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Ganglion Cyst

Ganglion of Joint

Ganglion cysts are non-neoplastic lumps, usually located at the wrists and fingers.


Presentation

Most of the ganglion cysts are asymptomatic and sometimes remain undetected for long. They normally appear like a small bump, that changes in size, and usually does not move. They are normally pea sized, round or oval, an average size being about 2 cm, but their size can vary to as large as a golf ball. Cysts larger than 5 cm normally have to be surgically excised. Some cysts may appear suddenly and resolve spontaneously.

Ganglion cysts are normally painless unless they compress the adjacent nerve fibre, or restrict joint movement which results in dull aching continuous pain. Sometimes when the ganglion cyst gets attached to a tendon, it can also present with tingling numbness and muscle weakness. The cause of pain is unknown and is mainly due to adjacent nerve compression, though the most common presentation of the patient would be a non tender swelling or a mass. They never spread to other parts of the body. Along with pain, there may be slight limitation of movement of the affected joint.

Spontaneous Hemorrhage
  • OBJECTIVE: To describe a case of a subacute radiculopathy resulting from a spontaneous hemorrhage into a lumbar ganglion cyst.[ncbi.nlm.nih.gov]
Localized Pain
  • Usually only a cosmetic problem but local pain and neurovascular compression may occur. Conservative management usually suffices if no neurovascular compromise. Aspiration of dorsal cysts can be therapeutic and diagnostic.[bestpractice.bmj.com]
  • You may experience localized pain after surgery, which can be relieved by numbing medications, over-the-counter pain medications, or prescription pain medications. You may also experience swelling at the removal site.[healthline.com]
Inguinal Mass
  • In this study, we present a rare case of a 76-year-old man with a 3-month history of progressive swelling of right lower extremity and 2-month history of a known inguinal mass, which was initially thought as hemangioma by using ultrasound.[ncbi.nlm.nih.gov]
Recurrent Infection
  • Minimally invasive ultrasound-guided aspiration techniques are described but potential shortcomings include cyst recurrence, infection and fascicular or vessel injury.[jbsr.be]
Trismus
  • Ganglion cysts within the temporomandibular joint (TMJ), although uncommon, typically present with swelling, pain, trismus, and difficulty with mastication.[ncbi.nlm.nih.gov]
Venous Insufficiency
  • Lower limb edema caused by a giant ganglion cyst of hip joint, rather than deep venous insufficiency or lymphedema, is unusual particularly for guiding clinical practice.[ncbi.nlm.nih.gov]
Subcutaneous Mass
  • A 9-year-old boy had a subcutaneous mass on his left wrist. Ultrasound displayed a well-defined, multilobulated anechoic mass containing a few internal septa between the extensor pollicis longus and the extensor carpi radialis longus tendons.[ncbi.nlm.nih.gov]
  • What you should be alert for in the history Ganglion cysts are benign, mucin-filled, subcutaneous masses that typically arise from underlying joint capsules, tendons, or tendon sheaths.[clinicaladvisor.com]
Shoulder Pain
  • All these patients presented with only chronic shoulder pain as their chief complaint, and preoperative MRI showed the cyst over the inferior aspect of a torn glenoid labrum.[ncbi.nlm.nih.gov]
Joint Stiffness
  • Surgery can also result in joint stiffness which may take several weeks to resolve. These risks are extremely low and can be discussed in detail with your physician.[muirortho.com]
  • Complications of treatment may include joint stiffness and scar formation. Recurrence of the lesion is more common following excision of a volar ganglion cyst in the wrist.[en.wikipedia.org]
  • This has proven no more effective than simple aspiration and in postoperative patients leads to prolonged joint stiffness and decreased range of motion [18]. Most studies, even with repeat aspirations, demonstrate a success rate of only 30-50%.[physio-pedia.com]
  • This led to the former nickname of "Bible bumps" or " Gideon 's disease" for these cysts. [2] [24] This treatment risks injuring the person and thus is not recommended. [25] Complications Edit Complications of treatment may include joint stiffness and[en.m.wikipedia.org]
Thigh Pain
  • A 29-year-old woman presented with severe left thigh pain and dysesthesia for a month. Magnetic resonance imaging revealed a dumbbell like mass in the intervertebral foramen between second and third lumbar vertebrae on the left side.[ncbi.nlm.nih.gov]
Hip Pain
  • 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.[ncbi.nlm.nih.gov]
  • The case of a female runner presenting with previously undiagnosed chronic hip pain is reported.[tandfonline.com]
Tinel's Sign
  • Baseline examination revealed a soft tumour which was palpable at the level of the head of the fibula; Tinel sign was positive at that point. Muscle strength was 2/5 in the anterior tibialis muscle and 3/5 in the extensor hallucis longus muscle.[elsevier.es]
  • Although minimal tenderness without swelling was present around the left fibular head, Tinel's sign was not evoked along the course of the peroneal nerve.[asianjns.org]
Foot Drop
  • Foot drop resulting from weakness of the dorsiflexor muscles of the foot is a relatively uncommon presentation and closely related to L5 neuropathy caused by a disc herniation.[ncbi.nlm.nih.gov]
Dysesthesia
  • This case report describes a 43-year-old woman with a previous anterior cruciate ligament reconstruction and medial meniscectomy who presented with right knee dysesthesias radiating into her medial ankle with associated allodynia.[ncbi.nlm.nih.gov]
  • A 29-year-old woman presented with severe left thigh pain and dysesthesia for a month. Magnetic resonance imaging revealed a dumbbell like mass in the intervertebral foramen between second and third lumbar vertebrae on the left side.[doi.org]
  • The cysts may intrude into the spine, which may cause pain and dysesthesia in distant extremities.It has been proposed recently that cystic adventitial disease, in which a cyst occurs within the popliteal artery near the knee, may occur by an articular[en.wikipedia.org]
Numbness of the Hand
  • Surgery is mostly chosen when the mass is painful, restricting movement, or causes tingling numbness of the hand. Surgery is a simple arthroscopic or mini-open wide awake excision of the ganglion cyst.[symptoma.com]
  • If there is swelling within the tunnel, the nerve can become compressed, resulting in pain, weakness, and/or numbness in the hand and wrist, radiating up the arm. Scleroderma.[arthritis.org]
  • If you have thickness or nodules in your hands or fingers, color change in your hands and fingers that is not due to weather, or tingling and numbness in your hands and fingers, you may have a serious condition.[carpaltunnelpros.com]
  • The numb arm and hand. Am Fam Physician . 1995;51:103–16. 9. Rettig AC. Wrist problems in the tennis player. Med Sci Sports Exerc . 1994;26:1207–12. 10. Creamer P.[aafp.org]
Radiculopathy
  • Lumbar intraspinal ganglion cysts are a rare cause of lumbar radiculopathy. These cysts are often extradural and next to facet joints. Sometimes they are related to ligamentum flavum or posterior longitudinal ligament.[ncbi.nlm.nih.gov]
  • Key Words: Ganglion cyst ; Radiculopathy ; Lumbar vertebra ; Posterior longitudinal ligament[doi.org]
Mononeuropathy
  • BACKGROUND: Ulnar neuropathy at the elbow (UNE) is the second most common mononeuropathy of the upper extremity. One rare cause of UNE is nerve mass lesions, including intraneural ganglion cysts (IGCs).[ncbi.nlm.nih.gov]

