Tibial intraneural ganglia at the ankle and knee: incorporating the unified (articular) theory in adults and children

AbstractIntraneural ganglion cysts are rare mucinous cyst originating within the epineurium of peripheral nerves. They occur most commonly in the peroneal nerve. However, they have also been described in many nerves in the vicinity of synovial joints. Intraneural ganglion cysts in the upper extremity are rare. Those at the elbow joint comprise only 9% of intraneural ganglion ever reported.A 66-year-old and right-handed male patient presented with a sudden onset of right-hand weakness. He initially noticed paresthesia with decreased sensation in the lateral two digits and radial palm in his right hand. Physical examination showed thenar muscle atrophy and muscle weakness of the abductor pollicis brevis in the right hand. Preoperative diagnosis of intraneural ganglion cyst was made on the basis of characteristic magnetic resonance imaging (MRI) findings. On exploration, the ulnar nerve was identified proximal to the elbow joint. Its articular branch was addressed and divided from the elbow joint.To the best of our knowledge, addressing the articular branch connecting the glenohumeral joint for the treatment of intraneural ganglion at the elbow has only been reported twice. We experienced a rare occurrence of intraneural ganglion cyst at the elbow manifesting an ulnar neuropathy. Here, we report intraoperative findings for the articular branch-connected to intraneural ganglion of the ulnar nerve at the elbow. Early diagnosis of intraneural ganglion with precise identification of the pathology and addressing the articular branch with atraumatic dissection of ganglion cyst are essential to achieve successful treatment for this rare lesion.

Download Full-text

Ultrasound facilitates the diagnosis of tarsal tunnel syndrome: intraneural ganglion cyst of the tibial nerve

Journal of Ultrasound ◽

10.1007/s40477-018-0314-5 ◽

2018 ◽

Vol 22 (1) ◽

pp. 95-98 ◽

Cited By ~ 2

Author(s):

Wei-Ting Wu ◽

Ke-Vin Chang ◽

Levent Özçakar

Keyword(s):

Tibial Nerve ◽

Ganglion Cyst ◽

Tarsal Tunnel ◽

Tarsal Tunnel Syndrome ◽

Intraneural Ganglion ◽

Intraneural Ganglion Cyst ◽

Tunnel Syndrome

Download Full-text

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

Journal of Neurosurgery ◽

10.3171/jns-07/08/0296 ◽

2007 ◽

Vol 107 (2) ◽

pp. 296-307 ◽

Cited By ~ 71

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.

Download Full-text

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

Neurosurgical FOCUS ◽

10.3171/foc.2007.22.6.1 ◽

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.

Download Full-text

High-resolution MRI of a peroneal intraneural ganglion cyst arising from the knee joint: illustrative case

Journal of Neurosurgery: Case Lessons ◽

10.3171/case21130 ◽

2021 ◽

Vol 1 (21) ◽

Author(s):

Brandon W. Smith ◽

Megan M. Jack ◽

Garret M. Powell ◽

Matthew A. Frick ◽

Kimberly K. Amrami ◽

...

Keyword(s):

High Resolution ◽

Knee Joint ◽

Ganglion Cyst ◽

High Resolution Imaging ◽

Synovial Joint ◽

Intraneural Ganglion ◽

Intraneural Ganglion Cyst ◽

Articular Branch ◽

Ganglion Cysts ◽

Resolution Imaging

BACKGROUND The advancement of high-resolution imaging and increased clinical experience have led to an increased understanding of the formation and treatment of intraneural ganglion cysts. Nearly all intraneural ganglion cysts in the common peroneal nerve have been reported to arise from a joint connection to the superior tibiofibular joint. The authors have identified four cases of intraneural ganglion cysts arising from the knee joint itself; however, none of these reported cases were well described, documented, or illustrated with high-resolution imaging. OBSERVATIONS Here the authors present the case of an intraneural ganglion cyst arising from the knee joint and causing intermittent weakness and pain. The articular branch to the knee joint was clearly demonstrated on high-resolution magnetic resonance imaging and confirmed at surgical exploration. The patient was treated with articular branch ligation and has had complete resolution of his symptoms without recurrence of the cyst on follow-up imaging. LESSONS This case adds to the mounting evidence that intraneural cyst pathology is dependent on a connection to a synovial joint as stated in the unifying theory of intraneural cyst development.

Download Full-text

Recurrent intraneural ganglion cyst of the tibial nerve

Journal of Neurosurgery ◽

10.3171/jns.2000.92.2.0334 ◽

2000 ◽

Vol 92 (2) ◽

pp. 334-337 ◽

Cited By ~ 46

Author(s):

Robert J. Spinner ◽

John L. D. Atkinson ◽

C. Michel Harper ◽

Doris E. Wenger

Keyword(s):

Tibial Nerve ◽

Ganglion Cyst ◽

Symptomatic Relief ◽

Proximal Tibiofibular Joint ◽

Cell Of Origin ◽

Intraneural Ganglion ◽

Intraneural Ganglion Cyst ◽

Content Type ◽

Ganglion Cysts ◽

Tibiofibular Joint

✓ Different theories have evolved to explain the pathogenesis and the cell of origin of intraneural ganglion cysts. Reportedly only three cases of intraneural ganglion of the tibial nerve have been located within the popliteal fossa, and all of these were thought to arise within the nerve. The authors report a case of a recurrent tibial intraneural ganglion in which a connection to the proximal tibiofibular joint was demonstrated on magnetic resonance (MR) images and at surgery. Surgical ligation of the articular branch and evacuation of the cyst led to symptomatic relief, and an MR image obtained 1 year after surgery documented no recurrence. This case reinforces the fact that surgeons need to consider and search for an articular connection in all cases of intraneural ganglia, especially in those that have recurred.

Download Full-text

An intraneural ganglion cyst of the ulnar nerve at the wrist: a case report and literature review

Journal of International Medical Research ◽

10.1177/0300060520982701 ◽

2021 ◽

Vol 49 (1) ◽

pp. 030006052098270

Author(s):

Gu Heng Wang ◽

Tian Mao ◽

Ya Lan Chen ◽

Cheng Xu ◽

Shu Guo Xing ◽

...

Keyword(s):

Magnetic Resonance Imaging ◽

Ulnar Nerve ◽

Ganglion Cyst ◽

Resonance Imaging ◽

Intraneural Ganglion ◽

Intraneural Ganglion Cyst ◽

Case Presentation ◽

Articular Branch ◽

Ganglion Cysts ◽

External Neurolysis

Background Intraneural ganglion cysts of the ulnar nerve at the wrist are rare and poorly understood. We report a case of an intraneural ganglion cyst at the level of the wrist. Case presentation: A 48-year-old man presented with the complaints of weakness for 6 months and serious aggravation for 1 month in his right hand. After examinations, including ultrasound, the patient was diagnosed with an intraneural ganglion cyst. Intraoperatively, with exposure of the ulnar nerve, we found that the intraneural ganglion cyst was at the level of Guyon’s canal and extended approximately 6 cm proximally. Postoperatively, sensation of the fingers was normal, but atrophy of his muscles and limited straightening of his ring and little fingers were similar to those preoperatively. Conclusions Diagnosis of an intraneural cyst before surgery is mostly based on ultrasound and magnetic resonance imaging. Transection of the articular branch is an important measure to prevent recurrence of this cyst. If the ulnar nerve is compressed and causes symptoms, nerve decompression, including removal/aspiration of the cyst, and sometimes external neurolysis of the nerve, are necessary to relieve the symptoms and allow regeneration of the nerve. However, these should be performed without damaging the nerve fascicles.

Download Full-text