) at the final follow-up assessment (p < 0.001). The mean MMWS improved from 46 (range: 25-65) pre-operatively to 91 (range: 70-100) at the final follow-up (p = 0.0002). No major intra- or postoperative complications were observed. Conclusions: SL instability may have an important role in the aetiology of ODGCs, and arthroscopic dorsal ligamentocapsulodesis can provide pain relief and functional improvement without recurrence at the short- to mid-term follow-up in the treatment of ODGCs. Level of Evidence: Level IV (Therapeutic).

Cystic lesions and bursae around the knee: do they matter in knee osteoarthritis?

The cause of knee osteoarthritis (OA) and knee pain associated with OA is not well understood. Periarticular cystic lesions and bursae around the knee are among the most common morphologic features identified on MRI in the setting of OA. Despite widespread association of these lesions with knee OA and their inclusion in semiquantitative MRI scoring assessment systems for knee OA, the role that these lesions play in the development of knee pain and OA remains uncertain. In this discussion, we review the cystic lesions and bursae most commonly associated with OA of the knee, examine their relation and role in whole organ imaging assessments of OA, and present the literature investigating the associations of periarticular cysts and cyst-like lesions with knee pain and OA.

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.

Excision with Temporary Interphalangeal Joint Pin Fixation for Toe Ganglion Cysts

Background

Toe ganglion cysts are often symptomatic and recurrent. Communicating lesions between ganglion cysts and the interphalangeal joint (IPJ) or tendon sheath make it difficult to prevent a recurrence. Temporary restriction of the joint and tendon motion can facilitate surgical site healing. This study analyzed the clinical results of temporary pin fixation of the IPJ after toe ganglion cyst excision.

Methods

Sixteen patients with symptomatic toe ganglion cysts underwent surgical treatment. Excision alone was initially performed on 10 patients. Six patients underwent temporary pin fixation of the IPJ after ganglion cyst excision. Repeat excision with pin fixation was performed for recurrence in two patients after excision only. Clinical evaluations and postoperative complications were analyzed.

Results

Fourteen of 16 toe ganglion cysts were located near the IPJ. Two cysts not adjacent to the joint completely healed after excision alone. Seven of 14 cysts near the joint recurred after initial excision alone and required repeated reoperation. Eight cysts did not recur after excision with pin fixation, including 2 that recurred after excision alone.

Conclusions

Temporary IPJ pin fixation after excision for ganglion cysts can be effective for preventing the recurrence of ganglion cysts adjacent to toe IPJ.

Periosteal ganglion cyst of tibia: A rare case report

INTRODUCTION AND IMPORTANCE

Periosteal ganglion cyst is a rare disorder, found only in 55 out of 100,000 people annually. Periosteal ganglion location may cause partial external cortical destruction with irregular saucerization and erosion. This report presents a rare case of periosteal ganglion cyst that occurred of the cruris sinistra.

CASE PRESENTATION

A male patient, 68 years old, came with complaint of a lump in the left cruris since one year ago. Nine months later, the lump has increased in size like a chicken egg and still felt painless. MRI result revealed a well-circumscribed multilocular cystic lesion in the peri-osseous soft tissue of the tibia. We performed directly excisional biopsy within the mass, and the histopathology result was periosteal ganglion cyst.

CLINICAL DISCUSSION

The exact pathogenesis of periosteal ganglion is unclear. Synovial herniation and mucoid degeneration of the connective tissue of the periosteum are two suggested mechanisms. In some cases, ganglion cysts may compress nearby nerves. Surgical treatment is recommended for patients who still experience symptoms after non-surgical management has failed. Complete resection of the cyst and surrounding periosteum is recommended to prevent recurrence. After 6 months post-operative follow up clinical examination, no recurrence symptoms founded on the patient.

CONCLUSION

Periosteal ganglion is a rare lesion and may mimic other bone surface lesions. Resection of the periosteal ganglion cyst with surrounding periosteum is important to prevent recurrence.

Intratendinous ganglion cyst of extensor indicis propius tendon: A case report

INTRODUCTION AND IMPORTANCE

The intratendinous ganglion cyst is an extremely rare entity. Thus, the global incidence has not been reported yet. The literature search showed scarce case reports and none has reported its occurrence in extensor indicis propius (EIP) tendon. The benign nature and the region at the dorsal hand mimic to the more common dorsal wrist ganglion. However, the surgical treatment arises significant risk to the function and may require subsequent tendon graft or tendon transfer.

CASE PRESENTATION

A 51-year-old-female presented with 4 years history of a slow-growing lump over the dorsal region of the right hand with discomfort during finger motions. The ultrasonography confirmed the diagnosis of dorsal wrist ganglion.

CLINICAL DISCUSSION

Intraoperatively, unlike the common presentation which is the well encapsulated mass originating from the carpal joint, the mass was found within the EIP tendon sheath and infiltrate the tendon substance. Surgical debulking was done and left the tendon partially intact. The frayed part was trimmed to ensure a smooth gliding. On the 6 month follow up, patient was symptom-free without any recurrence.

CONCLUSION

The intratendinous growth of a ganglion must be identified preoperatively for a proper management plan and inform consent. The intratendinous ganglion cysts frequently weaken the tendon. Hence, surgical excision is necessary with the preparation of secondary tendon reconstruction.

The potential pitfalls of synovial sarcoma mimicking intraneural ganglion cyst: A case report and literature review

INTRODUCTION AND IMPORTANCE

Synovial sarcoma is a rare soft tissue sarcoma (STS) that accounts for 5-10 % of all STS. Synovial sarcoma of the peripheral nerve is very rare, with only 26 cases reported in the literature. Hence, this case report describes an unusual presentation of synovial sarcoma mimicking intraneural ganglion cysts and a literature review.

PRESENTATION OF CASE

We describe a 36-year-old female who presented to our clinic complaining of left leg pain for six years. MRI was done, which revealed a cystic lesion. With an impression of intraneural ganglion cyst versus nerve sheath tumor of the common peroneal nerve. The patient underwent exploration surgery and mass excision. The mass was sent for histopathology following excision, where the results indicated monophasic synovial sarcoma. An additional surgery, an epineurectomy of the common peroneal nerve and tumor bed excision, was followed by adjuvant chemotherapy with a Doxorubicin-based regimen. Following surgery, our patient's neurological symptoms improved.

CLINICAL DISCUSSION

The mainstay of treatment in synovial sarcoma is surgical excision with a Doxorubicin-based regimen of chemotherapy and/or radiotherapy based on tumor characteristics. Tumors smaller than 5 cm in MRI usually show homogenous enhancement and can be mistaken for benign tumors. Hence, a biopsy should be done before surgery to avoid misdiagnosis.

