Outcomes Following Surgery for Common Peroneal Nerve Intraneural Ganglion Cysts: A Case Series and Systematic Review.

Background: Intraneural ganglia are a rare cause of common peroneal nerve palsy. Although several treatment modalities exist, surgical intervention is recommended, especially in the setting of neurological dysfunction. We present a case series and systematic review on the clinical outcomes following surgical excision of common peroneal nerve intraneural ganglia. Methods: We performed a retrospective chart review of all patients who had undergone surgery for common peroneal nerve intraneural ganglia at Queen Elizabeth Hospital in Birmingham, UK, from 2012 to 2022. Demographic and pre- and postoperative findings were collected. A comprehensive literature search of MEDLINE and EMBASE databases was also performed to identify similar studies. Data were subsequently extracted from included studies and qualitatively analyzed. Results: Five patients at our center underwent procedures to excise intraneural ganglia. There was a male preponderance. Pain, foot drop, and local swelling were the common presenting features. Postoperatively, all patients who completed follow-up demonstrated improved motor function with no documented cyst recurrence. The systematic review identified 6 studies involving 128 patients with intraneural ganglia treated with surgery. Similar findings were reported, with objective and subjective measures of foot and ankle function and symptoms improving after surgical intervention. The recurrence rate varied from 0% to 25%, although most recurrences were extraneural. Conclusions: Excision of intraneural ganglia is associated with symptomatic relief and functional improvement. Recurrence rates are relatively low and are rarely intraneural.

Intraneural ganglion cyst of the common peroneal nerve causing foot drop in a 12-year old child.

OBJECTIVES: Intraneural ganglia are benign fluid-filled cysts contained within the subepineurial space of peripheral nerves. The common peroneal nerve at the fibular neck is by far the most frequently involved, although other nerves can be affected as well. Although the differential diagnosis of foot drop in adults and children show some differences, clinical presentation, diagnostic workup, treatment and follow-up of intraneural ganglia are quite similar in both groups. The primary objective was to create an overview of intraneural ganglia in children, with an emphasis on diagnostic workup and potential pitfalls during neurosurgical intervention, based on all available literature concerning this topic and own center experiences. As a secondary objective, we tried to raise the awareness concerning this unique cause of foot drop in childhood. PATIENTS AND METHODS: We performed a review of the literature, in which children who developed foot drop secondary to an intraneural ganglion cyst of the common peroneal nerve were examined. A total of eleven articles obtained from MEDLINE were included. Search terms included: "pediatric", "children", "child", "intraneural ganglia", "intraneural ganglion cysts", "foot drop", "peroneal nerve" and "fibular nerve". Additional studies were identified by checking reference lists. Furthermore, we present the case of a 12-year old girl with foot drop caused by an intraneural ganglion cyst. She underwent cyst decompression with evacuation of intraneural cyst fluid and articular branch disconnection. PRISMA and CARE statement guidelines were followed. RESULTS: We hypothesize that minor injury caused a breach in the joint capsule, resulting in synovial fluid egression along the articular nerve branch, corroborating the unifying articular theory and emphasizing the need for ligation of said branch. Foot drop is a predominant characteristic, explained by the proximity of the anterior tibial muscle motor branch near the articular branch nerve. In children, satisfactory motor recovery after surgical decompression is to be expected. CONCLUSION: Sudden or progressive foot drop in children warrants an exhaustive neurophysiological and radiological workup. The management of intraneural ganglia is specific, consisting of nerve decompression, articular branch ligation and joint disarticulation, if deemed necessary. Our surgical results support the unifying articular theory and emphasize the importance of ligation and transection of the articular branch nerve, distally from the anterior tibial muscle branch, in order to prevent intraneural ganglia recurrence. This well-documented case adds depth to the current literature on this sparsely reported entity.

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

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.

[Analysis of the results of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis.]

