Intraneural Ganglion Research Articles

Deep ulnar intraneural ganglia in the palm

While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood. We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation. A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts. Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.

A Rare Case of Intraneural Ganglion Cyst Involving the Tibial Nerve

Cystic lesions around the knee are a relatively common occurrence. Several types of cysts have been reported, including synovial, bursal, and ganglion. Ganglion cysts are not lined by synovial cells. Their location is highly variable, with occurrences described in the fat pads near the tibia or femur, muscles, nerves, and arteries. Intraneural ganglia are rare nonneoplastic cysts caused by the accumulation of thick mucinous fluid within the epineurium of peripheral nerves, encased in a dense fibrous capsule. These cysts can cause compression of the adjacent nerve fascicles, resulting in pain, paresthesias, weakness, muscle denervation, and atrophy. They are most commonly manifested by local and radiating pain, but sensory and motor deficits have also been described. Involvement of the tibial nerve is exceptionally rare, with <15 reported cases in the literature. We present a case of intraneural tibial ganglion cyst in a young woman. We also discuss the imaging features, differential considerations, proposed pathogenesis and anatomic origin, and treatment of this rare entity.

Intraneural Ganglion of the Tibial Nerve

Ozet: Tibial sinirin gangliyon kistleri cok nadirdir. Bu calismada, bilek ekleminin posteromedial kisminda belirgin bir kitle olan, 24 yasindaki bir erkek hasta olgusu sunmak istedik. Hasta, ayaginin plantar ve medial yuzeyinde aralikli, hafif ve belirsiz bir uyusma hissinden bahsetmekteydi. Manyetik rezonans goruntulemesi tarsal tunneldeki kistin varligini gostermistir. Cerrahi sirasinda, siniri cevreleyen derinin hemen yaninda kapsulle cevrili bir kist varligiyla karsilastik. Diseksiyon esnasinda, kistin intranoral olarak invaze oldugunu tespit ettik. Kist, mikrocerrahi teknikleri kullanilarak, sinirin perinoral ve intrafasikuler olarak diseksiyonu ile basariyla cikarildi. Hasta, cerrahiden sonra semptomlarindan kurtuldu.

Can trauma cause tibial intraneural ganglion cysts at the superior tibiofibular joint?

Can trauma cause tibial intraneural ganglion cysts at the superior tibiofibular joint?

Sciatic nerve tumor and tumor-like lesions—uncommon pathologies

Sciatic nerve mass-like enlargement caused by peripheral nerve sheath tumors or neurocutaneous syndromes such as neurofibromatosis or schwannomatosis has been widely reported. Other causes of enlargement, such as from perineuroma, fibromatosis, neurolymphoma, amyloidosis, endometriosis, intraneural ganglion cyst, Charcot-Marie-Tooth disease, and chronic inflammatory demyelinating polyneuropathy are relatively rare. High-resolution magnetic resonance imaging (MRI) is an excellent non-invasive tool for the evaluation of such lesions. In this article, the authors discuss normal anatomy of the sciatic nerve and MRI findings of the above-mentioned lesions.

Ultrasound-Guided Aspiration of Symptomatic Intraneural Ganglion Cyst Within the Tibial Nerve

Ultrasound Quarterly: March 2012 - Volume 28 - Issue 1 - p 42-43 doi: 10.1097/01.RUQ.0000412976.57318.fd

The arduous journey to find a portrait of Beauchêne fils

Earlier publications by our group have reported the major contributions of Beauchêne fils, Edme François Chauvot de Beauchêne (1778-1830), a prosector, and surgeon in Paris. These included a variety of firsts: the finding of an intraneural ganglion cyst, the description of the exploded skull (Beauchêne) technique, and the case of air pulmonary embolism. This article describes the exhaustive efforts necessary to locate a portrait of him. Information obtained along the circuitous journey through 13 generations over five centuries will clarify the important medical accomplishments by individuals of a noble family. The discovered portraits will allow scholars to honor accurately the individuals, particularly Beauchêne fils, in the future.

