scholarly journals Drop Foot Secondary to a Peroneal Intraneural Ganglion Connected to the Superior Tibiofibular Joint: A Case Report

2020 ◽  
Author(s):  
Kenan Kıbıcı ◽  
Berrin Erok ◽  
Akın Onat
Keyword(s):  
Peroneal Nerve ◽  
Imaging Modality ◽  
Axonal Neuropathy ◽  
Common Peroneal Nerve ◽  
Foot Drop ◽  
Intraneural Ganglion ◽  
Articular Branch ◽  
Ankle Eversion ◽  
Adjacent Structures ◽  
Tibiofibular Joint

AbstractPeroneal neuropathy is the most frequent mononeuropathy of the lower extremity. Intraneural ganglion cysts (INGCs) are among rare causes of peroneal nerve palsy. According to the articular (synovial) theory, the articular branch plays the key role in the pathogenesis. Patients present with pain around the fibular head and neck, motor weakness resulting in foot drop and paresthesia in the anterolateral calf and foot. Ultrasonography (US) and MRI are both useful in the diagnosis, but MRI is the best imaging modality in the demonstration of the articular connection and the relation of the cyst with adjacent structures, even without special neurography sequences. We present a 32-year-old male patient referred to our neurosurgery clinic with suspicion of lumbar radiculopathy. He presented with right foot drop which began 3 weeks prior. On examination, there was 90% loss in the ankle dorsiflexion and finger extension. Ankle eversion was also weakened. There was no low back or posterolateral thigh pain to suggest L5 radiculopathy and sciatic neuropathy. Following negative lumbar spine MRI, peripheral neuropathy was concerned. Electrodiagnostic evaluations findings were consistent with acute/subacute common peroneal nerve (CPN) axonal neuropathy. Subsequent MRI of knee showed a homogeneous, thin-walled tubular cystic lesion, extending along the course of the CPN and its articular branch. Full recovery of the neuropathy was achieved with early diagnosis and decompression via microsurgical epineurotomy. The diagnosis of INGC was confirmed by histopathologic examination. INGCs, although rare, should also be considered in the differential diagnosis of peripheral mononeuropathies.

scholarly journals Intraneural Synovial Cyst of the Common Peroneal Nerve: An Unusual Cause of Foot Drop with Four-Year Follow-Up

2019 ◽  
Vol 2019 ◽  
pp. 1-4
Author(s):  
Abrar Adil ◽  
Clint Basener ◽  
Jake Checketts
Keyword(s):  
Peroneal Nerve ◽  
Common Peroneal Nerve ◽  
Synovial Cyst ◽  
Foot Drop ◽  
Proximal Tibiofibular Joint ◽  
Cystic Fluid ◽  
Articular Branch ◽  
Tibiofibular Joint ◽  
The Common ◽  
Simple Decompression

In our case report, we describe a 55-year-old male patient with isolated foot drop due to an intraneural synovial ganglion. We successfully treated the lesion with decompression via epineurotomy combined with primary division of the recurrent articular branch of the common peroneal nerve (CPN). Compression neuropathies of the common peroneal nerve arise from a variety of causes. Intrinsic compression due to intraneural ganglion cysts of the CPN is rare. Previous reports of simple decompression of the cystic fluid have resulted in recurrence. The unified articular theory describes a pathway for fluid to fill from the proximal tibiofibular joint into the CPN via a recurrent articular branch. In our case, we divide this articular branch which we feel prevents recurrence.

Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory

2003 ◽  
Vol 99 (2) ◽  
pp. 330-343 ◽  
Author(s):  
Robert J. Spinner ◽  
John L. D. Atkinson ◽  
Robert L. Tiel
Keyword(s):  
Peroneal Nerve ◽  
Common Peroneal Nerve ◽  
Clinical Results ◽  
Articular Branch ◽  
Content Type ◽  
Superior Tibiofibular Joint ◽  
Imaging Characteristics ◽  
Objective Evidence ◽  
Tibiofibular Joint ◽  
Fine Print

