|
1
|
Gonzalez MR, Castillo-Flores S, Portmann-Baracco A, Pretell-Mazzini J. Ganglion Cysts Arising From the Proximal Tibiofibular Joint: Treatment Approach and Associated Outcomes-A Systematic Review. HSS J 2024; 20:556-566. [PMID: 39494424 PMCID: PMC11528768 DOI: 10.1177/15563316231172510] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/03/2023] [Indexed: 11/05/2024]
Abstract
Background: Proximal tibiofibular joint (PTFJ) ganglion cyst is a rare condition with a high rate of recurrence. Optimal treatment has not yet been determined. Purpose: We aimed to answer the following questions: (1) What are the most common treatments for PTFJ cysts and their associated recurrence rates? (2) What are the risk factors for failure to completely recover from symptoms? (3) What are the risk factors for cyst recurrence? Methods: A systematic review was performed using PubMed and EMBASE databases. Studies were assessed for inclusion and exclusion criteria, and quality analysis following the PRISMA guidelines. Information on demographic, clinical, and treatment characteristics was retrieved from articles. Results: The most common surgical treatment was cyst excision (75.3%). Patients with PTFJ arthrodesis and PTFJ resection had the lowest recurrence rates at 0% and 4.4%, respectively. Complete recovery from symptoms was more common in PTFJ resection (70.8%) than in PTFJ arthrodesis (42.9%). Risk factors for failure to achieve complete recovery from symptoms included intraneural compromise (odds ratio [OR] = 3.93), cyst recurrence (OR = 6.04), and being a contact sports athlete (OR = 9.85). Ligation of the articular branch of the peroneal nerve (PN) was a protective factor (OR = 0.29). A history of knee arthritis was the most important risk factor for cyst recurrence (OR = 20.01); PTFJ arthrodesis was a protective factor (OR = 0.04). Conclusion: This systematic review of level-IV studies found PTFJ resection or arthrodesis to be the most effective treatment options. Intraneural compromise of the common peroneal nerve, cyst recurrence, and participation in contact sports are risk factors for incomplete symptom recovery, and ligation of the articular branch of the PN is a protective factor. Knee arthritis is a risk factor for cyst recurrence. More rigorous study is needed.
Collapse
Affiliation(s)
| | | | | | - Juan Pretell-Mazzini
- Miami Cancer Institute, Division of Orthopedic Oncology, Baptist Health System South Florida, Plantation, FL, USA
| |
Collapse
|
|
2
|
Lee SH, Kim SH, Kim HS, Lee HU. Palsy of Both the Tibial Nerve and Common Peroneal Nerve Caused by a Ganglion Cyst in the Popliteal Area. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:876. [PMID: 38929493 PMCID: PMC11205490 DOI: 10.3390/medicina60060876] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/18/2024] [Accepted: 05/25/2024] [Indexed: 06/28/2024]
Abstract
A ganglion cyst is a benign mass consisting of high-viscosity mucinous fluid. It can originate from the sheath of a tendon, peripheral nerve, or joint capsule. Compressive neuropathy caused by a ganglion cyst is rarely reported, with the majority of documented cases involving peroneal nerve palsy. To date, cases demonstrating both peroneal and tibial nerve palsies resulting from a ganglion cyst forming on a branch of the sciatic nerve have not been reported. In this paper, we present the case of a 74-year-old man visiting an outpatient clinic complaining of left-sided foot drop and sensory loss in the lower extremity, a lack of strength in his left leg, and a decrease in sensation in the leg for the past month without any history of trauma. Ankle dorsiflexion and great toe extension strength on the left side were Grade I. Ankle plantar flexion and great toe flexion were Grade II. We suspected peroneal and tibial nerve palsy and performed a screening ultrasound, which is inexpensive and rapid. In the operative field, several cysts were discovered, originating at the site where the sciatic nerve splits into peroneal and tibial nerves. After successful surgical decompression and a series of rehabilitation procedures, the patient's neurological symptoms improved. There was no recurrence.