The aim of the study was to analyze the results of the use of laser destruction of the articular branch of the obturator nerve in elderly and senile patients with degenerative coxarthrosis. The results of treatment of 34 patients over 65 years of age with symptomatic degenerative diseases of the hip joint (HJD) and somatic contraindications for total hip arthroplasty have been prospectively studied. In the study group, in the period from 2017 to 2019, laser destruction of the articular branch of the obturator nerve (970 nm, frequency 9 Hz and power 3 W in a total dose of 100 J) was carried out. The average follow-up was 12 months. To assess the effectiveness of surgical treatment, the dynamics of the pain syndrome in the hip joint was analyzed according to the visual analogue scale, the quality of life according to the SF-36 questionnaire, the functional state of the hip joint according to the W.H.Harris scale and the presence perioperative surgical complications. As a result, it was found that the use of laser destruction of the articular branch of the obturator nerve in degenerative coxarthrosis in elderly and senile patients (if total hip arthroplasty was not possible) made it possible to significantly reduce the level of preoperative pain syndrome, restore the quality of life and improve the functional state of patients with low risks of surgical complications.

The articular branch of the peroneal nerve to the proximal tibiofibular joint descends at a mean height of approximately 18 mm distal to the postero-lateral tip of the fibular head.

PURPOSE: The aim of the study was to evaluate the anatomical details of the articular branch of the peroneal nerve to the proximal tibiofibular joint and to project the height of its descent in relation to the fibular length. METHODS: Twenty-five lower extremities were included in the study. Following identification of the common peroneal nerve, its course was traced to its division into the deep and superficial peroneal nerve. The articular branch was identified. The postero-lateral tip of the fibular head was marked and the interval from this landmark to the diversion of the articular branch was measured. The length of the fibula, as the interval between the postero-lateral tip of the fibular head and the tip of the lateral malleolus, was evaluated. The quotient of descending point of the articular branch in relation to the individual fibular length was calculated. RESULTS: The articular branch descended either from the common peroneal nerve or the deep peroneal nerve. The descending point was located at a mean height of 18.1 mm distal to the postero-lateral tip of the fibular head. Concerning the relation to the fibular length, this was at a mean of 5.1%, starting from the same reference point. CONCLUSION: The articular branch of the common peroneal nerve was located at a mean height of 18.1 mm distal to the the postero-lateral tip of the fibular head, respectively, at a mean of 5.1% of the whole fibular length starting from the same reference point. These details represent a convenient orientation during surgical treatment of intraneural ganglia of the common peroneal nerve, which may result directly from knee trauma and indirectly from ankle sprain.

Surgical Treatment of Intraneural Ganglion Cysts of the Ulnar Nerve at the Elbow: Long-Term Follow-up of 9 Cases.

BACKGROUND: Intraneural ganglion (IG) cysts have been considered curiosities and their pathogenesis remains controversial. OBJECTIVE: To clarify ulnar nerve at the elbow (UNE) pathogenesis and long-term surgical outcomes by presenting 9 rare cases of IG of the UNE. METHODS: Surgical treatment of IG was performed. Clinical symptoms, physical examinations, and electromyogram were evaluated pre- and postoperatively. At least 4 yr of follow-up was performed. RESULTS: The Tinel's sign became negative and local elbow pain disappeared in all 9 patients after surgery, and the average visual analog scale/score dropped from 4.9 (3-8) to 0 (0-0) after 6.2 d (2-10) on average. Two patients retained positive Froment test, "claw hand" and paresthesias with the 2-point discrimination much different from the contralateral little finger. Postoperative the UK Medical Research Council muscle strength score (MRC) grades of the flexor carpi ulnaris and the flexor digitorum profundus muscle of the fourth and fifth digits recovered to M4-M5 from M0-M2 in all 9 patients. The postoperative MRC grades of the third to fourth lumbrical muscles, the interossei, and the hypothenar recovered to M3-M5 from M0-M2 in 7 patients. Cystic articular branch (CAB) was found in all 9 patients intraoperatively. No symptomatic recurrence of IG was seen. The mean motor nerve conduction velocity of ulnar nerve across the elbow recovered from 5.3 to 41.2 m/s. CONCLUSION: A unifying articular theory is responsible for the pathogenesis of IG of UNE and disconnection of the CAB would prevent recurrence. The long-term outcome is good after surgical treatment of IG of UNE.