Object. Based on a large multicenter experience and a review of the literature, the authors propose a unifying theory to explain an articular origin of peroneal intraneural ganglia. They believe that this unifying theory explains certain intriguing, but poorly understood findings in the literature, including the proximity of the cyst to the joint, the unusual preferential deep peroneal nerve (DPN) deficit, the absence of a pure superficial peroneal nerve (SPN) involvement, the finding of a pedicle in 40% of cases, and the high (10–20%) recurrence rate. Methods. The authors believe that peroneal intraneural lesions are derived from the superior tibiofibular joint and communicate from it via a one-way valve. Given access to the articular branch, the cyst typically dissects proximally by the path of least resistance within the epineurium and up the DPN and the DPN component of the common peroneal nerve (CPN) before compressing nearby SPN fascicles. The authors present objective evidence based on anatomical, clinical, imaging, operative, and histological data that support this unifying theory. Conclusions. The predictable clinical presentation, electrical studies, imaging characteristics, operative observations, and histological findings regarding peroneal intraneural ganglia can be understood in terms of their origin from the superior tibiofibular joint, the anatomy of the articular branch, and the internal topography of the peroneal nerve that the cyst invades. Understanding the controversial pathogenesis of these cysts will enable surgeons to perform operations based on the pathoanatomy of the articular branch of the CPN and the superior tibiofibular joint, which will ultimately improve clinical results.

Peroneal intraneural ganglia: the importance of the articular branch. Clinical series

2003 ◽  
Vol 99 (2) ◽  
pp. 319-329 ◽  
Author(s):  
Robert J. Spinner ◽  
John L. D. Atkinson ◽  
Bernd W. Scheithauer ◽  
Michael G. Rock ◽  
Rolfe Birch ◽  
...  
Keyword(s):  
Neurological Deficit ◽  
Peroneal Nerve ◽  
Common Peroneal Nerve ◽  
Articular Branch ◽  
Content Type ◽  
Superior Tibiofibular Joint ◽  
Imaging Characteristics ◽  
Clinical Series ◽  
Tibiofibular Joint ◽  
Fine Print

Object. The peroneal nerve is the most common site of intraneural ganglia. The neurological deficit associated with these cysts is often severe and the operation to eradicate them is difficult. The aims of this multicenter study were to collate the authors' experience with a relatively rare lesion and to improve clinical outcomes by better understanding its controversial pathogenesis. Methods. Part I of this paper offers a description of 24 patients with peroneal intraneural ganglia who were treated by surgeons aware of the importance of the peroneal nerve's articular branch. Part II offers a description of three more patients who were seen after earlier operations in which the ganglion was excised, but the articular branch was not identified (all reportedly gross-total resections). Twenty-six of the 27 patients presented with clinical, electrophysiological, and imaging evidence of a common peroneal nerve (CPN) lesion, predominantly affecting the deep peroneal nerve (DPN) division, and one patient presented with a painful mass of the CPN that was not accompanied by a neurological deficit. In all 24 patients in Part I there was magnetic resonance (MR) imaging evidence of a connection between the cyst and the superior tibiofibular joint, including one patient in whom high-resolution (3-tesla) MR neurography demonstrated the pathological articular branch itself. At the operation, the communication proved to extend through the articular branch of the CPN in all cases. The operation consisted of drainage of the cyst and ligation of the articular branch. At a minimum follow-up period of 1 year, these patients experienced significant improvements in their neuropathic pain, but only mild improvements in their functional deficits. In none of the 24 patients was there evidence of an intraneural recurrence. In three patients, however, extraneural ganglia developed: two patients with symptoms subsequently underwent resection of the superior tibiofibular joint without further recurrence and one patient with no symptoms was followed clinically after the recurrence was detected incidentally on 1-year postoperative imaging. As predicted, in Part II all three patients in whom the articular branch had not been ligated experienced early intraneural recurrence; both postoperative MR images and original studies, which were retrospectively examined, demonstrated a connection with the superior tibiofibular joint. Conclusions. The clinical presentation, electrical studies, imaging characteristics, and operative observations regarding peroneal intraneural ganglia are predictable. Treatment must address the underlying pathoanatomy and should include decompression of the cyst and ligation of the articular branch of the nerve. To avoid extraneural recurrence, resection of the superior tibiofibular joint may also be necessary, but indications for this additional procedure need to be defined. These recommendations are based on the authors' belief that intraneural peroneal ganglia arise from the superior tibiofibular joint and are connected to it by the articular branch.

Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory

2007 ◽  
Vol 107 (2) ◽  
pp. 296-307 ◽  
Author(s):  
Robert J. Spinner ◽  
Kimberly K. Amrami ◽  
Alexandra P. Wolanskyj ◽  
Nicholas M. Desy ◽  
Huan Wang ◽  
...  
Keyword(s):  
Peroneal Nerve ◽  
Ganglion Cyst ◽  
Cyst Formation ◽  
Intraneural Ganglion ◽  
Intraneural Ganglion Cyst ◽  
Articular Branch ◽  
Superior Tibiofibular Joint ◽  
Tibiofibular Joint ◽  
Joint Connection ◽  
Articular Theory