Collapse
Affiliation(s)
| | | | | | - Hyun-Uk Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170, Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Gyeonggi-do, Republic of Korea; (S.-H.L.); (S.-H.K.); (H.-S.K.)
| |
Collapse
|
|
3
|
Khalefa MA, Hussain S, Bache EC. Common Peroneal Nerve Compression Neuropathy Due to a Large Synovial Cyst From the Proximal Tibiofibular Joint in a Teenager. Cureus 2023; 15:e46562. [PMID: 37933352 PMCID: PMC10625661 DOI: 10.7759/cureus.46562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 11/08/2023] Open
Abstract
Ganglion cysts are very rare in the lower limb and when present, ganglion cysts rarely cause compression neuropathy at any site. Peripheral nerve sheath tumors as a whole, are also very rare and mostly presented as a painful lump along the nerve path. Ganglion cysts are non-neoplastic gelatinous cysts, which lack true synovial lining. They can be divided into intraneural cysts which can be found within the epineurium of a peripheral nerve and lead to signs and symptoms of peripheral neuropathy or extraneural cysts which can develop from surrounding joints or tendon sheaths causing gradual nerve compression. Intraneural tumors of common peroneal nerve (CPN) are widely reported in the literature with varying degrees of symptoms; however, there are only a few case reports describing CPN palsy due to extraneural cysts. We are reporting a rare case of atraumatic CPN palsy, which resulted in irreversible foot drop in a teenage boy who presented with right leg radiating calf and foot pain. We recommend prompt investigation and excision of the cyst to decompress the nerve to increase the chances of early recovery and favorable outcomes.
Collapse
Affiliation(s)
- Mohamed A Khalefa
- Trauma and Orthopedics, The Royal Orthopedic Hospital, Birmingham, GBR
- Trauma and Orthopedics, Cairo University, Cairo, EGY
| | - Shakir Hussain
- Trauma and Orthopedics, The Royal Orthopedic Hospital, Birmingham, GBR
| | - Edwards C Bache
- Trauma and Orthopedics, Birmingham Children's Hospital, Birmingham, GBR
| |
Collapse
|
|
4
|
Wilson TJ, Stone JJ, Howe BM, Rock MG, Spinner RJ. Joint Outcomes Following Surgery for Superior Tibiofibular Joint-Associated Peroneal Intraneural Ganglion Cysts. Neurosurgery 2020; 86:383-390. [PMID: 31215635 DOI: 10.1093/neuros/nyz205] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Accepted: 12/20/2018] [Indexed: 11/14/2022] Open
Abstract
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.
Collapse
Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, Stanford University, Stanford, California
| | | | - B Matthew Howe
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Michael G Rock
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
|
5
|
Lucattelli E, Menichini G, Brogi M, Roselli G, Innocenti M. Long-Term Functional Outcome After Surgical Treatment of Peroneal Intraneural Ganglion Cyst. World Neurosurg 2019; 132:e217-e222. [PMID: 31493600 DOI: 10.1016/j.wneu.2019.08.195] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/22/2019] [Accepted: 08/24/2019] [Indexed: 11/17/2022]
Abstract
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.
Collapse
Affiliation(s)
- Elena Lucattelli
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy.
| | - Giulio Menichini
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Mattia Brogi
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| | - Giuliana Roselli
- Radiology Department, Careggi University Hospital, Florence, Italy
| | - Marco Innocenti
- Plastic and Reconstructive Microsurgery, Careggi University Hospital, Florence, Italy
| |
Collapse
|
|
6
|
Intraneural Ganglion Cysts of the Fibular Nerve: A Cause of Fluctuating Painful Foot Drop. Can J Neurol Sci 2018; 45:601-603. [PMID: 30041709 DOI: 10.1017/cjn.2018.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
|
7
|
Alves TI, Girish G, Kalume Brigido M, Jacobson JA. US of the Knee: Scanning Techniques, Pitfalls, and Pathologic Conditions. Radiographics 2017; 36:1759-1775. [PMID: 27726755 DOI: 10.1148/rg.2016160019] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Pain and other disorders of the knee are a common presenting complaint in the ambulatory setting. Although the cornerstones of imaging evaluation of the knee are radiographs and magnetic resonance (MR) imaging, ultrasonography (US) is less expensive than MR imaging, easily available, and of comparable accuracy in the evaluation of certain pathologic conditions of the knee. The benefits of US include portability, low cost, high spatial resolution, dynamic imaging, and ability to guide percutaneous interventions when indicated. US also allows direct patient contact, facilitating immediate clinical correlation and the ability to compare with the contralateral knee. US evaluation of the knee can be targeted to a specific region on the basis of the complaint or be a comprehensive review. For comprehensive evaluation, the knee is divided into anterior, medial, lateral, and posterior compartments for structured evaluation of the tendons, ligaments, joint space, osseous structures, as well as peripheral nerves and vasculature. US is particularly well suited for evaluating injuries of the quadriceps and patellar tendons, injuries of the medial and lateral collateral ligaments, joint effusions, and fluid collections around the knee. There is additional utility in evaluation of the distal hamstrings tendons, the iliotibial tract, the superficial patellar cortex, the common peroneal nerve, the popliteal vessels, and juxta-articular cystic collections including Baker cyst. In-depth appreciation of relevant sonographic anatomy, common pathologic conditions, knowledge of important pitfalls, and mastery of US technique will allow one to effectively use this powerful bedside tool for the evaluation of a wide variety of knee disorders. ©RSNA, 2016.