Intraoperative intravenous fluorescein as an adjunct during surgery for peroneal intraneural ganglion cysts.

The intraoperative use of intravenous fluorescein is presented in a case of peroneal intraneural ganglion cyst. When illuminated with the operative microscope and yellow filter, this fluorophore provided excellent visualization of the abnormal cystic peroneal nerve and its articular branch connection. The articular (synovial) theory for the pathogenesis of intraneural cysts is further supported by this pattern of fluorescence. Further, our report presents a novel use of fluorescein in peripheral nerve surgery.

Recognition of peroneal intraneural ganglia in an historical cohort with "negative" MRIs.

BACKGROUND: The objective of this study was to review an historical cohort of patients with peroneal neuropathy and magnetic resonance imaging (MRI) read as negative for mass or cyst to determine if occult peroneal intraneural ganglion cysts can be identified on subsequent imaging review and to use this as an estimation of how under-recognized this pathologic entity is. METHOD: The patient cohort utilized in this study was a previously published control cohort of 11 patients with peroneal neuropathy and MRI read as negative for mass or cyst. Clinical history, neurologic examination, and MRI studies of the knee were reviewed for each of the included patients. The primary outcome of interest was the presence of peroneal intraneural ganglion cyst on MRI. RESULTS: Overall, 7 of 11 (64%) patients in this historical "normal" cohort had evidence of a peroneal intraneural ganglion cyst on subsequent review of imaging. Deep peroneal-predominant weakness, knee pain, and tibialis anterior-predominant denervation/atrophy were seen more commonly in patients in whom an intraneural cyst was identified. CONCLUSIONS: This retrospective cohort study provides evidence that peroneal intraneural ganglion cysts are an historically under-recognized cause of peroneal neuropathy, with 64% of this historical "negative" cohort having evidence of a cyst on subsequent imaging review. Larger studies are needed to determine the treatment ramifications of identifying small cysts and to determine the clinical features suggestive of an intraneural ganglion cyst.

The nearly invisible intraneural cyst: a new and emerging part of the spectrum.

OBJECTIVE The authors have observed that a subset of patients referred for evaluation of peroneal neuropathy with "negative" findings on MRI of the knee have subtle evidence of a peroneal intraneural ganglion cyst on subsequent closer inspection. The objective of this study was to introduce the nearly invisible peroneal intraneural ganglion cyst and provide illustrative cases. The authors further wanted to identify clues to the presence of a nearly invisible cyst. METHODS Illustrative cases demonstrating nearly invisible peroneal intraneural ganglion cysts were retrospectively reviewed and are presented. Case history and physical examination, imaging, and intraoperative findings were reviewed for each case. The outcomes of interest were the size and configuration of peroneal intraneural ganglion cysts over time, relative to various interventions that were performed, and in relation to physical examination and electrodiagnostic findings. RESULTS The authors present a series of cases that highlight the dynamic nature of peroneal intraneural ganglion cysts and introduce the nearly invisible cyst as a new and emerging part of the spectrum. The cases demonstrate changes in size and morphology over time of both the intraneural and extraneural compartments of these cysts. Despite "negative" MR imaging findings, nearly invisible cysts can be identified in a subset of patients. CONCLUSIONS The authors demonstrate here that peroneal intraneural ganglion cysts ride a roller coaster of change in both size and morphology over time, and they describe the nearly invisible cyst as one end of the spectrum. They identified clues to the presence of a nearly invisible cyst, including deep peroneal predominant symptoms, fluctuating symptoms, denervation changes in the tibialis anterior muscle, and abnormalities of the superior tibiofibular joint, and they correlate the subtle imaging findings to the internal fascicular topography of the common peroneal nerve. The description of the nearly invisible cyst may allow for increased recognition of this pathological entity that occurs with a spectrum of findings.

Intraneural ganglion cyst of the ulnar nerve in an unusual location: A case report.

