Extreme intraneural ganglion cysts

Clinical article

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Object

The mechanism responsible for exceptional examples of intraneural ganglia with extensive longitudinal involvement has not been understood. Such cases of intraneural cysts, seemingly remote from a joint, have been thought not to have articular connections. Decompression and attempted resection of the cyst has led to intraneural recurrence and poor neurological recovery. The purpose of this report is not only to clarify the pathogenesis of these cysts, but also to discuss their treatment based on modern concepts of intraneural ganglia.

Methods

Two examples of extreme longitudinal propagation of intraneural ganglia are presented.

Results

A patient with a moderate tibial neuropathy was found to have a tibial intraneural ganglion. Prospective interpretation of the MR imaging study demonstrated the cyst's origin from the posterior portion of the superior tibiofibular joint (STFJ), with proximal extension within the sciatic nerve to the lower buttock region. Communication between the STFJ and the cyst was confirmed with direct knee MR arthrography. The tibial intraneural cyst was treated successfully by a relatively limited exposure in the distal popliteal fossa: the cyst was decompressed, the articular branch disconnected, and the STFJ resected. Postoperatively, the patient improved neurologically and there was no evidence of recurrent cyst on postoperative MR imaging. A second patient, previously reported by another group, was reexamined 22 years after surgery. This patient had an extensive peroneal intraneural ganglion that extended into the sciatic nerve from the knee to the buttock; no joint connection or recurrent cyst had initially been described. In this patient, the authors hypothesized and established with MR imaging the presence of both: a joint connection to the anterior portion of the STFJ from the peroneal articular branch as well as recurrent cyst within the peroneal and tibial nerves.

Conclusions

This paper demonstrates that extreme intraneural cysts are not clinical outliers but represent extreme examples of other more typical intraneural cysts. They logically obey the same principles, previously described in the unified articular (synovial) theory. The degree of longitudinal extension is probably due to high intraarticular pressures within the degenerative joint of origin. The generalizability of the mechanistic principles is highlighted by the fact that these 2 cases, involving the tibial and the peroneal nerve respectively, both extended well distant (that is, to the buttock) from the STFJ via their respective articular branch of origin. These extensive intraneural cysts can be treated successfully by disconnecting the affected articular branch and by resection of the joint of origin, rather than by a more aggressive operation resecting the cyst and cyst wall.

Abbreviations used in this paper: FSE = fast spin echo; STFJ = superior tibiofibular joint.
Article Information

Contributor Notes

Address correspondence to: Robert J. Spinner, M.D., Mayo Clinic, 200 First Street NW, Gonda 8S-214, Rochester, Minnesota 55905. email: spinner.robert@mayo.edu.Please include this information when citing this paper: published online May 21, 2010; DOI: 10.3171/2010.4.JNS091969.

© AANS, except where prohibited by US copyright law.

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References
  • 1

    Bonar SFViglione WSchatz JScolyer RAMcCarthy SW: An unusual variant of intraneural ganglion of the common peroneal nerve. Skeletal Radiol 35:1651712006

    • Search Google Scholar
    • Export Citation
  • 2

    Boursinos LADimitriou CG: Ulnar nerve compression in the cubital tunnel by an epineural ganglion: a case report. Hand (N Y) 2:12152007

    • Search Google Scholar
    • Export Citation
  • 3

    Choi SHKim CHKim MOJung HY: [Intraneural ganglion of the ulnar nerve. A case report.]. J Korean Assn EMG–Electrodiagn Med 1:2222251999. (Korean)

    • Search Google Scholar
    • Export Citation
  • 4

    Elangovan SOdegard GMMorrow DAWang HHébert-Blouin MNSpinner RJ: Intraneural ganglia: a clinical problem deserving a mechanistic explanation and model. Neurosurg Focus 26:2E112009

    • Search Google Scholar
    • Export Citation
  • 5

    Harbaugh KSTiel RLKline DG: Ganglion cyst involvement of peripheral nerves. J Neurosurg 87:4034081997

  • 6

    Jacobs RRMaxwell JAKepes J: Ganglia of the nerve. Presentation of two unusual cases, a review of the literature, and a discussion of pathogenesis. Clin Orthop Relat Res 113:1351441975

    • Search Google Scholar
    • Export Citation
  • 7

    Kline DGHudson AR: Nerve Injuries: Operative Results for Major Nerve Injuries Entrapments and Tumors PhiladelphiaWB Saunders1995. 554

    • Search Google Scholar
    • Export Citation
  • 8

    Krishnan KGSchackert G: Intraneural ganglion cysts: a case of sciatic nerve involvement. Br J Plast Surg 56:1831862003

  • 9

    Lang CJNeubauer UQaiyumi SFahlbusch R: Intraneural ganglion of the sciatic nerve: detection by ultrasound. J Neurol Neurosurg Psychiatry 57:8708711994