Workup

Most of the ganglion cysts are easily diagnosed by a mere physical examination. They are very smooth and pliable to touch, usually 1-2 cm cystic structures that are well attached to the underlying tendon or capsule. There are no signs of inflammation and the swelling can be felt separate from the skin.

Physical examination is usually sufficient to confirm the diagnosis, but sometimes various imaging techniques to determine any underlying or adjacent pathology are carried out. Radiographs [4] are rarely suggested unless indicated, to detect any bony involvement.

Ultrasonography may be done to determine whether the swelling is cystic or solid. It may also be done to check involvement of an artery or blood vessel. Very rarely cystic fluid aspiration is necessary for further confirmation.

Magnetic Resonance Imaging (MRI) is also used nowadays for diagnosis of ganglions especially wrist ganglions. The drawback is that this procedure is very expensive. All the above mentioned imaging techniques are mainly used only for confirmation of the diagnosis.

Treatment

Other than the wait and watch policy, ganglions do not require emergency treatment unless they cause severe pain or restrict movement affecting daily routine. Most disappear spontaneously. Depending upon the presentation, various treatments adopted are aspiration or surgery for removal. Aspiration involves removal of the cystic fluid by an incision with the help of a hypodermic needle, mainly ultrasound-guided. Post aspiration the site is injected with a corticosteroid mainly to reduce inflammation and prevent reoccurrence of cystic fluid. The doctor may splint the joint to provide immobilisation. Though splinting does not really help.

Surgery is mostly chosen when the mass is painful, restricting movement, or causes tingling numbness of the hand. Surgery is a simple arthroscopic or mini-open wide awake excision [5] of the ganglion cyst. Arthroscopic surgery is becoming more and more common due to minimal scar formation and faster recovery. Post-surgery doctors may advice physiotherapy or occupational therapy depending on the patient’s needs.

