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GanglionCyst:Background,Anatomy,Pathophysiology

GanglionCyst
Author:ReneeGenova,MDChiefEditor:HarrisGellman,MDmore...
Updated:Jul07,2016

Background
Tumorsofthehandarefoundtobebenign95%ofthetimeinthecourseof
excludingacutaneousmalignancy. [1]Representingabout60%ofthesebenign
tumorsistheganglioncyst. [2]Althoughnodefinitiveetiologyhasbeenestablished,
thetheorythattheganglionisthedegenerationofthemucoidconnectivetissue,
specificallycollagen,hasdominatedsince1893,whenLedderhosedescribeditas
such. [3]
Theproblemsthatganglioncystspresentcanbevariedandareduetotheir
location.Mostoften,thecystwillpresentatthedorsalwrist,accountingfor6070%
ofallhandandwristganglia, [4]andarisefromthescapholunatejoint. [5]Aganglion
cystcanalsoarisefromtheradioscaphoidorscaphotrapezialjointvolarly. [5,6]
Theselocationscancausejointinstability,weakness,andlimitationofmotion. [5]
Compressionofthemediannervecanoccurwhenavolarradialganglionarises
withinthecarpalcanal. [5]Theulnarnervemayalsobecompressedwithinthetunnel
ofGuyonwhentheganglionpresentsontheulnarsideofthewrist. [7]Thepatient
canexperienceparesthesiasandpainfromaganglioncyst,andinsuchcases,
surgicaltreatmentshouldbeconsidered,toprovideafavorableoutcomewithfew
complications.
Multiplenonsurgicalmodalitieshavebeenusedovertheyearsforganglioncyst,
includingsimpleaspiration.Surgery(openorarthroscopic)oftenbecomes
necessary,andcurrentevidencesuggeststhatarthroscopicganglionexcisionisa
practicalandsuccessfulmeansofdorsalganglioncystremoval. [4,8,9,10]
Pharmacologicagentsareunderconstantinvestigationinthemedicalarena.
Potentialadvancesinsclerosingagentsspecifictothetreatmentofganglioncysts
mayleadtoadefinitivemedicaltreatmentofganglions,whichwouldavoidsurgery.

Anatomy
Dorsalgangliamostoftenaffectthescapholunatejoint,andthescaphoid
interosseusligamentandextensortendonsmustbeconsideredbecausetheyare
closelyassociatedwiththejointcapsule.Volargangliaarecommonlyassociated
withtheradioscaphoidandscaphotrapezialjoints,withproximitytothepalmar
cutaneousbranchofthemediannerveandthemediannerveitself.Mucouscysts
canbeanatomicallyassociatedwiththegerminalmatrixandaregenerallydisplaced
lateraltothemidlinebytheextensortendon. [2]

Pathophysiology
Althoughganglioncystscanbeunilobulated,theyaremostoftenmultilobulated,
withseptamadefromconnectivetissueseparatingthelobesorcavities. [3]
Thornburgpointsoutthatbecausethereisnoepithelialliningofthecystwall,a
ganglioncystisnotatruecystand,becauseofthishistologicobservation,the
theoriesofsynovialherniationorsynovialtumorformationarenotsupportedand
maybedisputed. [2]
Hyaluronicacidpredominatesthemucopolysaccharidesthatmakeupthefluid
withinthecystscavity,whereascollagenfibersandfibrocytesmakeupthewall
lining. [3]Thedevelopmentofthesecystsishistologicallyobservablebeginningwith
swollencollagenfibersandfibrocytes,followedbyadegenerationandliquefaction
oftheseelements,aterminationofdegeneration,and,lastly,aproliferationofthe
connectivetissue,resultinginaborderthatisdenseintexture. [3]

Etiology
Theetiologyoftheganglioncysthasbeendescribedasanoutpouchingof
synoviumasanirritationofarticulartissue,creatinganewformationand,the
mostcommonandacceptedtheory,asadegenerationofconnectivetissueand
cysticspaceformation. [3]Ithasalsobeensuggestedthatdegenerationofthe
connectivetissueiscausedbyanirritationorchronicdamagecausingthe
mesenchymalcellsorfibroblaststoproducemucin. [2]

Epidemiology
Ganglioncystsarethemostcommonsofttissuetumorsofthehandandwrist.
Althoughanyonecanbeaffectedbyganglioncysts,theyoccurthreetimesasoften
inwomenastheydoinmen.Mucouscystsarefoundinthedistalinterphalangeal
(DIP)jointandgenerallypresentwithosteoarthritis,andtherefore,theyaremost
commonlyseeninolderpatients.Ganglioncystsarepredominantlyseeninyoung
adultsandarerareinchildren. [2]