CONCLUSION

Even though it is extremely rare, synovial sarcoma of the lower extremity should be considered when a painful swelling of the lower leg is associated with a long duration of symptoms. Such lesions are best managed by surgical excision and postoperative chemotherapy.

Intraneural Ganglion of the Thumb Digital Nerve - A Case Report and Review of Literature

Intraneural ganglia are rare, benign cysts that form within the epineurium of the affected nerve. Patients present with features of compressive neuropathy, including numbness. We report a 74-year-old male patient with pain and numbness on his right thumb of 1-year duration. Magnetic resonance imaging revealed a cystic lesion with a possible scaphotrapezium-trapezoid joint connection. The articular branch was not identified during the surgery and decompression with excision of the cyst wall was done. A recurrence of the mass was noted 3 years later, but the patient was asymptomatic and no additional intervention was done. Decompression alone can relieve the symptoms of an intraneural ganglion, but excision of the articular branch may be essential in preventing its recurrence. Level of Evidence: Level V (Therapeutic).

Simultaneous laparoscopic and arthroscopic excision of a huge juxta-articular ganglionic cyst compressing the sciatic nerve: A case report

BACKGROUND

A large ganglionic cyst extending from the hip joint to the intrapelvic cavity through the sciatic notch is a rare space-occupying lesion associated with compressive lower-extremity neuropathy. A cyst in the pelvic cavity compressing the intrapelvic-sciatic nerve is easily missed in the diagnostic process because it usually presents as atypical symptoms of an extraperitoneal-intrapelvic tumor. We present a case of a huge ganglionic cyst that was successfully excised laparoscopically and endoscopically by a gynecologist and an orthopedic surgeon.

CASE SUMMARY

A 52-year-old woman visited our hospital complaining of pain and numbness in her left buttock while sitting. The pain began 3 years ago and worsened, while the numbness in the left lower extremity lasted 1 mo. She was diagnosed and unsuccessfully treated at several tertiary referral centers many years ago. Magnetic resonance imaging revealed a suspected paralabral cyst (5 cm × 5 cm × 4.6 cm) in the left hip joint, extending to the pelvic cavity through the greater sciatic notch. The CA-125 and CA19-9 tumor marker levels were within normal limits. However, the cyst was compressing the sciatic nerve. Accordingly, endoscopic and laparoscopic neural decompression and mass excision were performed simultaneously. A laparoscopic examination revealed a tennis-ball-sized cyst filled with gelatinous liquid, stretching deep into the hip joint. An excisional biopsy performed in the pelvic cavity and deep gluteal space confirmed the accumulation of ganglionic cysts from the hip joint into the extrapelvic intraperitoneal cavity.

CONCLUSION

Intra- or extra- sciatic nerve-compressing lesion should be considered in cases of sitting pain radiating down the ipsilateral lower extremity. This large juxta-articular ganglionic cyst was successfully treated simultaneously using laparoscopy and arthroscopy.

The Efficacy of Nonsurgical and Surgical Interventions in the Treatment of Pediatric Wrist Ganglion Cysts

PURPOSE

The treatment of ganglion cysts of the wrist remains understudied in the pediatric population, with the literature showing variable recurrence rates following different interventions. This study sought to determine whether surgical and nonsurgical management of pediatric ganglion cysts was associated with improved resolution rates when compared to observation alone.

METHODS

We identified 654 cases of pediatric ganglion cysts treated across 5 institutions between 2012 and 2017. The mean age at presentation was 11.6 ± 5.2 years. Of the patients, 315 had >2 years (mean, 50.0 months) of follow-up, either via chart review or telephone callbacks. There were 4 different treatment groups: (1) observation, (2) cyst aspiration, (3) removable orthosis, and (4) surgical excision.

RESULTS

For patients followed >2 years, the cyst resolved in 44% (72/163) of those observed. Only 18% (9/49) of those treated with aspiration resolved, and 55% (12/22) of those treated with an orthosis resolved. Surgical excision was associated with resolution of the cyst in 73% (59/81) of patients. Observation had higher rates of resolution compared to aspiration. Orthosis fabrication and observation had similar rates of cyst resolution. Surgery had the highest rates of resolution when compared to observation and aspiration. Patients older than 10 years were less likely to have the cyst resolve with observation (35%; 28/80) than those younger than 10 years (53%; 44/83) at >2 years of follow-up.

CONCLUSIONS

This study did not find evidence that nonsurgical treatments were associated with improved rates of cyst resolution compared to observation alone in a large pediatric sample. Surgical excision had the overall highest rate of resolution. Despite the costs and increased clinic time of orthosis fabrication and aspiration, these treatments were not associated with improved rates of cyst resolution in pediatric ganglion cysts compared to observation, with aspiration having higher rates of recurrence compared to observation.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

PROMIS Measures in Patients with Ganglion Cysts: Who Chooses Surgical Excision Over Non-Operative Management?

Background: Ganglion cysts are common soft tissue masses of the hand and wrist. It is unclear why some patients pursue surgical excision and others do not. The objective of this study is to compare Patient-Reported Outcomes Measurement Information Systems (PROMIS) scores between patients with ganglion cysts undergoing surgical versus non-surgical treatment. Methods: Patients presenting to a tertiary, academic hand clinic diagnosed with a wrist ganglion cyst, based on clinical exam, were identified. PROMIS Physical Function (PF), Pain Interference (PI), and Depression scores at the time of diagnosis were reviewed. Data were then stratified according to surgical or non-surgical intervention, with subgroup analysis of dorsal versus volar ganglions and patients that chose to trial cyst aspiration. All results were compared utilizing the appropriate statistical methods. Results: Of 757 ganglion cyst patients, 264 underwent surgical excision and 493 were treated non-surgically. No difference was noted in PROMIS PF or Depression scores. However, the surgical cohort reported significantly increased preoperative PI scores (Table 2). A higher percentage of patients treated non-surgically received an aspiration attempt compared to those who ultimately received surgery (Table 3). Finally, patients with volar ganglion cysts had significantly increased PI and depression scores, as well as lower PF scores (Table 4). Conclusions: Presenting PROMIS PI may indicate an increased tendency to pursue surgical treatments and aid in the identification of ganglion cyst patients who are more likely to pursue surgical excision. Further research should focus on correlating absolute differences in PROMIS values with clinical significance.

