Clinical outcome after decompression of intraneural peroneal ganglion cyst and its morphologic correlation to postoperative nerve ultrasound

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OBJECTIVE

Intraneural ganglion cysts are rare and benign mucinous lesions that affect peripheral nerves, most frequently the common peroneal nerve (CPN). The precise pathophysiological mechanisms of intraneural ganglion cyst development remain unclear. A well-established theory suggests the spread of mucinous fluid along the articular branch of the peroneal nerve as the underlying mechanism. Clinical outcome following decompression of intraneural ganglion cysts has been demonstrated to be excellent. The aim of this study was to evaluate the correlation between clinical outcome and ultrasound-detected morphological nerve features following decompression of intraneural ganglion cysts of the CPN.

METHODS

Data were retrospectively analyzed from 20 patients who underwent common peroneal nerve ganglion cyst decompression surgery at the Universität Ulm/Günzburg Neurosurgery Department between October 2003 and October 2017. Postoperative clinical outcome was evaluated by assessment of the muscular strength of the anterior tibial muscle, the extensor hallucis longus muscle, and the peroneus muscle according to the Medical Research Council grading system. Hypesthesia was measured by sensation testing. In all patients, postoperative morphological assessment of the peroneal nerve was conducted between October 2016 and October 2017 using the iU22 Philips Medical ultrasound system at the last routine follow-up appointment. Finally, the correlations between morphological changes in nerve ultrasound and postoperative clinical outcomes were evaluated.

RESULTS

During the postoperative ultrasound scan an intraneural hypoechogenic ring structure located at the medial side of the peroneal nerve was detected in 15 (75%) of 20 patients, 14 of whom demonstrated an improvement in motor function. A regular intraneural fasicular structure was identified in 3 patients (15%), who also reported recovery. In 1 patient, a recurrent cyst was detected, and 1 patient showed intraneural fibrosis for which recovery did not occur in the year following the procedure. Two patients (10%) developed neuropathic pain that could not be explained by nerve ultrasound findings.

CONCLUSIONS

The results of this study demonstrate significant recovery from preoperative weakness after decompression of intraneural ganglion cysts of the CPN. A favorable clinical outcome was highly correlated with an intraneural hypoechogenic ring-shaped structure on the medial side of the CPN identified during a follow-up postoperative ultrasound scan. These study results indicate the potential benefit of ultrasound scanning as a prognostic tool following decompression procedures for intraneural ganglion cysts of the CPN.

ABBREVIATIONS ATM = anterior tibial muscle; CPN = common peroneal nerve; EHLM = extensor hallucis longus muscle; MRC = Medical Research Council; PM = peroneus muscle.

Article Information

Correspondence Andreas Knoll: University of Ulm, Günzburg, Germany. andreas.knoll@uni-ulm.de.

INCLUDE WHEN CITING Published online June 28, 2019; DOI: 10.3171/2019.3.JNS182699.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Intraneural ganglion cyst of the peroneal nerve. A: Cyst within the articular branch just rounding the fibular head (white triangle) with dorsal through transmission characterizing cyst fluid in the ultrasound image (white arrow). B: The same nerve just proximal to the fibular head, where the articular branch joins the common peroneal nerve (white arrow and yellow circle). Figure is available in color online only.

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    Patient 6. A: Intraneural hypoechogenic ring structure (white arrow) on the medial side of the peroneal nerve at the level above the fibular head (white triangle). B: The same nerve proximal to the fibular head with normal intrafascicular structure 144 months postoperatively (white arrow). Figure is available in color online only.

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    Patient 7. A: Intraneural hypoechogenic ring structure (white arrow) on the medial side of the peroneal nerve at the level above the fibular head (white triangle). B: The same nerve again proximal to the fibular head 10 months postoperatively (white arrow). Figure is available in color online only.

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    Demographic baseline characteristics of group 1, with patients who recovered from impaired motor function. A: Age of patients at the time of surgery. B: Time interval from onset of symptoms to surgery. C: Time of follow-up, when neurosonography and clinical examination were performed. D: Representative patient ultrasound images. Hypoechogenic ring structure in postoperative neurosonography, which could be detected in 77% of the patient cohort, is shown in representative ultrasound images of patients 5 and 17. Patient 1 presented with a recurrent cyst but showed recovery as well. Patients 10, 11, and 16 showed regular fascicular structure in neurosonography postoperatively at the time of follow-up (shown in representative ultrasound image of patient 11). In patients 3 and 6, who developed neuropathic pain, no other alterations that could be responsible for pain were detected sonographically. Neruosonography showed only the hypoechogenic ring structure. nr. = number.

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    Demographic baseline characteristics of group 2, with patients who had not recovered from impaired motor function at the time of this report. A: Age of patients at the time of surgery. B: Time interval from onset of symptoms to surgery. C: Time of follow-up, when neurosonography and clinical examination were performed. D: An intraneural fibrosis, which could be detected in patient 2, is shown in the neurosonography. Patient number 14, by contrast, showed a hypoechogenic ring structure without further nerve damage, but this patient was lost to follow-up 2 months after surgery.

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