Collapse
Affiliation(s)
- Timothy I Alves
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Gandikota Girish
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Monica Kalume Brigido
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| | - Jon A Jacobson
- From the Department of Radiology, Division of Musculoskeletal Imaging, University of Michigan Health System, 2910 S Taubman Center, SPC 5326, 1500 E Medical Center Dr, Ann Arbor, MI 48109
| |
Collapse
|
|
8
|
The cubital tunnel syndrome caused by the intraneural or extraneural ganglion cysts: Case report and review of the literature. J Plast Reconstr Aesthet Surg 2017; 70:1404-1408. [PMID: 28803901 DOI: 10.1016/j.bjps.2017.05.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/26/2017] [Accepted: 05/09/2017] [Indexed: 11/23/2022]
Abstract
Cubital tunnel syndrome is the second most common nerve compression syndrome in peripheral nerve compression disease. Although potential ulnar nerve entrapment can occur at multiple points along its course, such as the arcade of struthers, the medial intermuscular septum, the medial epicondyle, the cubital tunnel, and the deep flexor pronator aponeurosis, the most common site of entrapment is the cubital tunnel. However, cubital tunnel syndrome could also be caused by the occupying masses along the course of ulnar nerve, such as intraneural or extraneural ganglia. The cubital tunnel syndrome caused by intraneural or extraneural ganglion cysts has been rarely reported. In our hospital, there were 184 patients with cubital tunnel syndrome who underwent surgical treatment from January 2010 to January 2014. Of these patients, 16 had extraneural cysts and 3 had intraneural ganglion cysts. The incidence rate of cysts in the cubital tunnel was 10.33%. Electromyography was used as routine examination. Ultrasound was used only in some patients in whom elbow mass was suspected. In the surgery of the cubital tunnel syndrome combined with cyst, if any other cysts were found, we should be remove completely the cyts and decompress the ulnar nerve thoroughly with the ulnar nerve being anterior transposition. These cysts were confirmed by histopathological examination. Finally, we compared the clinical features of patients who had a medial elbow ganglion with those of patients who had only cubital tunnel syndrome. B ultrasound can significantly improve the diagnosis. All patients were followed up for 4 months to 2 years, and the curative effect was good.
Collapse
|
|
9
|
Panwar J, Mathew A, Thomas BP. Cystic lesions of peripheral nerves: Are we missing the diagnosis of the intraneural ganglion cyst? World J Radiol 2017; 9:230-244. [PMID: 28634514 PMCID: PMC5441458 DOI: 10.4329/wjr.v9.i5.230] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/17/2017] [Accepted: 03/16/2017] [Indexed: 02/06/2023] Open
Abstract
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.
Collapse
|
|
10
|
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
| |
Collapse
|
|
11
|
Wilson TJ, Hébert-Blouin MN, Murthy NS, García JJ, Amrami KK, Spinner RJ. The nearly invisible intraneural cyst: a new and emerging part of the spectrum. Neurosurg Focus 2017; 42:E10. [DOI: 10.3171/2016.12.focus16439] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The authors have observed that a subset of patients referred for evaluation of peroneal neuropathy with “negative” findings on MRI of the knee have subtle evidence of a peroneal intraneural ganglion cyst on subsequent closer inspection. The objective of this study was to introduce the nearly invisible peroneal intraneural ganglion cyst and provide illustrative cases. The authors further wanted to identify clues to the presence of a nearly invisible cyst.
METHODS
Illustrative cases demonstrating nearly invisible peroneal intraneural ganglion cysts were retrospectively reviewed and are presented. Case history and physical examination, imaging, and intraoperative findings were reviewed for each case. The outcomes of interest were the size and configuration of peroneal intraneural ganglion cysts over time, relative to various interventions that were performed, and in relation to physical examination and electrodiagnostic findings.
RESULTS
The authors present a series of cases that highlight the dynamic nature of peroneal intraneural ganglion cysts and introduce the nearly invisible cyst as a new and emerging part of the spectrum. The cases demonstrate changes in size and morphology over time of both the intraneural and extraneural compartments of these cysts. Despite “negative” MR imaging findings, nearly invisible cysts can be identified in a subset of patients.