Ganglion cyst at the proximal tibiofibular joint - A rare cause of compression neuropathy of the peroneal nerve

Ganglion cysts are fluid filled sacs which develop near joints and tendons and are usually asymptomatic. Lower limb ganglion cysts are rare occurrences especially those situated around joint spaces causing nerve compression. We present the case of a 68 year-old female with history of progressive swelling in the left antero-lateral leg, associated with pain, and neurological symptoms of peroneal nerve compression. Magnetic resonance imaging (MRI) revealed a large proximal tibiofibular joint ganglion cyst causing peroneal nerve compression. One year following the left sided presentation, the patient presented with similar but less severe symptoms in her right antero-lateral leg. MRI revealed a small juxta-articular ganglion cyst in the right proximal tibiofibular joint space. We discuss etiology, symptoms, and management of lower limb ganglion cysts.

Waste not, want not: Report of a completely calcified C1-C2 juxtafacet cyst and literature review

Background

Calcified juxtafacet cysts in the cervical spine are extremely rate. Such symptomatic cysts commonly cause neck pain, radiculopathy, or even myelopathy. MR and CT studies typically document cord/ root compression. On occasion, some of these cysts will spontaneously regress, while many others may warrant surgical removal.

Case Description

A 70-year-old male presented with a 2-year history of a progressive tetraparesis. The preoperative MR/CT studies showed a C1-C2 left extradural mass occupying more than half of the spinal canal. On MR, it was homogeneously hypointense on both T1- and T2-weighted images, while the CT showed a calcified cyst. Intraoperative and histopathological findings documented a calcified cervical juxtafacet cyst (i.e. ganglion subtype) that was fully excised without sequelae.

Conclusion

C1-C2 juxtafacet cervical cyst should be considered when a patient presents with myelopathy due to a calcified MR/CT documented paraspinal lesion contributing to significant cervical cord/root compression.

Recurrence of Ganglion Cysts Following Re-excision

Background

The recurrence of ganglion cysts after surgical excision has a reported rate of 4% to 40%. Recurrence rate after revision surgical excision is unknown. The purpose of this study was to define the incidence of recurrent ganglion cysts in patients who underwent a secondary excision procedure.

Methods

With Institutional Review Board approval, we retrospectively identified by CPT code and reviewed charts of patients who had recurrent ganglion cyst excision performed over a five-year period (2010 - 2014). Recurrence was defined as reappearance of a cyst in the same area as it was previously. Demographic information including recurrences and revision surgeries was collected in addition to outcome variables such as patient satisfaction, pain levels, and functional limitations.

Results

Out of the 42 revision cases identified 20 patients were reached. Mean time to recurrence of the cyst after the first ganglion cyst excision was 2.5 years (range: 1 month - 12 years). After the second ganglion cyst excision, three patients (15%) had a recurrence, each occurring within one year (mean: 11 months; range: 9-12). One of the three patients underwent a third successful ganglion cyst excision. The other two patients declined surgical intervention to date. Patients without a second recurrence (n=17) reported an average pain score of 0.1 (range: 0-2) on a scale of 1-10. Three (18%) reported some difficulty with day-to-day activities due to their scar. Seven (41%) patients reported at least transient numbness or tingling. Mean satisfaction was 9.8 on a scale of 1-10, and 100% reported that they would undergo another ganglion cyst excision should they ever have another recurrence.

Conclusion

Patients should be advised about the risk of recurrence after re-excision of ganglion cysts, which was noted to be 15% in our cohort. This rate of recurrence is similar to that of primarily excised cysts.

Intra-articular leiomyoma of the knee mimicking a ganglion cyst in a child: A case report and review of literature

INTRODUCTION AND IMPORTANCE

Angioleiomyoma is a rare benign soft tissue tumor of smooth muscle getting its origin from the muscular layer of vessel walls. The localized type of leiomyoma occurs on the skin, deep soft tissues, in the genitourinary, gastrointestinal, and respiratory tracts.

CASE PRESENTATION

We report a case of a 16-year-old patient who presented with an intra-articular leiomyoma developed in the anterior cruciate ligament and treated with arthroscopy.

CLINICAL DISCUSSION

Angioleiomyoma can occur anywhere in the body and is most often seen in the extremities, particularly the lower limbs, but is very rare in the knee joint. Angioleiomyoma should be included in the differential diagnosis of nodular lesions mimicking loose body, such as lipomas, inclusion cysts, ganglion, pigmented villonodular synovitis (PVNS), fibroma, nodular synovitis, hemangioma, synovial sarcoma, myopericytoma, leiomyosarcomas, glomus tumor.

CONCLUSION

Angioleiomyoma related to the cruciate ligaments of the knee should be considered in the differential diagnosis of a painful knee especially when associated with a decreased of range of motion of knee. The arthroscopic debridement should be considered the treatment of choice in order to reliably restore active ROM.

Unusual multiloculated serpiginous ganglion of the foot

Ganglions are cystic lesion more commonly seen around the wrist joint. Gangliomas of plantar aspect of the foot are rare. We have presented a case of an unusual serpiginous ganglioma of the plantar aspect of the foot. Less literature is available regarding plantar foot gangliomas. The treatment is challenging because of occurrence of the lesion at weight bearing zone. Available options for treatment includes conservative with splint, intralesional injection,arthroscopic excision and open excision.

Common Complaints of the Hands and Feet

Primary care providers frequently care for complaints of the hands and feet. Here, the author describes the typical presentations of hand osteoarthritis, carpal tunnel syndrome, ganglion cysts, plantar fasciitis, onychomycosis, and Morton neuroma. Useful physical examination techniques are described. The history and physical examination are usually sufficient to diagnose these conditions without the need for more advanced testing. All of these conditions have evidence-based therapy that can be initiated by the primary care provider. These treatments as well as reasons to refer to a specialist are reviewed.

Differentiation of ulnar neuropathy at the wrist due to ganglion cyst from ulnar neuropathy at the elbow

OBJECTIVE

Here, we aimed to describe the clinical, electrodiagnostic (EDx) and ultrasonographic (US) findings in a series of patients with ulnar neuropathy at the wrist (UNW) due to compression by a ganglion cyst. We also sought features that differentiate UNW from ulnar neuropathy at the elbow (UNE).

METHODS

We reviewed electronic medical records of consecutive patients with UNW caused by ganglion cysts. We compared their clinical, EDx and US findings to findings in our previously reported prospective series of UNE patients.

RESULTS

We identified 10 patients with UNW caused by ganglion cyst compression, who all presented with intrinsic hand muscle weakness and atrophy. Compared to 175 UNE patients they less often complained of paresthesia (60% vs. 98%) and presented less sensory loss in the palm (30% vs. 96%) and little finger (50% vs. 95%). They more often had distal ulnar motor latency recorded from the abductor digiti minimi (ADM)>3.6ms (80% vs. 30%), and denervation activity on needle EMG in the first dorsal interosseous (FDI) compared to ADM (100% vs. 60%). Only 20% of our UNW patients had ulnar nerve swelling at the site of compression on US.

