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.

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.

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

2011 ◽  
Vol 114 (1) ◽  
pp. 236-239 ◽  
Author(s):  
Gavin A. Davis ◽  
Ian H. Cox
Keyword(s):  
Clinical Utility ◽  
Tibial Nerve ◽  
Ganglion Cyst ◽  
Tarsal Tunnel ◽  
Intraneural Ganglion ◽  
Intraneural Ganglion Cyst ◽  
Articular Branch ◽  
Ganglion Cysts ◽  
Adults And Children ◽  
Articular Theory

Object The etiology of intraneural ganglia has been debated for centuries, and only recently a unifying theory has been proposed. The incidence of tibial nerve intraneural ganglia is restricted to the occasional case report, and there are no reported cases of these lesions in children. While evidence of the unifying theory for intraneural ganglia of the common peroneal nerve is strong, there are only a few reports describing the application of the theory in the tibial nerve. In this report the authors examine tibial nerve intraneural ganglia at the ankle and knee in an adult and a child, respectively, and describe the clinical utility of incorporating the unifying (articular) theory in the management of tibial intraneural ganglia in adults and children. Methods Cases of tibial intraneural ganglion cysts were examined clinically, radiologically, operatively, and histologically to demonstrate the application of the unified (articular) theory for the development of these cysts in adults and children. Results Two patients with intraneural ganglion cysts of the tibial nerve were identified: an adult with an intraneural ganglion cyst of the tibial nerve at the tarsal tunnel and a child with an intraneural ganglion cyst of the tibial nerve at the knee. In each case, preoperative MR imaging demonstrated the intraneural cyst and its connection to the adjacent joint via the articular branch to the subtalar joint and superior tibiofibular joint. At surgery the articular branch was identified and resected, thus disconnecting the tibial nerve intraneural cyst from the joint of origin. Conclusions These cases detail the important features of intraneural ganglion cysts of the tibial nerve and document the clinical utility of incorporating the unifying (articular) theory for the surgical management of tibial intraneural ganglia in adults and children.

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 An inferior alveolar intraneural cyst: a case example and an anatomical explanation to support the articular theory within cranial nerves

2015 ◽  
Vol 122 (6) ◽  
pp. 1433-1437 ◽  
Author(s):  
Stepan Capek ◽  
Ioannis G. Koutlas ◽  
Rhys P. Strasia ◽  
Kimberly K. Amrami ◽  
Robert J. Spinner
Keyword(s):  
Cranial Nerve ◽  
Ganglion Cyst ◽  
Plain Radiograph ◽  
Cranial Nerves ◽  
Cyst Formation ◽  
Mandibular Canal ◽  
Intraneural Ganglion ◽  
Intraneural Ganglion Cyst ◽  
Preoperative Ct ◽  
Joint Connection

The authors describe the case of an intraneural ganglion cyst involving a cranial nerve (V3), which was found to have a joint connection in support of an articular origin within the cranial nerves. An inferior alveolar intraneural cyst was incidentally discovered on a plain radiograph prior to edentulation. It was resected from within the mandibular canal with no joint connection perceived at surgery. Histologically, the cyst was confirmed to be an intraneural ganglion cyst. Reinterpretation of the preoperative CT scan showed the cyst arising from the temporomandibular joint. This case is consistent with the articular (synovial) theory of intraneural ganglion cysts. An anatomical explanation and potential joint connection are provided for this case as well as several other cases of intraneural cysts in the literature, and thus unifying cranial nerve involvement with accepted concepts of intraneural ganglion cyst formation and propagation.

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 Ulnar Neuropathy due to Intraneural Ganglion Cyst of the Ulnar Nerve at the Elbow

2018 ◽  
Vol 07 (03) ◽  
pp. 260-264 ◽  
Author(s):  
Byung-chul Son ◽  
Jin-gyu Choi ◽  
Hak-cheol Ko
Keyword(s):  
Ulnar Nerve ◽  
Elbow Joint ◽  
Glenohumeral Joint ◽  
Ganglion Cyst ◽  
Ulnar Neuropathy ◽  
Intraneural Ganglion ◽  
Intraneural Ganglion Cyst ◽  
Articular Branch ◽  
Right Hand ◽  
Ganglion Cysts

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.

Ultrasound diagnosis of an intraneural ganglion cyst of the peroneal nerve

1992 ◽  
Vol 76 (3) ◽  
pp. 538-540 ◽  
Author(s):  
Frans S. S. Leijten ◽  
Willem-Frans Arts ◽  
Julien B. C. M. Puylaert
Keyword(s):  
Peroneal Nerve ◽  
Ganglion Cyst ◽  
Ultrasound Diagnosis ◽  
Intraneural Ganglion ◽  
Intraneural Ganglion Cyst ◽  
Content Type ◽  
Definition Of ◽  
Exact Definition ◽  
Fine Print

✓ The authors present the case of an intraneural ganglion cyst of the peroneal nerve. The cyst was diagnosed by means of ultrasound, which also gave an exact definition of its size and location, confirmed at operation. Some controversial aspects of these lesions are discussed.

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.

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