Teaching Neuro Images : Peroneal intraneural ganglion cyst

An 11-year-old boy presented with a 3-month history of progressive left foot drop. Clinical findings were consistent with left peroneal mononeuropathy, but neurophysiologic studies failed to demonstrate signs of peroneal nerve entrapment. Magnetic resonance neurography revealed a peroneal intraneural ganglion cyst (PIG) (figure, A–D). The patient underwent surgical resection of the PIG, resulting in mild improvement of symptoms. PIG are thought …

Intraneural ganglion cysts of obturator nerve causing obturator neuropathy

Intraneural ganglion cysts of obturator nerve causing obturator neuropathy

Sural Intraneural Ganglion Cysts Are Joint-related

The recent article by Kim and Kim [1] provides a valuable case of a rare sural intraneural ganglion cyst to the literature. We offer yet another example to highlight recent developments in our understanding of this entity. A 42-year-old woman presented with a 6 month history of the spontaneous onset of moderately severe pain developing in the right lateral rearfoot in the retrolateral malleolar region with radiating dysesthesias into the dorsolateral foot. Symptoms were worse with standing or with activity. Exam revealed a 3×2 cm soft tissue tubular mass along the course of the sural nerve which had features consistent with a ganglion cyst. It was tender to palpation. Percussion produced radiating paresthesias in the sural nerve distribution. Sensation was intact on the dorsal foot to light touch. Magnetic reconance imaging (MRI) demonstrated a sural intraneural ganglion cyst with a joint connection to the subtalar joint (Figs. 1, ​,2).2). At operation, this articular branch connection was identified, ligated and resected. The patient had full recovery immediately postoperatively; there was no clinical evidence of persistent pain or cyst at last follow-up examination. Fig. 1 Conventional MRI of a patient with sural intraneural ganglion originating from subtalar joint. Serial coronal T2-weighted fast spin echo (FSE) images with fat suppression from posterior to anterior demonstrates an intraneural cyst arising from the lateral ... Fig. 2 Three-dimensional rendering of conventional magnetic resonance images obtained in this patient with a sural intraneural ganglion cyst. Maximum intensity projection image created from the same series as Fig. 1 shows the entire course of the cyst (asterisk) ... As Kim and Kim [1] point out, the pathogenesis of these cysts has been controversial and poorly understood. Recent reports have clarified this. Layers of robust evidence have substantiated an articular origin for all types of intraneural cysts first at the prototypic site (the common fibular nerve) and then at other joints throughout the appendicular skeleton and axial spine [2,3]. The unifying articular (synovial) theory has been shown to be generalizable and universal. Joint connections must be assumed to be present. We have emphasized the difficulties in identifying the joint connection with imaging and at operation. Experience with both can reliably and reproducibly identify the joint connection. High resolution imaging (MRI or computed tomography imaging with or without arthrography; or ultrasound) with conventional or 3-dimensional renderings may show convincingly a seemingly occult joint connection [3,4], even when reported by others not to be present. The consistent articular connection has fostered an understanding of the principles of these cysts. A capsular defect allows the passage of joint fluid to pass from the joint (often degenerative) along an articular branch and into the parent nerve. Propagation follows the pass of least resistance within the epineurium of nerve. Intra-articular pressure and pressure fluxes influence cyst dimensions. We have identified 9 cases of sural intraneural ganglia (Appendix). Of these, joint connections were only found in 3 instances: twice to the subtalar joint and once to the calcaneocuboid joint. Nevertheless, we are confident that joint connections were present in all of the remaining cases in the literature, including the one by Kim and Kim [1]. These joint connections can be predicted and must be anticipated. The articular branch anatomy of the sural nerve [5] would explain all of the locations of these cysts (Fig. 3). The unifying articular theory could explain all of their patterns of propagation [2,3]. Fig. 3 The anatomy and pathoanatomy of known and potential sites of sural intraneural ganglion cysts. The drawing of the normal anatomy was based on descriptions by anatomists [5]. The confirmed joint-related sites of origin (subtalar and calcaneocuboid joints) ... Understanding the pathogenesis can help target surgery so as to simplify it. Surgery should include ligating or resecting the articular branch near the joint. The cyst itself need not be resected as it will be resorbed as long as the connection is disrupted. This approach minimizes intraneural dissection and eliminates intraneural recurrence, which is known to occur with high rates and was documented in several of these sural examples (Appendix). We believe that such recurrence would likely have been present in other patients (even those who were asymptomatic) if postoperative imaging had been performed. Resecting the nerve, while possible in the case of a distal cutaneous nerve (such as the sural nerve) and has been performed in several cases, could still result in intraneural (distal) recurrence. Furthermore, nerve sacrifice can not be extrapolated to other cases of intraneural ganglia involving major mixed peripheral nerves. Knowledge of current pathogenesis and experience with the imaging and operative findings with these rare cysts will improve outcomes and eliminate intraneural recurrences.