CONCLUSION

UNW potentially caused by ganglion cyst should be suspected in patients presenting with intrinsic hand muscle atrophy and weakness, particularly in cases with normal sensation, increased distal ulnar motor latency recorded from ADM and more severe neuropathic changes in FDI compared to ADM muscle.

Retro-odontoid Pseudotumor: Two Cases of Intradural Ganglion Cysts Arising From the Odontoid Process with Syringobulbia

BACKGROUND

Ganglion cysts mostly occur in the knuckles and wrists, but they rarely present in the odontoid process and can cause neurological symptoms by compressing the spinal cord. They are mostly localized in the epidural space, but may very rarely appear in the intradural space. There are no reports of cases of intradural ganglion cyst involving syringobulbia.

CASE DESCRIPTION

We report the presentation and management of 2 cases of an intradural ganglion cyst of the odontoid process. Several treatment options for ganglion cysts of the odontoid process have been reported, such as rest and use of a neck collar, posterior decompression and fusion, and transoral anterior decompression. Because our 2 cases progressed rapidly and had severe neurological symptoms, surgical treatment was performed for rapid decompression and definitive pathological diagnosis. The mass was resected as much as possible using the lateral occipital fossa approach, and the operation was completed without dissection of the brain stem or manipulation of the syringobulbia. Postoperatively, neurological symptoms promptly improved, and the syringobulbia reduced.

CONCLUSIONS

For intradural ganglion cysts with syringobulbia, we suggest relief of the compression by resection of the mass and treatment of the syringobulbia in 2 stages, if necessary, to avoid the risk of damage to the brainstem.

Injection Techniques for Common Chronic Pain Conditions of the Hand: A Comprehensive Review

INTRODUCTION

This compilation presents a comprehensive review of the literature on common chronic pain conditions of the hand. It briefly presents these common conditions with their biological background, diagnosis, and common management options. It then presents and compares the latest literature available for injection techniques to treat these diagnoses and compares the available evidence.

METHODS

A comprehensive literature review was performed in MEDLINE, PubMed, and Cochrane databases from 1996 to 2019 using the terms "hand pain", "injection techniques", "steroid injection", "chronic pain", "osteoarthritis", "rheumatoid arthritis", "carpal tunnel syndrome", "De Quervain's tenosynovitis", "ganglion cyst", "gout", "Raynaud's", and "stenosing tenosynovitis".

RESULTS

Hand pain is a common condition with 9.7% prevalence in men and 21.6% in women and can cause significant morbidity and disability. It also carries a significant cost to the individuals and the healthcare system, totaling in $4 billion dollars in 2003. Injection therapy is an alternative when conservative treatment fails. Osteoarthritis is the most common chronic hand pain syndrome and affects about 16% of the population. Its mechanism is largely mechanic, and as such, there is controversy if steroid injections are of benefit. Hyaluronic acid (HA) appears to provide substantial relief of pain and may increase functionality. More studies of HA are required to make a definite judgment on its efficacy. Similarly, steroid ganglion cyst injection may confer little benefit. Carpal tunnel syndrome is a compressive neuropathy, and only temporarily relieved with injection therapy. US-guidance provides significant improvement and, while severe cases may still require surgery, can provide a valuable bridge therapy to surgery when conservative treatment fails. Similar bridging treatments and increased efficacy under US-guidance are effective for stenosing tenosynovitis ("trigger finger"), though, interestingly, inflammatory background is associated with decreased effect in this case. When the etiology of the pain is inflammatory, such as in RA, corticosteroid (CS) injections provide significant pain relief and increased functionality. They do not, however, change the course of disease (unlike DMARDs). Another such example is De-Quervain tenosynovitis that sees good benefit from CS injections, and an increased efficacy with US-guidance, and similarly are CS injections for gout. For Raynaud's phenomenon, Botox injections have encouraging results, but more studies are needed to determine safety and efficacy, as well as the possible difference in effect between primary and secondary Raynaud's.

CONCLUSIONS

Chronic hand pain is a prevalent and serious condition and can cause significant morbidity and disability and interferes with independence and activities of daily living. Conservative treatment remains the first line of treatment; however, when first-line treatments fail, steroid injections can usually provide benefit. In some cases, HA or Botox may also be beneficial. US-guidance is increasing in hand injection and almost ubiquitously provides safer, more effective injections. Hand surgery remains the alternative for refractory pain.

Joint Outcomes Following Surgery for Superior Tibiofibular Joint-Associated Peroneal Intraneural Ganglion Cysts

BACKGROUND

Intraneural ganglion cysts are joint-connected, with the primary pathology residing in the associated joint. For peroneal intraneural ganglion cysts, the surgical strategy can include resection of the synovial surface of the superior tibiofibular joint (STFJ). However, the rate of instability postoperatively is unclear.

OBJECTIVE

To evaluate the rate of STFJ instability, following surgery for peroneal intraneural ganglion cysts. The second goal of the study was to assess the relationship between volume of resection of the STFJ and risk of extraneural recurrence.

METHODS

We performed a retrospective analysis of a cohort of patients with peroneal intraneural ganglion cysts. We analyzed clinical factors, including recurrence, and assessed the rate of postoperative STFJ instability. We created 3-dimensional models of the STFJ pre- and postoperatively to compare the volume of resection in recurrent cases and nonrecurrent cases using a case-control design.

RESULTS

The total cohort consisted of 65 subjects. No patient had evidence of radiological or clinical instability of the STFJ postoperatively. Extraneural radiological recurrence occurred in 6 (9%) patients. No intraneural recurrences were observed. The average volume of resection for patients with recurrence was 1349 mm3 (SD = 1027 mm3) vs 3018 mm3 (SD = 1433 mm3) in controls that did not have a recurrence (P = .018).

CONCLUSION

This study supports performing an aggressive STFJ resection to minimize the risk of extraneural recurrence. Superior tibiofibular joint resection is not associated with postoperative joint instability. A smaller volume resection is correlated with recurrence risk.

A rare cause of unilateral hypoglossal nerve palsy: case report of intraneural ganglion cyst of the hypoglossal nerve and review of the literature

Benign lesions of the soft tissue arising in the periarticular space, such as a ganglion cyst, can cause compression of adjacent nerve fascicles passing in the nearby joint space. Intraneural ganglion cysts involving the cranial nerves are particularly rare, with only a few previous cases reported in the literature.