CONCLUSIONS
The authors demonstrate here that peroneal intraneural ganglion cysts ride a roller coaster of change in both size and morphology over time, and they describe the nearly invisible cyst as one end of the spectrum. They identified clues to the presence of a nearly invisible cyst, including deep peroneal predominant symptoms, fluctuating symptoms, denervation changes in the tibialis anterior muscle, and abnormalities of the superior tibiofibular joint, and they correlate the subtle imaging findings to the internal fascicular topography of the common peroneal nerve. The description of the nearly invisible cyst may allow for increased recognition of this pathological entity that occurs with a spectrum of findings.
Collapse
Affiliation(s)
| | | | | | - Joaquín J. García
- 4Laboratory Medicine and Pathology, Mayo Clinic, Rochester, Minnesota; and
| | | | | |
Collapse
|
|
12
|
Jacobson JA, Wilson TJ, Yang LJS. Sonography of Common Peripheral Nerve Disorders With Clinical Correlation. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2016; 35:683-693. [PMID: 26931790 DOI: 10.7863/ultra.15.05061] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Accepted: 07/13/2015] [Indexed: 06/05/2023]
Abstract
Sonography is now considered an effective method to evaluate peripheral nerves. Low cost, high resolution, the ability to image an entire limb in a short time, and dynamic assessment are several of the positive attributes of sonography. This article will review the normal appearance of peripheral nerves as shown with sonography. In addition, the most common applications for sonography of the peripheral nerves will be reviewed, which include entrapment neuropathies, intraneural ganglion cyst, nerve trauma, and peripheral nerve sheath tumors. Clinical information related to nerve disorders is also included, as it provides valuable information that can be obtained during sonographic examinations, increasing diagnostic accuracy.
Collapse
Affiliation(s)
- Jon A Jacobson
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan USA.
| | - Thomas J Wilson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan USA
| | - Lynda J-S Yang
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan USA
| |
Collapse
|
|
13
|
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: 83] [Impact Index Per Article: 9.2] [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.
Collapse
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
| |
Collapse
|
|
14
|
Fascicular Involvement of the Posterior Tibial Nerve as a Result of Perineural Ganglion Cyst at the Posterior Tibial Nerve in the Calf: A Case Report and Review of Literature. J Clin Neuromuscul Dis 2015; 17:84-7. [PMID: 26583496 DOI: 10.1097/cnd.0000000000000100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We report a 19-year-old woman with a 6-month history of nontraumatic left foot numbness associated with intermittent weakness. Nerve conduction studies and electromyography localized the lesion to the posterior tibial nerve, below the innervation to the soleus and medial gastrocnemius muscles. MRI of the left leg revealed a multiloculated cystic collection near the proximal tibiofibular joint. Surgical excision and pathology confirmed the diagnosis of a ganglion cyst, in an atypical location distal to the popliteal fossa. We believe this is the first reported case of fascicular posterior tibial nerve involvement by a ganglion cyst in the calf.
Collapse
|
|
15
|
Desy NM, Lipinski LJ, Tanaka S, Amrami KK, Rock MG, Spinner RJ. Recurrent intraneural ganglion cysts: Pathoanatomic patterns and treatment implications. Clin Anat 2015; 28:1058-69. [PMID: 26296291 DOI: 10.1002/ca.22615] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/05/2015] [Indexed: 12/21/2022]
Abstract
The etiology of intraneural ganglion cysts has been poorly understood. This has resulted in the development of multiple surgical treatment strategies and a high recurrence rate. We sought to analyze these recurrences in order to provide a pathoanatomic explanation and staging classification for intraneural cyst recurrence. An expanded literature search was performed to identify frequencies and patterns in cases of intraneural ganglion cyst recurrences following primary surgery. Two univariate analyses were completed to identify associations between the type of revision surgery and repeat cyst recurrences. The expanded literature search found an 11% recurrence rate following primary surgery, including 64 recurrences following isolated cyst decompression (Group 1); six after articular branch resection (Group 2); and none following surgical procedures that addressed the joint (Group 3). Eight cases did not specify the type of primary surgery. In group 1, forty-eight of the recurrences (75%) were in the parent nerve, three involved only the articular branch, and one travelled along the articular branch in a different distal direction without involving the main parent nerve. In group 2, only one case (17%) recurred/persisted within the parent nerve, one recurred within a persistent articular branch, and one formed within a persistent articular branch and travelled in a different distal direction. Intraneural recurrences most commonly occur following surgical procedures that only target the main parent nerve. We provide proven or theoretical explanations for all identified cases of intraneural recurrences for an occult or persistent articular branch pathway.