The First Described Joint-Associated Intraneural Ganglion Cyst

This article describes the identification of the first known specimen in which an articular origin for an intraneural cyst was recognized. Prompted by early citations in the 20th century of a valuable 1904 tibial intraneural ganglion housed at St. Bartholomew's Hospital in London, we traveled there to research it. We fortuitously discovered a citation to an earlier joint-related specimen, one that had not previously been referenced correctly in subsequent publications on intraneural cysts for more than a century. The original anatomic description dating to 1884, summarized in 3 lines in a museum catalog, was attributed to T. Swinford Edwards. This cadaveric specimen affected the deep branch of the ulnar nerve and arose from a carpal joint. Additional information was provided in a Transactions in 1884. An original drawing of the specimen was published in a textbook written in 1889 by Anthony Bowlby, a former curator, both of which credited F. (Frederick) Swinford Edwards, a demonstrator in anatomy and surgery at St. Bartholomew's. Unfortunately, the specimen could not be located and is presumed lost. To establish this specimen as the first known example of a joint-related intraneural cyst, we completed a review of >400 other cases and confirmed this statement. The first observation of an articular origin for an intraneural cyst, made by 2 eminent surgeons, has not been properly acknowledged. Considered with a modern perspective, this historical case solidifies the articular (synovial) origin for these unusual intraneural cysts, a finding that has important treatment implications.

Posttraumatic torsional injury as an indirect cause of fibular intraneural ganglion cysts: Case illustrations and potential mechanisms

Trauma has been loosely associated with the development of fibular intraneural ganglion cysts. Sporadic reports of direct trauma to the proximal lateral leg in the region of the superior tibiofibular joint (STFJ) capsule support the development of a capsular rent and the subsequent egress of joint fluid from the articular joint. This report provides evidence to suggest that indirect trauma from torsion can link concomitant ankle injury and fibular nerve palsy (foot drop) and fibular intraneural ganglion cysts. We present two cases to illustrate different potential mechanisms. One patient sustained an ankle ligamentous injury which was translated through the interosseous membrane (IOM) to the proximal leg region, affecting the STFJ and the fibular nerve (ascending pathway). The second patient had blunt injury to the popliteal fossa in combination with a twisting injury to the leg. In this latter case we offer two plausible explanations: (1) combined knee and ankle injury resulting in an ascending pathway mechanism; and (2) a knee injury which disrupted the STFJ, resulting in a translational force down the leg (descending pathway). We believe that fibular intraneural cysts from the STFJ result from direct and indirect trauma. Additional reports of similar cases and sophisticated biomechanical testing will allow us to delineate the exact mechanisms for these injury patterns.

A Ganglion Within the Ulnar Nerve and Communication With the Distal Radioulnar Joint via an Articular Branch: Case Report

An intraneural ganglion is rare, and involvement of an articular nerve may suggest a possible pathogenesis. We report an intraneural ganglion of the ulnar nerve with a connection to the distal radioulnar joint via the articular branch. We excised the ganglion, the stalk, and the articular branch. To date, there has been no recurrence.

An Unusual Cause of Paralysis of the Peroneal Nerve

We present 3 cases of a 12-year-old boy, an 8-year-old girl, and a 9-year-old boy with progressive paresis of the peroneal nerve. Peroneal intraneural ganglia are a rare cause of paralysis of the lower limb in children; more often these symptoms occur because of exostosis. Ultrasound imaging in both patients showed a cystic mass near the fibular neck. Magnetic resonance imaging examination revealed that the ganglion is communicating with the proximal tibiofibular joint. Surgical exploration in these patients confirmed a cystic formation involving the common peroneal nerve. The ganglion originates from the articular nerve branch to the proximal tibiofibular joint. Total recovery of nerve function was seen 2 years later for the first patient, whereas the other 2 showed immediate postoperative improvement of peroneal nerve function and complete recovery within 6 to 8 weeks. On the other hand, patients with exostosis showed varying outcomes. In children with symptoms suspicious of nerve compression, fast diagnosis and immediate treatment are necessary to ensure the best possible recovery.