A rare case of posterior interosseous nerve palsy due to ganglion cyst arising from supinator muscle

Here we present a rare case of ganglion cyst of the elbow joint arising from supinator muscle causing posterior interosseous nerve (PIN) palsy in a 40-year-old female who presented with weakness in finger extension and carrying out routine activities with right hand since 2 weeks. Patient had pain over the right forearm radiating to the right hand since 3 months. She also noted a swelling in the right forearm, which was gradually increasing in size since last 1 month. Atraumatic PIN compression is uncommon and is usually caused by compression of PIN in the arcade of Frohse, by radial recurrent artery, and fibrous band around the radiocapitellar joint. Reports of PIN palsy caused by ganglionic cyst in the elbow joint are rare and case reports regarding the same are sparingly reported. Here we report a case of PIN palsy secondary to ganglion cyst arising from supinator muscle, which recovered completely after excision of the ganglion cyst.

Aspiration and steroid injection in ganglion cysts: An ultrasound guided evaluation of the response

PURPOSE

The Response of ganglion cysts to Intralesional steroids is variable. They may disappear completely to never recur again. Others may disappear for some period or show no response to the treatment. We wanted to analyse the response with the help of ultrasound. We also tried to search for the factors responsible for the unpredictable outcome.

METHODS

A single centre prospective cohort study was conducted. Ganglion cysts located near the wrist and the ankle region of the limbs were included in the study. Overall 40 patients were followed for 6 months. The ultrasound was used to measure the volume which was measured at zero & sixth month.

RESULTS

Volume of the cysts reduced to more than half in 45% of the participants. Complete disappearance was seen in only 10%.

CONCLUSION

Aspiration and steroid injection reduces the volume of the cyst. The effect wanes off progressively over a period of time. Majority will have a smaller cyst at sixth month at the same site. It may work better in the smaller cysts.

TYPE OF STUDY AND LEVEL OF EVIDENCE

Therapeutic, Level IV.

Ganglion cyst of Hoffa's fat pad of knee-a rare cause of knee pain and swelling-a case report and literature review

Ganglion cysts around knee joint are uncommon and that from Hoffa's fat pad are even rarer. We present a case of 30 year old male patient with complaint of pain and swelling in left knee joint. Radiograph did not show any bony abnormality. MRI showed large tubulocystic lesion within Hoffa's fat pad which showed low signal intensity on T1-weighted images and high signal intensity on T2-STIR images. Open excision of the lesion was done. Histopathology of the specimen confirmed the diagnosis of the ganglion cyst. In follow-up, patient had asymptomatic left knee with full range of motion and did not show any sign of recurrence. Ganglion cysts from fat pad though very rare but should be considered in differential diagnosis to have an early diagnosis and management. Symptomatic ganglion cyst should be excised by open procedure or arthroscopically depending upon the size and extent of the lesion.

Cervical C7 ganglion cyst causing compressive myelopathy: A rare case report

Background:

Juxtafacet cysts, synovial and ganglion cysts, emanate from the facet joints. Patients with these cysts are typically asymptomatic but may rarely present with radiculopathy and/or myelopathy.

Case Description:

A 72-year-old female presented with a 1-month history of progressive lower extremity weakness (left more than right), numbness, and urinary incontinence. Notably, she also had a C7 sensory level to pin appreciation of 1-month duration. The magnetic resonance imaging showed an extradural C7 cystic lesion whose capsule enhanced with gadolinium, causing severe cord compression. The patient underwent a left C7 hemilaminectomy for complete excision of the cyst; postoperatively in 2-weeks duration, she regained full neurological function. The final histopathology was consistent with a ganglion cyst.

Conclusion:

Cervical juxtafacet cysts rarely cause compressive myelopathy. They may be readily diagnosed and resected with excellent postoperative outcomes.

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.

How I do it? Transforaminal endoscopic decompression of intraspinal facet cyst

BACKGROUND

Transforaminal endoscopic surgery provides equivalent results to open surgery with added advantages of feasibility under local anesthesia, no injury to posterior elements, preservation of the ligamentum flavum, ease of revision surgery, and cost-effectiveness. The technique of transforaminal endoscopic excision of cysts of facet or zygapophyseal joints is scarcely described in literature.

METHODS

The transforaminal endoscopy is applicable to cyst lying in the extraforaminal, foraminal, and intraspinal regions. The "mobile" outside-in technique combined with osteotomy of the tip of the superior articular process facilitates intraspinal access for complete decompression.

CONCLUSION

Transforaminal endoscopic removal of the facet cyst is a viable alternative to traditional open surgery with added advantages of a minimal access procedure.

Case report and review of the literature

The transverse acetabular ligament is an unusual location for ganglion cysts. Only a few cases have been reported in the literature. They can be asymptomatic and represent an incidental finding or can cause an atypical pattern of hip joint/groin pain. We report a case of ganglion cyst arising from the TAL causing entrapment of the anterior branch of the obturator nerve with associated acute denervation of the abductor longus (AL), adductor brevis (AB), and gracilis muscles.

Adventitial Cystic Disease of the Radial Artery

Upper extremity adventitial cystic disease is rare, but the characteristic findings of this lesion should be known to the hand surgeon and used to guide treatment. We present a case of a young adult male who developed a painless mass in his distal forearm. Diagnostic imaging workup revealed a cystic mass that extended within and encased the radial artery. Both MRI and direct intraoperative visualization confirmed the presence of a stalk connecting the intra-mural radial artery mass to the radiocarpal joint. The mass and stalk were excised en bloc with fenestration of the volar capsule to prevent recurrence. This case demonstrates a less common example of upper extremity adventitial cystic disease and supports the articular theory of origin of these lesions. When surgical excision is performed, an attempt should be made to identify and excise the articular stalk in an effort to minimize risk of recurrence.

Acute lumbosacral hemorrhagic ganglion cyst after transforaminal epidural steroid injection

Epidural steroid injection is one of the most commonly used non-surgical treatments for degenerative lumbar vertebral disease. Its use has increased as degenerative lumbar vertebral disease has increased in frequency. Concomitant complications are being reported more often. In this report, we report a rare case of iatrogenic hemorrhagic cyst following epidural steroid injection. The patient underwent operative treatment with complete resolution of his symptoms

Clinical manifestation and arthroscopic treatment of symptomatic posterior cruciate ligament cyst

Background

Ganglion cyst of cruciate ligaments is a rare lesion; the prevalence is 0.3–0.8%. The purpose of this study was to present clinical features of symptomatic posterior cruciate ligament (PCL) cyst, introduce the arthroscopic excision technique, and evaluate the clinical outcome.

Methods

A series of 11 patients with symptomatic PCL cyst from November 2012 to December 2014 were involved in this retrospective study. Detailed medical history collecting and physical examination were conducted. Magnetic resonance imaging (MRI) scan was used to confirm the diagnosis. Arthroscopic resection was performed, and the sample of the cyst was taken for pathologic examination. The follow-up averaged 30.7 months. International Knee Documentation Committee (IKDC) score, the range of motion (ROM), and MRI evaluations were obtained pre- and postoperatively to assess the surgical outcome. SPSS software was used for statistics analysis.