INTRODUCTION: Intraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves. While the most common location of intraneural ganglion cysts is the ulnar nerve and its branches, intraneural ganglion cyst involving the superficial branch of the ulnar nerve has not yet been reported. PRESENTATION OF CASE: A-25-year-old woman presented with pain and a palpable mass in the hypothenar region of the volar side of her right hand. Her neuromuscular examination was normal. The pain was unresponsive to nonsurgical treatments. After confirming with imaging modalities, the initial diagnosis was considered as an intraneural ganglion cyst arising from superficial ulnar nerve. Excision of the ganglion and exploration of the articular branch (if seen in operation) decision was undertaken by the senior author. Whether MRI or intraoperative exploration, not identified an articular branch. DISCUSSION: Intraneural ganglion cysts of peripheral nerves may be seen in miscellaneous locations in the body. However, to our knowledge, an intraneural ganglion cyst involving the superficial branch of the ulnar nerve is unique. While a variety of theories have been proposed to enlighten the etiopathogenesis of intraneural ganglia, the latest and most affirmed is the unifying articular (synovial) theory. CONCLUSION: Intraneural ganglion cysts may be seen on the hypothenar side of the palm. The etiology and treatment of choice are closely associated with each other in this rare disorder. It is important to realize a related articular branch, otherwise the origin of cyst formation remains, and this may cause other para-articular cysts.

Pseudoaneurysm of the articular branch of the descending genicular artery following double-bundle anterior cruciate ligament reconstruction.

This report describes a case of a pseudoaneurysm of the articular branch of the descending genicular artery following double-bundle anterior cruciate ligament (ACL) reconstruction. An 18-year-old male received double-bundle ACL reconstruction. During ACL reconstruction, a far anteromedial portal was created for femoral tunnel drilling. The patient presented with pulsatile swelling on the medial side of the knee on the second post-operative day. The pseudoaneurysm was diagnosed using contrast computed tomography and Doppler ultrasonography and was subsequently treated by embolization with a microcatheter. Although a vascular injury is a very rare complication of knee arthroscopy, it should be considered a possibility in patients who undergo such procedures. LEVEL OF EVIDENCE: V.

Anatomical study of the articular branch of the lateral pectoral nerve to the shoulder joint.

PURPOSE: The purpose of this study was to document the distribution of the articular branch of the lateral pectoral nerve (LPN) to the shoulder and to identify a suitable point for its blockade. METHODS: This study involved the dissection of 43 shoulders of 22 unembalmed cadavers (6 male and 16 female) to identify the LPN and its articular branch to the shoulder. To identify the suitable anatomical point for blocking the articular branch of the LPN, several anatomical landmarks around the shoulder were measured. RESULTS: The articular branch of the LPN to the shoulder was present in 29 of 43 cases (67.4 %). The appropriate point to block the articular branch of the LPN was identified at a mean distance of 1.5 cm below the clavicle, on the line connecting the closest points between the clavicle and the coracoid process, and at a mean depth of 1.0 cm from the skin. CONCLUSION: The articular branch of the LPN to the shoulder, as well as the muscular and cutaneous branches of the LPN, covers a portion of the shoulder joint with suprascapular and axillary nerves. Surgeons might consider a peripheral block of the suprascapular, axillary, and LPNs to provide maximum block coverage after shoulder joint surgery.

Concurrent Lateral Dorsal Cutaneous and Deep Peroneal Intraneural Ganglion Cysts in the Foot.

Intraneural ganglion cysts are non-neoplastic collections of mucinous material within the epineurium of peripheral nerves. We present a rare case of 2 intraneural ganglion cysts in separate nerves of the foot, originating from different joints within the same joint complex. Our findings add to the large body of evidence supporting the unifying articular (synovial) theory. We emphasize the importance of delineating the cyst morphology and origins using high-resolution magnetic resonance imaging before surgery and searching for and resecting the articular branch or branches during surgery.