Collapse
Affiliation(s)
- Nicholas M Desy
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota
| | - Lindsay J Lipinski
- Department of Neurosurgery, School of Medicine and Biomedical Sciences, University of Buffalo, State University of New York, Buffalo, New York
| | - Shota Tanaka
- Department of Neurosurgery, Faculty of Medicine, the University of Tokyo, Tokyo, Japan
| | | | - Michael G Rock
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota
| | - Robert J Spinner
- Department of Orthopedics, Mayo Clinic, Rochester, Minnesota.,Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.,Department of Anatomy, Mayo Clinic, Rochester, Minnesota
| |
Collapse
|
|
16
|
Abstract
PURPOSE To review 15 patients who were treated for intraneural ganglions of the hand and wrist. METHODS Between 1990 and 2012, 15 patients were treated for intraneural ganglions of the hand and wrist. There were 9 women and 6 men, averaged age 42 years. Ten patients presented with a mass and 5 with symptoms of entrapment neuropathy. The ganglions involved the ulnar nerve at the wrist in 5 patients, the dorsal branch of the ulnar nerve in 2, the superficial radial nerve in 2, a digital nerve in 4, and the dorsal branch of a digital nerve in 2. Eight patients had magnetic resonance imaging evaluations that showed cystic masses that did not confirm intraneural ganglions. In all patients diagnosis was made intraoperatively. Ganglions were treated by intraneural dissection and excision of the cyst in 10 patients, excision of the articular branch and decompression of the cyst in 4, and excision of the ganglion and the nerve in 1. RESULTS Postoperative follow-up averaged 57 months. There were no complications or recurrences. Five patients had transient paresthesias that improved after an average of 2 months. Preoperative symptoms improved in all patients. Patients returned to normal daily and work activities at an average of 10 days. CONCLUSIONS Intraneural ganglions should be considered in the differential diagnosis of a mass in the vicinity of a nerve. Surgical excision is usually curative but simple excision of the articular branch and decompression of the cyst seems simpler and equally effective. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
Collapse
|
|
17
|
Prasad NK, Amrami KK, Jentoft ME, Spinner RJ. Concurrent Lateral Dorsal Cutaneous and Deep Peroneal Intraneural Ganglion Cysts in the Foot. J Foot Ankle Surg 2015; 55:401-5. [PMID: 25979292 DOI: 10.1053/j.jfas.2015.02.006] [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] [Received: 01/06/2015] [Indexed: 02/03/2023]
Abstract
Intraneural ganglion cysts are non-neoplastic collections of mucinous material within the epineurium of peripheral nerves. We present a rare case of 2 intraneural ganglion cysts in separate nerves of the foot, originating from different joints within the same joint complex. Our findings add to the large body of evidence supporting the unifying articular (synovial) theory. We emphasize the importance of delineating the cyst morphology and origins using high-resolution magnetic resonance imaging before surgery and searching for and resecting the articular branch or branches during surgery.
Collapse
Affiliation(s)
- Nikhil K Prasad
- Research Fellow, Department of Neurosurgery, Mayo Clinic, Rochester, MN
| | | | - Mark E Jentoft
- Senior Associate Consultant, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Robert J Spinner
- Professor and Chair, Department of Neurosurgery, Mayo Clinic, Rochester, MN.
| |
Collapse
|
|
18
|
Deep peroneal nerve palsy caused by an extraneural ganglion cyst: a rare case. Case Rep Orthop 2015; 2015:861697. [PMID: 25632363 PMCID: PMC4302346 DOI: 10.1155/2015/861697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2014] [Revised: 12/05/2014] [Accepted: 12/24/2014] [Indexed: 11/17/2022] Open
Abstract
Lower extremities peripheral neuropathies caused by ganglion cysts are rare. The most frequent location of occurrence is the common peroneal nerve and its branches, at the level of the fibular neck. We report the case of a 57-year-old patient admitted with foot drop, due to an extraneural ganglion of the upper tibiofibular syndesmosis, compressing the deep branch of the peroneal nerve. Although there have been many previous reports of intraneural ganglion involvement with the lower limb nerves, to our knowledge, this is the second reported occurrence of an extraneural ganglion distinctly localized to the upper tibiofibular syndesmosis and palsying deep peroneal nerve. The diagnosis was made preoperatively using MRI. The common peroneal nerve and its branches were recognized and traced to its bifurcation during the operation, and the ganglion cyst was removed. Two months after surgery, the patient was pain-free and asymptomatic except for cutaneous anesthesia in the distribution of the deep peroneal nerve.