Results

Eight males and 3 females with 6 left knees and 5 right knees were enrolled, the mean age was 34.4 years, and the duration of symptom was 19.0 months. All cases had a definite history of knee trauma or injury. The most common symptom was knee pain at flexion or in flexion-associated activities. MRI revealed the location and size of the cyst in each case. Pathologic examination showed the cyst wall was composed of dense fibroconnective tissue and widespread thick bundles of collagen, which is similar to the structure of ganglion cyst. At the final follow-up, MRI evaluation showed no cyst recurrence. The preoperative ROM and IKDC score were 2.3° to 108.6° and 40.5 ± 11.3, respectively, compared with the postoperative ROM and IKDC score which were 0° to 134.1° and 85.5 ± 4.8 (p < 0.05) separately.

Conclusions

We conclude that the etiology of symptomatic PCL cyst is most likely associated with trauma, pain on flexion is a typical manifestation of symptomatic PCL cyst, MRI evaluation is an ideal examination for the diagnosis, and arthroscopic resection of symptomatic PCL cysts has a good outcome with no recurrence.

Electronic supplementary material

The online version of this article (10.1186/s13018-018-0798-x) contains supplementary material, which is available to authorized users.

Ganglion Cyst as a Rare Complication of Hip Arthroscopy Resolved With THA: A Case Report

BACKGROUND

A rare complication of hip arthroscopy is the development of a ganglion cyst. These cysts can affect structures surrounding the hip joint. In some cases, the femoral artery may be involved, leading to claudication or a pulsatile mass that can resemble an aneurysm.

CASE DESCRIPTION

We present the case of a 62 year-old male who complains of 3 months of right hip pain. Workup reveals a degenerative labrum with cam impingement. After a discussion of various treatment options, the patient elected for arthroscopy to correct the impingement. An anterior capsulotomy was created to establish access to the joint. Cam decompression was indicated to address the impingement. The patient developed a recurring ganglion cyst following the procedure that was not permanently prevented with cyst aspiration. Total hip arthroplasty with ganglion cyst decompression resolved the ganglion cyst and resolved the hip pain.

CONCLUSIONS

This is the first case report that describes the development of a ganglion cyst following hip arthroscopy. Arthroplasty and ganglion cyst decompression in the presence of degenerative joint disease presents a viable treatment option for these cysts. Additionally, this case suggests interportal capsulotomy closure may prevent ganglion cyst development and should be considered when performing hip arthroscopy.

Isolated medial plantar neuropathy caused by a large ganglion cyst diagnosed with MRI: A case report

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Compression neuropathy caused by a ganglion cyst is a rare entity.

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MRI remains an excellent diagnostic modality to evaluate the masses in the foot.

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This is a very rare report of isolated medial plantar neuropathy by a ganglion cyst.

Introduction

Although ganglion cysts are common soft tissue tumors, nerve compression syndrome caused by a ganglion cyst in the lower extremities is very rare. Herein, we report a 57-year-old man who presented with hypoesthesia in the sole of his right foot for 6 months. We believe that reporting this rare case will help clinicians update their knowledge on possible causes of the plantar neuropathy, and avoid diagnostic delay.

Presentation of case

The patient had pain and numbness in the inner right sole, as well as a tingling and dull sensation. Tenderness around the area of abnormal sensation was not evident. Percussion at the abductor tunnel gave a positive Tinel’s sign in the medial plantar nerve. No mass was palpable in the right foot. Based on the electrophysiological findings, we diagnosed medial plantar nerve entrapment in the right foot. Magnetic resonance imaging (MRI) was conducted to identify a 5.5-cm long elongated cystic lesion as the cause of entrapment. The patient underwent surgical removal of the cystic mass, with histologic examination confirming the diagnosis of a large ganglion cyst.

Discussion

The feasibility of nerve conduction studies and electromyography for detection of nerve entrapment is still controversial. MRI is considered the best diagnostic modality, if biopsy is not feasible.

Conclusion

We suggest that foot imaging and electrophysiological studies should be considered for patients with isolated median plantar neuropathy to exclude the presence of space-occupying lesions, especially when conservative treatment is not effective.

Cystic lesions of peripheral nerves: Are we missing the diagnosis of the intraneural ganglion cyst?

AIM

To highlight the salient magnetic resonance imaging (MRI) features of the intraneural ganglion cyst (INGC) of various peripheral nerves for their precise diagnosis and to differentiate them from other intra and extra-neural cystic lesions.

METHODS

A retrospective analysis of the magnetic resonance (MR) images of a cohort of 245 patients presenting with nerve palsy involving different peripheral nerves was done. MR images were analyzed for the presence of a nerve lesion, and if found, it was further characterized as solid or cystic. The serial axial, coronal and sagittal MR images of the lesions diagnosed as INGC were studied for their pattern and the anatomical extent along the course of the affected nerve and its branches. Its relation to identifiable anatomical landmarks, intra-articular communication and presence of denervation changes in the muscles supplied by involved nerve was also studied.

RESULTS

A total of 45 cystic lesions in the intra or extraneural locations of the nerves were identified from the 245 MR scans done for patients presenting with nerve palsy. Out of these 45 cystic lesions, 13 were diagnosed to have INGC of a peripheral nerve on MRI. The other cystic lesions included extraneural ganglion cyst, paralabral cyst impinging upon the suprascapular nerve, cystic schwannoma and nerve abscesses related to Hansen's disease involving various peripheral nerves. Thirteen lesions of INGC were identified in 12 patients. Seven of these affected the common peroneal nerve with one patient having a bilateral involvement. Two lesions each were noted in the tibial and suprascapular nerves, and one each in the obturator and proximal sciatic nerve. An intra-articular connection along the articular branch was demonstrated in 12 out of 13 lesions. Varying stages of denervation atrophy of the supplied muscles of the affected nerves were seen in 7 cases. Out of these 13 lesions in 12 patients, 6 underwent surgery.

CONCLUSION

INGC is an important cause of reversible mono-neuropathy if diagnosed early and surgically treated. Its classic MRI pattern differentiates it from other lesions of the peripheral nerve and aid in its therapeutic planning. In each case, the joint connection has to be identified preoperatively, and the same should be excised during surgery to prevent further cyst recurrence.