Prognosis
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Regardlessoftreatment,recurrenceispossible,butthecauseisunclear.
Rizzoetalperformedastudyofarthroscopicexcisionofdorsalwristgangliaand
foundstatisticallysignificantincreasesinwristextensionandgripstrength
postoperatively,ascomparedtopreoperativevalues. [10]Ofthe41patientsinthe
study,34hadnopainpostoperatively,andsevenhadmildoroccasionalpain.Only
twopatientsexperiencedrecurrence,butthegangliarecurredagainfollowinga
secondremovalusingopenexcision,suggestingthatthearthroscopictechnique
maynothavebeenthecauseoffailure.Althoughsomepatientsreportedwrist
stiffnessafterthesurgery,motionwasfullyrestoredby6monthsforthelast
patient.
EdwardsandJohansenprospectivelyevaluatedoutcomesofarthroscopicdorsal
wristgangliaresectionandfoundthatthepatientsexperiencedsignificantincreased
functionanddecreasedpainwithin6weeksafterarthroscopicresectionrecurrence
andcomplicationratesappearedcomparabletothoseofopenresections. [8]
Ganglioncystsalsohadahighassociationwithcertaininterosseouslaxities,and
recurrentcystsoriginatingfromthemidcarpaljointwerenotcontraindicationsfor
arthroscopicresection.Theauthorsnotedthatassessmentofthemidcarpaljointis
necessaryforcompleteresectionofmostganglioncysts,andidentificationofa
discretestalkisanuncommonfindingandisnotnecessaryforsuccessfulresection.
Rocchietalcomparedtwoformsoftreatmentofvolarwristganglia:openexcision
vialongitudinalvolarskinincisionandarthroscopicresectionthroughtwoorthree
dorsalports. [9]Theresultsofthestudysuggestedthatarthroscopicresectionisa
reasonablealternativetoopenexcisionintreatingradiocarpalvolarganglia,
becauseitisassociatedwithlesspostoperativemorbidityandabettercosmetic
result.Midcarpalvolarganglia,however,accordingtotheauthors,shouldstillbe
treatedbyopenremoval.
ClinicalPresentation

ContributorInformationandDisclosures
Author
ReneeGenova,MDUniversityofSouthCarolinaSchoolofMedicine
Disclosure:Nothingtodisclose.
Coauthor(s)
JohnJWalsh,IV,MDProfessorandChairman,DepartmentofOrthopedicSurgery,UniversityofSouthCarolina
SchoolofMedicine
JohnJWalsh,IV,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOrthopaedic
Surgeons,ChristianMedicalandDentalAssociations,AmericanSocietyforSurgeryoftheHand
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:ReceivedsalaryfromMedscapeforemployment.for:Medscape.
ThomasRHuntIII,MDProfessorandChairman,JosephBarnhartDepartmentofOrthopedicSurgery,Baylor
CollegeofMedicine
ThomasRHuntIII,MDisamemberofthefollowingmedicalsocieties:AmericanOrthopaedicAssociation,
AmericanOrthopaedicSocietyforSportsMedicine,SouthernOrthopaedicAssociation,AOFoundation,
AmericanAcademyofOrthopaedicSurgeons,AmericanAssociationforHandSurgery,AmericanSocietyfor
SurgeryoftheHand,MidAmericaOrthopaedicAssociation
Disclosure:ReceivedroyaltyfromTornierforindependentcontractorReceivedownershipinterestfromTornierfor
noneReceivedroyaltyfromLippincottforindependentcontractor.
ChiefEditor
HarrisGellman,MDConsultingSurgeon,BrowardHandCenterVoluntaryClinicalProfessorofOrthopedic
SurgeryandPlasticSurgery,DepartmentsofOrthopedicSurgeryandSurgery,UniversityofMiami,LeonardM
MillerSchoolofMedicineClinicalProfessorofSurgery,NovaSoutheasternSchoolofMedicine
HarrisGellman,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofMedicalAcupuncture,
AmericanAcademyofOrthopaedicSurgeons,AmericanOrthopaedicAssociation,AmericanSocietyforSurgery
oftheHand,ArkansasMedicalSociety,FloridaMedicalAssociation,FloridaOrthopaedicSociety
Disclosure:Nothingtodisclose.
AdditionalContributors
PeterMMurray,MDProfessorandChair,DepartmentofOrthopedicSurgery,MayoClinicCollegeofMedicine
DirectorofEducation,MayoFoundationforMedicalEducationandResearch,JacksonvilleConsultant,
DepartmentofOrthopedicSurgery,MayoClinic,JacksonvilleConsultingStaff,NemoursChildren'sClinicand
Wolfson'sChildren'sHospital
PeterMMurray,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOrthopaedic
Surgeons,AmericanOrthopaedicAssociation,AmericanSocietyforReconstructiveMicrosurgery,Orthopaedic
ResearchSociety,SocietyofMilitaryOrthopaedicSurgeons,AmericanAssociationforHandSurgery,American
SocietyforSurgeryoftheHand,FloridaMedicalAssociation
Disclosure:Nothingtodisclose.
Acknowledgements
GordonDerman,MDAssociateDirector,HandandUpperExtremitySurgery,AssistantProfessor,Department
ofPlasticandReconstructiveSurgery,RushUniversityMedicalCenter
Disclosure:Nothingtodisclose.
GeorgeJKouris,MDSeniorFellow,DepartmentofPlasticandReconstructiveSurgery,RushPresbyterianSt
Luke'sMedicalCenter

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Disclosure:Nothingtodisclose.

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