Collapse
|
|
19
|
Lee YS, Kim JE, Kwak JH, Wang IW, Lee BK. Foot drop secondary to peroneal intraneural cyst arising from tibiofibular joint. Knee Surg Sports Traumatol Arthrosc 2013; 21:2063-5. [PMID: 23007411 DOI: 10.1007/s00167-012-2194-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Accepted: 08/27/2012] [Indexed: 10/27/2022]
Abstract
UNLABELLED An 11-year-old boy presented to our outpatient clinic with a three-month history of pain over the fibular head area and gait difficulty. Surgical exploration revealed a mass arising from the superior tibiofibular joint invading the peroneal nerve along the articular branch of the common peroneal nerve. The pathogenesis of the intraneural ganglion of the peroneal nerve may be an articular origin and superior tibiofibular joint is the central point. LEVEL OF EVIDENCE V.
Collapse
Affiliation(s)
- Yong Seuk Lee
- Department of Orthopedic Surgery, Gachon University School of Medicine, Gil Hospital, Incheon, Korea.
| | | | | | | | | |
Collapse
|
|
20
|
Ozden R, Uruc V, Kalacı A, Dogramacı Y. Compression of common peroneal nerve caused by an extraneural ganglion cyst mimicking intermittent claudication. J Brachial Plex Peripher Nerve Inj 2013; 8:5. [PMID: 23721086 PMCID: PMC3707792 DOI: 10.1186/1749-7221-8-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Accepted: 05/17/2013] [Indexed: 11/13/2022] Open
Abstract
Peripheral neuropathies caused by ganglion cysts are rare. They seldom cause serious complications especially in the lower extremities. The case was a 51-year-old woman referred by her physician to the vascular surgeon with diagnosis including intermittent (vascular) claudication and deep venous thrombosis. Primarily vascular surgeon performed a doppler ultrasound of the lower extremity and calculation of the ankle-brachial index. There were no abnormal pathological findings. Careful physical examination revealed soft swelling and tenderness around the fibular head and neck. Weakness was observed in foot eversion and dorsiflexion. There was pain and tingling in the distribution of the peroneal nerve. and referring the patient to orthopedic surgeon owing to concern for a potential compressive lesion at the right proximal tibiofibular region. Electromyogram studies and physical examination confirmed a diagnosis of compression neuropathy of common peroneal nerve. Magnetic resonance imaging revealed a fluid-filled, lobulated mass indicating a ganglion cyst. One months after decompression, the patient had no complaint. Fast diagnosis and immediate management are essential to regain best possible recovery.
Collapse
Affiliation(s)
- Raif Ozden
- Department of Orthopaedics and Traumatology, Faculty of Medicine, Mustafa Kemal University, Antakya, Hatay, Turkey.
| | | | | | | |
Collapse
|
|
21
|
Van den Bergh FRA, Vanhoenacker FM, De Smet E, Huysse W, Verstraete KL. Peroneal nerve: Normal anatomy and pathologic findings on routine MRI of the knee. Insights Imaging 2013; 4:287-99. [PMID: 23709403 PMCID: PMC3675257 DOI: 10.1007/s13244-013-0255-7] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2013] [Revised: 04/12/2013] [Accepted: 04/18/2013] [Indexed: 01/30/2023] Open
Abstract
Background Peroneal nerve lesions are not common and are often exclusively assessed clinically and electromyographically. Methods On a routine MR examination without dedicated MR-neurography sequences the peroneal nerve can readily be assessed. Axial T1-weighted sequences are especially helpful as they allow a good differentiation between the nerve and the surrounding fat. Results The purpose of this article is to review the normal anatomy and pathologic conditions of the peroneal nerve around the knee. Conclusion In the first part the variable anatomy of the peroneal nerve around the knee will be emphasized, followed by a discussion of the clinical findings of peroneal neuropathy and general MR signs of denervation. Six anatomical features may predispose to peroneal neuropathy: paucity of epineural tissue, biceps femoris tunnel, bifurcation level, superficial course around the fibula, fibular tunnel and finally the additional nerve branches. In the second part we discuss the different pathologic conditions: accidental and surgical trauma, and intraneural and extraneural compressive lesions. Teaching Points • Six anatomical features contribute to the vulnerability of the peroneal nerve around the knee. • MR signs of muscle denervation within the anterior compartment are important secondary signs for evaluation of the peroneal nerve. • The most common lesions of the peroneal nerve are traumatic or compressive. • Intraneural ganglia originate from the proximal tibiofibular joint. • Axial T1-weighted images are the best sequence to visualise the peroneal nerve on routine MRI.