Intraneural ganglion in the digital nerve of the thumb: A case report

Intraneural ganglion cysts of the peripheral nerve in the upper extremity are uncommon and usually originate within the epineurium of the peripheral nerve. The current report discusses a 57-year-old woman with a neuropathic nodular mass on the thenar area of the left hand. Magnetic resonance images showed a lobulated, homogeneous mass of high signal intensity on T2-weighted images and low signal intensity with peripheral enhancement on T1-weighted images. Excisional biopsy and histopathologic examination confirmed an intraneural ganglion cyst of the digital nerve of the thumb. A successful result was obtained by surgical treatment, and there was no recurrence of abnormal sensation and paraesthesia during the 3-year follow-up period.

An intraneural ganglion cyst causing unilateral hypoglossal nerve palsy

Intracranial ganglion cysts are rare. We report a patient with a rare unilateral hypoglossal nerve palsy caused by an intraneural ganglion cyst. To our knowledge, there are only four reports of ganglion/synovial cysts causing unilateral hypoglossal nerve palsy. Our aim is to present the fifth report, and to compare our findings with the others.

Ultrasound-guided aspiration of symptomatic intraneural ganglion cyst within the tibial nerve

Ultrasound-guided aspiration of symptomatic intraneural ganglion cyst within the tibial nerve

An anatomically based imaging sign to detect adventitial cyst derived from the superior tibiofibular joint

The origin for complex intraneural cysts remains controversial despite recent emerging evidence to support their articular origin. The coexistence of intraneural and adventitial cysts has been described due to the proximate neurovascular bundle, i.e., the articular (neural) branch and vessels at the joint capsule. To clarify the pathogenesis, anatomically based imaging patterns can be identified. This paper characterizes a common finding identified on MRI describing the adventitial component originating from the superior tibiofibular joint (STFJ). MRIs of patients with fibular (peroneal) (n = 24) and tibial (n = 7) intraneural ganglion cysts were reviewed. Eleven patients with fibular intraneural ganglion cysts were identified as having a coexisting adventitial component. In all cases, the adventitial cyst extended from the anterior portion of the STFJ, within the capsular vessels, and along the anterior tibial vessels. The reproducible anatomy permitted the identification of an imaging pattern: the "vascular U" sign, consisting of cystic anterior tibial vessels running through the interosseous membrane between the proximal tibia and fibula. This sign was seen on axial MR image(s) obtained at the level of the fibular neck in all cases. To generalize these findings, the rare tibial intraneural ganglion cysts (derived from the posterior aspect of the STFJ) were examined; two cases had coexisting adventitial cysts with visualization of the vascular U sign. This new imaging pattern can improve the identification of adventitial cysts at the level of the STFJ.

Case Report: Intraneural Ganglion Cyst of the Ulnar Nerve at the Wrist

We report a case of a 69-year-old male who presented with pain, weakness, and clumsiness of his right hand. Initial evaluation suggested possible neoplastic process affecting his cervical spine, which was fortunately ruled out by bone biopsy. Subsequent electrodiagnostic studies and magnetic resonance imaging confirmed a lesion of the deep ulnar motor branch. Exploration of Guyon's canal was performed, and an intraneural ganglion involving the deep motor branch of the ulnar nerve was found and excised. Despite more than 14months of symptomatic duration, the patient made a near-complete recovery with virtually no functional limitations. This provides supporting evidence for a functional benefit of intraneural ganglion excision and nerve decompression even in cases of chronic muscle atrophy.

The MRI appearance and importance of the “very” terminal branches of the recurrent articular branch in fibular intraneural ganglion cysts

The MRI appearance and importance of the “very” terminal branches of the recurrent articular branch in fibular intraneural ganglion cysts