Object The pathogenesis of intraneural ganglia has been a controversial issue for longer than a century. Recently the authors identified a stereotypical pattern of occurrence of peroneal and tibial intraneural ganglia, and based on an understanding of their pathogenesis provided a unifying articular explanation. Atypical features, which occasionally are observed, have offered an opportunity to verify further and expand on the authors' proposed theory. Methods Three unusual cases are presented to exemplify the dynamic features of peroneal and tibial intraneural ganglia formation. Results Two patients with a predominant deep peroneal nerve deficit shared essential anatomical findings common to peroneal intraneural ganglia: namely, 1) joint connections to the anterior portion of the superior tibiofibular joint, and 2) dissection of the cyst along the articular branch of the peroneal nerve and proximally. Magnetic resonance (MR) images obtained in these patients demonstrated some unusual findings, including the presence of a cyst within the tibial and sural nerves in the popliteal fossa region, and spontaneous regression of the cysts, which was observed on serial images obtained weeks apart. The authors identified a clinical outlier, a case that could not be understood within the context of their previously reported theory of intraneural ganglion cyst formation. Described 32 years ago, this patient had a tibial neuropathy and was found at surgery to have tibial, peroneal, and sciatic intraneural cysts without a joint connection. The authors' hypothesis about this case, based on their unified theory, was twofold: 1) the lesion was a primary tibial intraneural ganglion with proximal extension followed by sciatic cross-over and distal descent; and 2) a joint connection to the posterior aspect of the superior tibiofibular joint with a remnant cyst within the articular branch would be present, a finding that would help explain the formation of different cysts by a single mechanism. The authors proved their hypothesis by careful inspection of a recently obtained postoperative MR image. Conclusions These three cases together with data obtained from a retrospective review of the authors' clinical material and findings reported in the literature provide firm evidence for mechanisms underlying intraneural ganglia formation. Thus, expansion of the authors' unified articular theory permits understanding and elucidation of unusual presentations of intraneural cysts. Whereas an articular connection and fluid following the path of least resistance was pivotal, the authors now incorporate dynamic aspects of cyst formation due to pressure fluxes. These basic principles explain patterns of ascent, cross-over, and descent down terminal nerve branches based on articular connections, paths of diminished resistance to fluid flow within recognized anatomical compartments, and the effects of fluctuating pressure gradients.

scholarly journals Peroneal and Tibial Intraneural Ganglion Cysts in the Knee Region: A Technical Note

2010 ◽  
Vol 67 (3) ◽  
pp. ons71-ons78 ◽  
Author(s):  
Robert J. Spinner ◽  
Marie-Noëlle Hébert-Blouin ◽  
Kimberly K. Amrami ◽  
Michael G. Rock
Keyword(s):  
Peroneal Nerve ◽  
Neck Region ◽  
Technical Note ◽  
Intraneural Ganglion ◽  
Articular Branch ◽  
Knee Region ◽  
Improved Outcomes ◽  
Ganglion Cysts ◽  
Tibiofibular Joint ◽  
Articular Theory

Abstract BACKGROUND: Recent research has resulted in an improved understanding of the pathogenesis and treatment of intraneural ganglia, particularly with respect to the most common form, the peroneal nerve at the fibular neck region. OBJECTIVE: To outline the mechanism for the development and propagation of intraneural ganglia located in the knee region, along with their treatment, as well as highlight how shared principles can be exploited for successful treatment of the more commonly occurring peroneal intraneural ganglia. METHODS: A surgical approach has been developed for peroneal intraneural cysts based on the pathogenesis. The treatment of the less common tibial intraneural cysts is designed along the same principles. RESULTS: A strategy consisting of (1) disarticulation (resection) of the superior tibiofibular joint (ie, the source), (2) disconnection of the articular branch connection (ie, the conduit), and (3) decompression (rather than resection) of the cyst has improved outcomes and eliminated intraneural recurrences in peroneal intraneural cysts. These same principles and techniques can be applied to the rarer tibial intraneural ganglia derived from the same joint. The mechanism of development and propagation for intraneural cysts in the knee region as well as a surgical technique and its rational are described and illustrated. CONCLUSION: Understanding the joint-related basis of intraneural cysts leads to simple targeted surgery that addresses the joint, its articular branch, and the cyst. The success of the shared surgical strategy for both peroneal and tibial intraneural ganglia confirms the principles of the unifying articular theory.

scholarly journals When size does not matter: a rare case of popliteal artery aneurysm presenting with foot drop and its endovascular management

2019 ◽  
Vol 2019 (12) ◽  
Author(s):  
Jeong-moh J Yahng ◽  
Lei Ying
Keyword(s):  
Popliteal Artery ◽  
Peroneal Nerve ◽  
Rare Case ◽  
Common Peroneal Nerve ◽  
Nerve Compression ◽  
Foot Drop ◽  
Arterial Aneurysm ◽  
Popliteal Aneurysm ◽  
Acute Limb Ischaemia ◽  
Adjacent Structures