Collapse
Affiliation(s)
- F. R. A. Van den Bergh
- Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, campus Duffel, Rooienberg 25, 2570 Duffel, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - F. M. Vanhoenacker
- Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, campus Duffel, Rooienberg 25, 2570 Duffel, Belgium
- Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - E. De Smet
- Department of Radiology, AZ Sint-Maarten Duffel-Mechelen, campus Duffel, Rooienberg 25, 2570 Duffel, Belgium
- Department of Radiology, University Hospital Antwerp, Wilrijkstraat 10, 2650 Edegem, Belgium
| | - W. Huysse
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| | - K. L. Verstraete
- Faculty of Medicine and Health Sciences, Ghent University, De Pintelaan 185, 9000 Ghent, Belgium
| |
Collapse
|
|
22
|
|
|
23
|
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: 0.9] [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.
Collapse
|
|
24
|
Chhabra A, Faridian-Aragh N, Chalian M, Soldatos T, Thawait SK, Williams EH, Andreisek G. High-resolution 3-T MR neurography of peroneal neuropathy. Skeletal Radiol 2012; 41:257-71. [PMID: 21416383 DOI: 10.1007/s00256-011-1146-y] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2010] [Revised: 02/22/2011] [Accepted: 02/28/2011] [Indexed: 02/02/2023]
Abstract
The common peroneal nerve (CPN), a major terminal branch of the sciatic nerve, can be subject to a variety of pathologies, which may affect the nerve at any level from the lumbar plexus to its distal branches. Although the diagnosis of peripheral neuropathy is traditionally based on a patient's clinical findings and electrodiagnostic tests, magnetic resonance neurography (MRN) is gaining an increasing role in the definition of the type, site, and extent of peripheral nerve disorders. Current high-field MR scanners enable high-resolution and excellent soft-tissue contrast imaging of peripheral nerves. In the lower extremities, MR neurography has been employed in the demonstration of the anatomy and pathology of the CPN, as well as in the detection of associated secondary muscle denervation changes. This article reviews the normal appearance of the CPN as well as typical pathologies and abnormal findings at 3.0-T MR neurography of the lower extremity.
Collapse
Affiliation(s)
- Avneesh Chhabra
- The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins Hospital, 601 North Caroline Street, JHOC 3262, Baltimore, MD 21287, USA.
| | | | | | | | | | | | | |
Collapse
|
|
25
|
Okada M, Sakaguchi K, Oebisu N, Takamatsu K, Nakamura H. A ganglion within the ulnar nerve and communication with the distal radioulnar joint via an articular branch: case report. J Hand Surg Am 2011; 36:2024-6. [PMID: 21975094 DOI: 10.1016/j.jhsa.2011.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2011] [Revised: 08/10/2011] [Accepted: 08/11/2011] [Indexed: 02/02/2023]
Abstract
An intraneural ganglion is rare, and involvement of an articular nerve may suggest a possible pathogenesis. We report an intraneural ganglion of the ulnar nerve with a connection to the distal radioulnar joint via the articular branch. We excised the ganglion, the stalk, and the articular branch. To date, there has been no recurrence.
Collapse
Affiliation(s)
- Mitsuhiro Okada
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan.
| | | | | | | | | |
Collapse
|
|
26
|
Hébert-Blouin MN, Pirola E, Amrami KK, Wang H, Desy NM, Spinner RJ. An anatomically based imaging sign to detect adventitial cyst derived from the superior tibiofibular joint. Clin Anat 2011; 24:893-902. [DOI: 10.1002/ca.21190] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 03/05/2011] [Accepted: 03/07/2011] [Indexed: 11/05/2022]
|
|
27
|
Chen WA, Barnwell JC, Li Y, Smith BP, Li Z. An ulnar intraneural ganglion arising from the pisotriquetral joint: case report. J Hand Surg Am 2011; 36:65-7. [PMID: 21093175 DOI: 10.1016/j.jhsa.2010.08.033] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2009] [Revised: 08/21/2010] [Accepted: 08/31/2010] [Indexed: 02/02/2023]
Abstract
Intraneural ganglions of the hand are rare and remain poorly understood. We report a case of an intraneural ganglion arising from the pisotriquetral joint that penetrated the ulnar nerve at Guyon's canal. Although rare, these ganglions should be considered in the differential diagnosis of any neoplasms causing compression neuropathy.
Collapse
Affiliation(s)
- Wayne A Chen
- Department of Orthopaedic Surgery, Wake Forest University School of Medicine, Winston-Salem, NC 27157, USA
| | | | | | | | | |
Collapse
|
|
28
|
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: 1.3] [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.
Collapse
|
|
29
|
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: 4.0] [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.