Cystic Disease of the Groin Presenting as Compression of a Femoral Vessel

In this study, we describe our diagnosis and treatment of two patients who presented with femoral vessel compression caused by a cystic lesion in the groin. One case was diagnosed as adventitial cystic disease (ACD) of the common femoral artery resulting in leg claudication and the other was diagnosed as a ganglion cyst (GC) causing femoral vein compression and unilateral leg swelling. The operative findings differed between these two cases with respect to the dissection of the cyst and femoral vessel, but the postoperative histological examination results were similar. The pathogenesis of ACD and GC is not fully understood, and further investigation is needed to delineate the exact pathology of these uncommon conditions.

Type A ganglion cysts of the radiocapitellar joint may involve compression of the superficial radial nerve

INTRODUCTION

Two types of ganglion cysts at the elbow have been described depending on their anatomic location. Type A ganglion cyst is located proximal to the arcade of Frohse, and type B distal to it. Compressive neuropathies of the radial nerve at the level of the radial tunnel may lead to two different clinical entities with different clinical manifestations. These different conditions depend on which branch is involved. Although compression of the deep motor branch due to a ganglion cyst has been previously described, affection of the superficial sensory branch is considered much rarer. The aim of this study was to describe a series of patients in which painful and dysesthetic symptoms arose from superficial radial nerve compression due to type A ganglion cysts coming from the radiocapitellar joint.

METHODS

A review of currently available literature about the disease was carried out. The clinical, histological and radiological records of a series of eight cases (seven patients) with compression of the superficial radial nerve diagnosed and treated between 2008 and 2011 were retrospectively reviewed. All patients complained of pain and dysesthesia at the lateral aspect of the elbow. All patients were initially diagnosed and managed as lateral epicondylitis. Persistence of the symptoms was evidenced in all patients after a course of six months of non-operative management. Magnetic resonance imaging was performed and revealed the presence of a mass compatible with a ganglion cyst coming from the radiocapitellar joint, pushing up the superficial sensory branch of the radial nerve and compressing it against the extensor carpi radialis brevis. Surgical excision was performed in all cases.

RESULTS

Histology confirmed the diagnosis of ganglion cysts. Histological findings consisted of dense fibrous tissue, with no synovial or epithelial lining and mucoid material with foamy macrophages. The mean follow-up after surgical excision was 28months (range 24-30). The symptoms subsided in all cases. No complications were registered during the follow-up.

CONCLUSION

Type A ganglion cysts of the radiocapitellar joint may involve compression of the superficial radial nerve. Our series of eight cases may suggest that this pathology might not be as rare as it was thought before. This evidence may be useful for the orthopaedic population, who may have another differential diagnosis when managing cases of painful symptoms located in the lateral aspect of the elbow.

TYPE OF STUDY

Therapeutic study.

LEVEL OF EVIDENCE

IV.

An Unusual Cause of Foot Drop: Peroneal Extraneural Ganglion Cyst

Peripheral neuropathies caused by ganglion cysts are quite rare, especially in the lower extremities. The case of a 64-year-old male with a 2-day history of foot drop and tenderness in the region of the left fibular neck is presented. Physical examination and electromyogram findings verified peroneal nerve palsy. Ultrasonography showed cystic mass localized proximal of the peroneal muscle structures. Magnetic resonance imaging revealed a cystic-appearing mass around the fibular neck that compressed the common peroneal nerve. Surgical excision and ligation of the cyst pedicle were performed. The pathology reports confirmed the diagnosis of a ganglion cyst. The patient regained full function within two months of the surgery. Early sensory symptoms before foot drop should be considered as an indication of surgical excision to prevent delayed damage. Ligation or electrocoagulation of the cyst pedicle should be a part of surgical procedure to avoid recurrences.

Hidradenoma masquerading digital ganglion cyst: A rare phenomenon

Introduction

Mucous cyst is the commonest soft tissue tumor in the dorsum of the distal interphalangeal joint (DIPJ) of the finger. We report the first case of a recurring eccrine tumor (nodular hidradenoma), mimicking a mucous/ganglion cyst, on the dorsum of the DIPJ.

Case report

A 54 year old man presented with painless, hemispherical, colored swelling on the dorsum of his right middle finger (dominant hand), which appeared to have recurred from a previous surgery. The lesion was excised and operative findings from the medical notes showed the gross appearance to be a soft, white, glistening, smooth-surfaced, myxoid nodule resembling a “ganglion cyst”. Immunohistochemistry showed the tumour to be positive for S100, smooth muscle actin and cytokeratin 7. Ductal differentiation was confirmed by staining for epithelial membrane antigen and carcinoembryonic antigen. The histological features were that of atypical and solid cystic hidradenoma.

Discussion

This is the first reported case of this rare tumour presenting as mucous cyst. We conduct a review of the literature of nodular hidradenomas, illustrating the immunohistologic findings in this tumour to emphasise the atypical features.We emphasise the importance of considering hidradenoma in the differential diagnosis of such lesions of the finger, in view of its high recurrence rate and the possibility of malignant transformation.

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We describe the rare phenomenon of an atypical cystic hidradenoma mimicking in presentation a mucous ganglion cyst on the DIPJ of the finger.

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We put this rarity into context by performing a literature review of reported presentations of such tumours.

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We emphasise the importance of a thorough and systematic assessment in patients presenting with such lesions.

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Also highlighted is the importance of considering these tumours in the differential diagnosis of lesions of the DIPJ.

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Thorough immunohistochemistry of resulting biopsies is invaluable in aiding diagnosis in these scenarios of ambiguous soft tissue swellings.

Intratendinous ganglion cyst of the extensor digitorum longus tendon: A case report

INTRODUCTION

Ganglion cysts are benign lesions, common in the hand and wrist. Intratendinous ganglion, however, are rare. We present the first reported case of an intratendinous ganglion cyst in an extensor digitorum longus (EDL) tendon of the foot.

CASE REPORT

A 35-year old presented with a left-sided painful dorsolateral foot swelling. Ultrasound suggested a ganglion cyst in proximity to the EDL tendon of the 5th toe. Two distinct swellings were identified on surgical exploration, including a 6×1cm ganglion lying within the EDL tendon substance that had resulted in tendon splitting. The lesions were excised and EDL tendon repaired. Histological analysis confirmed that both lesions were ganglion cysts. Post-operative recovery was uneventful.

DISCUSSION

Intratendinous ganglion cysts are rare lesions that pose a unique set of diagnostic and treatment challenges. Unlike conventional ganglion, their diagnosis may not be possible until surgical exploration. They have been reported to increase the risk of spontaneous tendon rupture. As such, a lower operative threshold should be applied to prevent their progression. A high index of suspicion should be applied to any ganglion reported radiologically to be in close contact with tendons. If diagnosed upon surgical exploration, it is essential that the operating surgeon is prepared to appropriately modify the procedure to involve primary tendon repair, tendon transfer or tenodesis.