In comparison to aspiration, arthroscopic surgery has lesser reoccurrence and since it is minimally invasive it is more widely adopted. The prognosis of these swellings varies and chances of reappearance of these swellings are high. Normally these harmless tumours go away by themselves or may require a simple surgery. However, since they have a tendency to reappear, no single mode of treatment is enough.

Prognosis

The prognosis is good. It is most often a cosmetic condition and can be easily dealt with surgically.

Etiology

The exact cause is uncertain. Current theories suggest herniation or out-pouching of the connective tissue through the joint capsule or tendon sheath which mainly occurs due to degeneration of the connective tissue. Excessive stress and movement of joint also tends to cause growth of these harmless tumours. Thus, a defect in the capsule of the joint or tendon sheath allows the distension and bulging. There is a lot of uncertainity regarding the origin of these soft tissue tumors [1].

Epidemiology

The incidence is high in women; the cysts are three times more common in women than men between twenty to forty years of age and very rarely affect children below ten years of age. Most of the tumours of the hand are benign [2] with 60% being ganglion cysts.

Sex distribution
Age distribution

Pathophysiology

The common sites of the ganglion cysts are joints of the wrists and fingers, especially the dorsal aspect of the wrist along the extensor carpi radialis. This accounts for 80% of all the cysts. They also affect the knee joints around the cruciate ligaments and the shoulder joints typically around the acromioclavicular joint.

Occasionally, minute ganglia occur on the flexor aspect of the fingers which although very small are very painful. Depending on the location and attachment, if the cyst occurs overlying soft tissue and bone, they are known as interosseous ganglion cysts. Very rarely, if attached to a muscle, mainly in the gastrocnemius muscle, it is known as intramuscular ganglion cyst.

Histologically, these cysts have multiple lobules separated by septae. Due to absence of epithelial lining, these are not true cysts. The cystic fluid is mainly made up of mucopolysacchrides, mainly consisting of hyaluronic acid and smaller amounts of albumen and globulin. The septae are made of loosely arranged layers of collagen fibres and fibrocytes. These cysts are connected to the joint by a pedicle or a stalk which has a tortuous lumen. The communication between the cyst and the joint is through this stalk which is one way, demonstrated by a contrast dye which travels from the joint to the cyst but not the other way, thus forming a one way valve mechanism [3]. This mechanism is facilitated by micro cysts present in the tissue around the pedicle.

Prevention

Since there is no known cause for ganglion cysts, there is no method of prevention. Early detection and treatment are recommended.

Summary

Ganglion cysts are localised, tense cystic swellings, which usually occur along the joints and tendons of the appendicular skeleton. They contain a gelatinous jelly-like fluid microscopically similar to the synovial fluid; hence are also known as a synovial cyst.

They are benign and generally self limiting and tend to appear and disappear as well as change in size very rapidly. These cysts are smooth to touch and usually attached to the tendon sheath or capsule of the joint.

Patient Information

Ganglion cysts are harmless, non-cancerous swellings which usually occur on the joints of the hands and feet, especially on the back of the wrist. They are small, smooth, bump-like structures which usually appear attached to the tendons below.

They are painless and usually do not require any treatment unless they cause pain or restrict movement. It’s not fully understood how it occurs. The ganglion cysts tends to occur more in women than men. They never spread to other parts of the body. Although they tend to persist most often, they may intermittently appear and disappear. The cysts can be left alone if not symptomatic but if they are larger than 5 cm a surgical excision is advised.

If the cyst causes pain, it is best to seek medical care, the medical health provider will be the best to judge whether the ganglion cyst is a cause of concern or whether no treatment is needed at all.

Generally no tests are required; the doctor diagnoses it by a simple clinical physical examination. The most common treatment used which is patient friendly is a simple surgery for complete removal of the lump. This results in lesser chances of the cysts reappearing. Aspiration of the cystic fluid with the help of a needle is also done, but then the cyst tends to reoccur.
Home care treatment in the form of poultices, plasters and heat is not at all advised as it may aggravate the condition.

References

Article

  1. Colman MW, Lozano-Calderon S, Raskin KA, Hornicek Fj et al. Non- neoplastic soft tissue masses that mimic sarcoma. Orthop Clin North Am. 2014 Apr;45(2):245-55.
  2. Darowish M, Sharma J. Evaluation and Treatment of Chronic Hand Conditions. Med Clin North Am. 98:4 2014 Jul pg 801-815
  3. Craig A Camasta. Excision of the ganglion cyst. The Podiatry Institute. 1993.
  4. Cooper Grant. (2006) Pocket Guide to Musculoskeletal Diagnosis. Springer. P63.
  5. Bismil MSK ,Bismil QMK. The wide awake approach to hand and wrist ganglia. OA Case Reports. 2013 Nov 15;2(13):129.

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Last updated: 2019-07-11 22:12