Collapse
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
| |
Collapse
|
|
30
|
Wang H, Terrill RQ, Tanaka S, Amrami KK, Spinner RJ. Adherence of intraneural ganglia of the upper extremity to the principles of the unifying articular (synovial) theory. Neurosurg Focus 2009; 26:E10. [PMID: 19435440 DOI: 10.3171/foc.2009.26.2.e10] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Intraneural ganglia are nonneoplastic mucinous cysts contained within the epineurium of peripheral nerves. Their pathogenesis has been controversial. Historically, the majority of authors have favored de novo formation (degenerative theory). Because of their rarity, intraneural ganglia affecting the upper limb have been misunderstood. This study was designed to critically analyze the literature and to test the hypothesis that intraneural ganglia of the upper limb act analogously to those in the lower limb, being derived from an articular source (synovial theory). METHODS Two patients with digital intraneural cysts were included in the study. An extensive literature review of intraneural ganglia of the upper limb was undertaken to provide the historical basis for the study. RESULTS In both cases, the digital intraneural ganglia were demonstrated to have joint connections; the one patient in whom an articular branch was not appreciated initially had evidence on postoperative MR images of persistence of intraneural cyst after simple decompression was performed. Eighty-six cases of intraneural lesions were identified in varied locations of the upper limb: the most common sites were the ulnar nerve at the elbow and wrist, occurring 38 and 22 times, respectively. Joint connections were present in only 20% of the cases published by other groups. CONCLUSIONS The authors believe that the fundamental principles of the unifying articular (synovial) theory (that is, articular branch connections, cyst fluid following a path of least resistance, and the role of pressure fluxes) previously described to explain intraneural ganglia in the lower limb apply to those cases in the upper limb. In their opinion, the joint connection is often not identified because of the cysts' rarity, radiologists' and surgeons' inexperience, and the difficulty visualizing and demonstrating it because of the small size of the cysts. Furthermore, they believe that recurrence (subclinical or clinical) is not only underreported but also predictable after simple decompression that fails to address the articular branch. In contrast, intraneural recurrence can be eliminated with disconnection of the articular branch.
Collapse
Affiliation(s)
- Huan Wang
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | | | | |
Collapse
|
|
31
|
Spinner RJ, Amrami KK, Wang H, Kliot M, Carmichael SW. Cross-over: a generalizable phenomenon necessary for secondary intraneural ganglion cyst formation. Clin Anat 2008; 21:111-8. [PMID: 18220283 DOI: 10.1002/ca.20590] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The appearances of intraneural ganglion cysts are being elucidated. We previously introduced the cross-over phenomenon to explain how a fibular (peroneal) or tibial intraneural ganglion cyst arising from the superior tibiofibular joint could give rise to multiple cysts: cyst fluid ascending up the primarily affected nerve could reach the level of the sciatic nerve, fill its common epineurial sheath and spread circumferentially (cross over), at which time pressure fluxes could result in further ascent up the sciatic or descent down the same parent nerve or the opposite, previously unaffected fibular or tibial nerves. In this study, we hypothesized that cross-over could occur in other nerves, potentially leading to the formation of more than one intraneural ganglion cyst in such situations. We analyzed the literature and identified a single case that we could review where proximal extension of an intraneural ganglion cyst involving a nerve at a different site could theoretically undergo cross-over in another major nerve large enough for available magnetic resonance images to resolve this finding. A case of a suprascapular intraneural ganglion cyst previously reported by our group that arose from the glenohumeral joint and extended to the neck was reanalyzed for the presence or absence of cross-over. An injection of dye into the outer epineurium of the suprascapular nerve in a fresh cadaveric specimen was performed to test for cross-over experimentally. Retrospective review of this case of suprascapular intraneural ganglion cyst demonstrated evidence to support previously unrecognized cross-over at the level of the upper trunk, with predominant ascent up the C5 and the C6 nerve roots and subtle descent down the anterior and posterior divisions of the upper trunk as well as the proximal portion of the suprascapular nerve. This appearance gave rise to multiple interconnected intraneural ganglion cysts arising from a single distant connection to the glenohumeral joint. The injection study also demonstrated the cross-over phenomenon and produced a similar pattern as the cyst dissection. This article illustrates that cross-over can occur in another nerve (apart from the prototype fibular nerve). Furthermore, understanding the more complex anatomic nature of the upper trunk cross-over model provides insight into important mechanistic information regarding the bidirectional propagation patterns and formation of primary and secondary intraneural ganglion cysts not afforded by the previously described sciatic nerve cross-over model.
Collapse
Affiliation(s)
- Robert J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
| | | | | | | | | |
Collapse
|