Considerations in performing open surgical excision of dorsal wrist ganglion cysts

PURPOSE

To investigate which conditions should be considered to make a successful resection of the entire ganglion complex during open excision.

METHODS

We reviewed 52 patients who underwent open surgical excision of dorsal wrist ganglions. The inclusion criterion was a symptomatic ganglion causing pain, weakness and limitation of range of motion. The mean follow-up was 26 (range 12-45) months. We recorded operative details including whether or not the stalk was identified, how the ganglia were resected, and where the stalk originated. Intentional rupture of cyst was performed when the stalk was not easily identified with dissection. Pain score was measured using a visual analog scale system pre-operatively and post-operatively. Recurrence was also described.

RESULTS

A stalk was identified in eight cases using dissection and in 43 cases by rupturing the cyst. The entire ganglion complex was resected in 50 cases. The stalk originated most commonly in the radio-lunate joint. The average pain score improved from 3.9 to 1.8 after ganglion removal. The ganglion recurred in two cases where incomplete resection of the ganglion was made.

CONCLUSIONS

In the majority of ganglions, it is difficult to identify the stalk and its capsular attachment due to a large cyst with severe adhesion to adjacent soft tissues including joint capsule. Rupturing a cyst on purpose helps to identify the stalk and minimize capsular loss. A ganglion over the radiolunate joint was most commonly found and excision of joint capsule over scapholunate joint without identification of the stalk and its capsular attachment might result in recurrence. Recurrence was definitely related to incomplete resection which was more commonly made in ganglions over uncommon sites.

LEVEL OF EVIDENCE

Level III, therapeutic study. See the guidelines online for a complete description of level of evidence.

Ultrasound-guided aspiration of wrist ganglions: a follow-up survey of patient satisfaction and outcomes

BACKGROUND

Ganglion cysts are one of the most frequently occurring masses of the wrist, often causing pain and interfering with daily activity. Ultrasound (US)-guided aspiration is a treatment for ganglion cysts of the wrist.

PURPOSE

To examine the results and patient satisfaction of US-guided aspiration of wrist ganglion cysts.

MATERIAL AND METHODS

Medical records from August 2009 through December 2013 were reviewed to identify all adult patients referred to a single musculoskeletal radiologist for US-guided aspiration of a painful wrist ganglion cyst. Records were reviewed for patient demographics, cyst size, location, and morphology. Outcomes and patient satisfaction were evaluated using a telephone questionnaire at a minimum of 9 months after the procedure.

RESULTS

Of 56 consecutive patients identified, follow-up data were available for 39 patients (69%) at a minimum of 9 months. There were 21 volar and 18 dorsal ganglion cysts. The overall recurrence rate was 20% (8 of 39 patients) and only five patients reported a pain score of greater than 2 out of 10. The mean age of patients with recurrence of the cyst was greater than that of patients without recurrence (52 vs. 35 years, P = 0.03). Satisfaction with the outcome was high and varied by recurrence. There were no acute complications including infection, hemorrhage, or allergic reaction.

CONCLUSION

US-guided aspiration is a safe and potentially effective treatment for ganglion cysts of the wrist, with high patient satisfaction. US-guided aspiration may be particularly advantageous for volar ganglion cysts, and in patients who are poor surgical candidates.

Surgical management of Juxtafacet cysts in the lumbar spine

INTRODUCTION

Juxtafacet cysts of the lumbar spine are extradural degenerative lesions associated with symptoms of lower back pain and radiculopathy. The aim of this study is to evaluate the efficacy of surgery and address controversial issues in the treatment of symptomatic juxta facet cysts in the Neurosurgical Department of our hospital and review of the literature.

METHODS

Data from seven patients (age range 58-68 years, mean age 63 years) with low back and radicular leg pain due to a lumbar facet joint cyst were retrospectively analyzed. Demographic data, cyst level, presence of concominant local pathology, treatment and results of treatment were recorded. After surgery there was no case of a recurrent cyst during the follow-up period. The mean follow-up period of patients at the time of this study was 4 years.

RESULTS

All patients had back pain, while five also experienced unilateral radicular leg pain and two had bilateral leg pain. Four patients had neurogenic claudication. MRI identified the cyst and highlighted underlying pathology in all cases. All patients underwent surgical cyst excision. Post-operatively, all patients showed a total resolution of symptoms with sustained benefit at final evaluation.

CONCLUSION

Surgery is a safe and effective treatment for lumbar juxtafacet cysts.

A ganglion cyst derived from a synovial cyst: A case report

The synovial and ganglion cysts originating from the facet joint have been named under the name of the Juxtafacet cyst by the several researchers. They put forward that the synovial cyst originated from the synovial joint. But, they failed to clarify the pathophysiology of the formation of the ganglion cyst. In this case report, we reported a 67-year-old male patient was referred to the emergency from another center with the complaint of a left leg pain and weakness in the left foot and patient was treated with microchirurgical technique. His patological examination was evaluated a ganglion cyst. We have discussed and explained the pathophysiology of the formation of a ganglion cyst derivered from a synovial cyst. And separately, we have presented the spinal cysts by grouping them under a new classification called a cystic formation of the soft tissue attachments of the mobile spine as well as dividing them into sub-groups.

Cystic lesion around the hip joint

This article presents a narrative review of cystic lesions around the hip and primarily consists of 5 sections: Radiological examination, prevalence, pathogenesis, symptoms, and treatment. Cystic lesions around the hip are usually asymptomatic but may be observed incidentally on imaging examinations, such as computed tomography and magnetic resonance imaging. Some cysts may enlarge because of various pathological factors, such as trauma, osteoarthritis, rheumatoid arthritis, or total hip arthroplasty (THA), and may become symptomatic because of compression of surrounding structures, including the femoral, obturator, or sciatic nerves, external iliac or common femoral artery, femoral or external iliac vein, sigmoid colon, cecum, small bowel, ureters, and bladder. Treatment for symptomatic cystic lesions around the hip joint includes rest, nonsteroidal anti-inflammatory drug administration, needle aspiration, and surgical excision. Furthermore, when these cysts are associated with osteoarthritis, rheumatoid arthritis, and THA, primary or revision THA surgery will be necessary concurrent with cyst excision. Knowledge of the characteristic clinical appearance of cystic masses around the hip will be useful for determining specific diagnoses and treatments.

Ultrasound diagnosis of a ganglion cyst within an extensor digitorum brevis manus muscle

A unique case of a ganglion cyst within the extensor digitorum brevis manus muscle diagnosed by ultrasound in an 18-year-old girl is presented. Different anatomical variations and the clinical importance of this accessory muscle are also discussed.