    • Search Google Scholar
    • Export Citation
  • 10

    Nucci FArtico MSantoro ABardella LDelfini RBosco S: Intraneural synovial cyst of the peroneal nerve: report of two cases and review of the literature. Neurosurgery 26:3393441990. (see comment)

    • Search Google Scholar
    • Export Citation
  • 11

    Shinawi MHicks JGuillerman RPJones JBrandt MPerez M: Multiple ganglion cysts (‘cystic ganglionosis’): an unusual presentation in a child. Scand J Rheumatol 36:1451482007

    • Search Google Scholar
    • Export Citation
  • 12

    Spinner RJAmrami KKAngius DWang HCarmichael SW: Peroneal and tibial intraneural ganglia: correlation between intraepineurial compartments observed on magnetic resonance images and the potential importance of these compartments. Neurosurg Focus 22:6E172007

    • Search Google Scholar
    • Export Citation
  • 13

    Spinner RJAmrami KKWang HKliot MCarmichael SW: Cross-over: a generalizable phenomenon necessary for secondary intraneural ganglion cyst formation. Clin Anat 21:1111182008

    • Search Google Scholar
    • Export Citation
  • 14

    Spinner RJAmrami KKWolanskyj APDesy NMWang HBenarroch EE: Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory. J Neurosurg 107:2963072007

    • Search Google Scholar
    • Export Citation
  • 15

    Spinner RJAtkinson JLDTiel RL: Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory. J Neurosurg 99:3303432003

    • Search Google Scholar
    • Export Citation
  • 16

    Spinner RJDesy NMRock MGAmrami KK: Peroneal intraneural ganglia. Part I Techniques for successful diagnosis and treatment. Neurosurg Focus 22:6E162007

    • Search Google Scholar
    • Export Citation
  • 17

    Spinner RJDesy NMRock MGAmrami KK: Peroneal intraneural ganglia. Part II Lessons learned and pitfalls to avoid for successful diagnosis and treatment. Neurosurg Focus 22:6E272007

    • Search Google Scholar
    • Export Citation
  • 18

    Spinner RJHébert-Blouin MNAmrami KK: A complex cyst characterized into its individual components: a shared pathogenesis from the superior tibiofibular joint. J Surg Orthop Advances [in press]2010

    • Search Google Scholar
    • Export Citation
  • 19

    Spinner RJHébert-Blouin MNAmrami KKRock MG: Peroneal and tibial intraneural ganglia in the knee region: a technical note. Neurosurgery [in press]2010

    • Search Google Scholar
    • Export Citation
  • 20

    Spinner RJHébert-Blouin MNTrousdale RTMidha RRussell SMYamauchi T: Intraneural ganglia in the hip and pelvic region. Clinical article. J Neurosurg 111:3173252009

    • Search Google Scholar
    • Export Citation
  • 21

    Spinner RJLuthra GDesy NMAnderson MLAmrami KK: The clock face guide to peroneal intraneural ganglia: critical “times” and sites for accurate diagnosis. Skeletal Radiol 37:109110992008

    • Search Google Scholar
    • Export Citation
  • 22

    Spinner RJMokhtarzadeh ASchiefer TKKrishnan KGKliot MAmrami KK: The clinico-anatomic explanation for tibial intraneural ganglion cysts arising from the superior tibiofibular joint. Skeletal Radiol 36:2812922007

    • Search Google Scholar
    • Export Citation
  • 23

    Spinner RJScheithauer BWDesy NMRock MGHoldt FCAmrami KK: Coexisting secondary intraneural and vascular adventitial ganglion cysts of joint origin: a causal rather than a coincidental relationship supporting an articular theory. Skeletal Radiol 35:7347442006

    • Search Google Scholar
    • Export Citation
  • 24

    Spinner RJVincent JFWolanskyj APScheithauer BW: Intraneural ganglion cyst: a 200-year-old mystery solved. Clin Anat 21:6116182008

    • Search Google Scholar
    • Export Citation
  • 25

    Spinner RJWang HHébert-Blouin MNSkinner JAAmrami KK: Sciatic cross-over in patients with peroneal and tibial intraneural ganglia confirmed by knee MR arthrography. Acta Neurochir (Wien) 151:89982009

    • Search Google Scholar
    • Export Citation
  • 26

    Swartz KRWilson DBoland MFee DB: Proximal sciatic nerve intraneural ganglion cyst. Case Report Med [epub ahead of print]2009

  • 27

    Wadstein T: Two cases of ganglia in the sheath of the peroneal nerve. Acta Orthop Scand 2:2212301931

  • 28

    Wang HTerrill RQTanaka SAmrami KKSpinner RJ: Adherence of intraneural ganglia of the upper extremity to the principles of the unifying articular (synovial) theory. Neurosurg Focus 26:2E102009

    • Search Google Scholar
    • Export Citation
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