Abstract Popliteal artery aneurysms (PAA) are the commonest arterial aneurysm of the periphery. It is defined as focal dilation more than 50% of the normal vessel diameter, which usually varies between 7 and 11 mm. The most common presentation for PAA is claudication due to luminal stenosis caused by mural thrombus or acute limb ischaemia due to thromboembolism. It is much less common for patients to present with mass effect symptoms due to compression of adjacent structures, and of these, common peroneal nerve compression is particularly uncommon. We present a rare case of a 92-year-old female presenting with 4-month history of left foot drop with radiological evidence of common peroneal nerve compression secondary to PAA measuring 22 × 21 mm in size. To the best of our knowledge, this is the smallest reported popliteal aneurysm presenting with foot drop. We also present the endovascular treatment option used.

Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory

2007 ◽  
Vol 22 (6) ◽  
pp. 1-12
Author(s):  
Robert J. Spinner ◽  
Kimberly K. Amrami ◽  
Alexandra P. Wolanskyj ◽  
Nicholas M. Desy ◽  
Huan Wang ◽  
...  
Keyword(s):  
Peroneal Nerve ◽  
Ganglion Cyst ◽  
Cyst Formation ◽  
Intraneural Ganglion ◽  
Intraneural Ganglion Cyst ◽  
Articular Branch ◽  
Superior Tibiofibular Joint ◽  
Tibiofibular Joint ◽  
Joint Connection ◽  
Articular Theory

Object The pathogenesis of intraneural ganglia has been a controversial issue for longer than a century. Recently the authors identified a stereotypical pattern of occurrence of peroneal and tibial intraneural ganglia, and based on an understanding of their pathogenesis provided a unifying articular explanation. Atypical features, which occasionally are observed, have offered an opportunity to verify further and expand on the authors' proposed theory. Methods Three unusual cases are presented to exemplify the dynamic features of peroneal and tibial intraneural ganglia formation. Results Two patients with a predominant deep peroneal nerve deficit shared essential anatomical findings common to peroneal intraneural ganglia: namely, 1) joint connections to the anterior portion of the superior tibiofibular joint, and 2) dissection of the cyst along the articular branch of the peroneal nerve and proximally. Magnetic resonance (MR) images obtained in these patients demonstrated some unusual findings, including the presence of a cyst within the tibial and sural nerves in the popliteal fossa region, and spontaneous regression of the cysts, which was observed on serial images obtained weeks apart. The authors identified a clinical outlier, a case that could not be understood within the context of their previously reported theory of intraneural ganglion cyst formation. Described 32 years ago, this patient had a tibial neuropathy and was found at surgery to have tibial, peroneal, and sciatic intraneural cysts without a joint connection. The authors' hypothesis about this case, based on their unified theory, was twofold: 1) the lesion was a primary tibial intraneural ganglion with proximal extension followed by sciatic cross-over and distal descent; and 2) a joint connection to the posterior aspect of the superior tibiofibular joint with a remnant cyst within the articular branch would be present, a finding that would help explain the formation of different cysts by a single mechanism. The authors proved their hypothesis by careful inspection of a recently obtained postoperative MR image. Conclusions These three cases together with data obtained from a retrospective review of the authors' clinical material and findings reported in the literature provide firm evidence for mechanisms underlying intraneural ganglia formation. Thus, expansion of the authors' unified articular theory permits understanding and elucidation of unusual presentations of intraneural cysts. Whereas an articular connection and fluid following the path of least resistance was pivotal, the authors now incorporate dynamic aspects of cyst formation due to pressure fluxes. These basic principles explain patterns of ascent, cross-over, and descent down terminal nerve branches based on articular connections, paths of diminished resistance to fluid flow within recognized anatomical compartments, and the effects of fluctuating pressure gradients.

scholarly journals Deep Peroneal Nerve Palsy Caused by an Extraneural Ganglion Cyst: A Rare Case

2015 ◽  
Vol 2015 ◽  
pp. 1-4 ◽  
Author(s):  
Dimitrios Nikolopoulos ◽  
George Safos ◽  
Neoptolemos Sergides ◽  
Petros Safos
Keyword(s):  
Peroneal Nerve ◽  
Ganglion Cyst ◽  
Common Peroneal Nerve ◽  
Foot Drop ◽  
Peripheral Neuropathies ◽  
Tibiofibular Syndesmosis ◽  
Deep Peroneal Nerve ◽  
Intraneural Ganglion ◽  
Ganglion Cysts ◽  
The Common

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.

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