The vascular supply of hip joint and its clinical significant / Suministro vascular de la articulación de la cadera y su significado clínico

The hip joint gains its vascular supply from the superior gluteal arteries as well as from the medial and lateral circumflex femoral arteries with the first perforating artery. In gluteal trauma, the superior and inferior gluteal artery may be affected which may end with vascular insult of hip joint. The current study includes a dissection of 171 cadavers to examine the vascular supply of hip joint. In 99.3% of articular branch arises from the superior gluteal artery either directly or indirectly (95.4% or in 3.9%, respectively). In 81% of articular branch arises from the inferior gluteal artery either directly or indirectly in 78% or in 3%. In 20.3% of articular branch arises from the coexistence of sciatic artery either directly or indirectly (17.7% or in 2.6%, respectively). Infrequently, the internal pudendal artery gives articular branch in 0.4%. Further, there is no difference between male and female in hip joint supply in current study. Based on current study's result, the dominant articular branch of vascular supply of the hip joint comes from the superior gluteal artery whereas the inferior gluteal artery comes beyond due its congenital absence. The coexistence sciatic artery is a replacement artery for superior or inferior gluteal artery in case of congenital absence. Due to aneurysm of the three previous arteries after trauma, it is important to study their course and articular branches to avoid iatrogenic fault of joint vascular insult during surgical management of either true or false aneurysm.

La articulación de la cadera obtiene su suministro vascular desde las arterias glúteas superiores, así como desde las arterias circunflejas femorales lateral y medial y la primera arteria perforante. En el trauma glúteo, las arteria glúteas superior e inferior pueden verse afectadas, lo que puede terminar con una lesión vascular de la articulación de la cadera. Este estudio incluyó la disección de 171 cadáveres con el fin de examinar el suministro vascular de la articulación de la cadera. El 99,3% de las ramas articulares se originan de la arteria glútea superior, ya sea directa o indirectamente (95,4% o en 3,9%, respectivamente). En 81% de los casos, la rama articular sse origina de la arteria glútea inferior, directa o indirectamente (78% y 3%, respectivamente). El 20,3% de la rama articular se origina de la conexistencia de la arteria ciática, ya sea directa o indirectamente (17,7% y 2,6%, respectivamente), y con poca frecuencia, la arteria pudenda interna origina una rama articular (0,4%). Además, los resultados no mostraron diferencia en el suministro de articulación de la cadera entre hombres y mujeres. En base a nuestros resultados, podemos señalar que la rama articular dominante de suministro vascular de la articulación de la cadera proviene de la arteria glútea superior, mientras que la arteria glútea inferior aporta de manera escasa debido a su ausencia congénita. La coexistencia de una arteria ciática, constituye un reemplazo de las arterias glútea superior o inferior en caso de ausencia congénita. En caso de un aneurisma de alguna de las tres arterias anteriores, posterior a un trauma, resulta importante estudiar su curso y ramas articulares para evitar una lesión vascular iatrogénica conjunta durante el tratamiento quirúrgico de aneurisma de tipo verdadero o falso.

Radiofrequency denervation of the hip joint for pain management: case report and literature review.

BACKGROUND: A 55-year-old male presented with severe pain and functional limitations as a result of left hip osteoarthritis. He had failed multiple treatments while waiting for a hip arthroplasty, including physical therapy, medications, and various intra-articular injections. Thermal radiofrequency lesioning of the obturator and femoral articular branches to the hip joint was offered in the interim. OBJECTIVES: To our knowledge, this is the first report to describe an inferior-lateral approach for lesioning the obturator branch, the clinical application of successive lesions to increase denervation area, and outcomes in a patient receiving a second treatment with previously good results. METHODS: To discuss relevant and technical factors for this specific case, we reviewed previous literature on hip joint radiofrequency and critically evaluated previous anatomic studies in the context of radiofrequency. RESULTS: The first treatment provided significant benefit for a period of 6 months. A second treatment was employed providing only mild to moderate benefit until his joint replacement surgery 4 months later. Literature review revealed studies of low quality secondary to small sample sizes, patient selection methodology, inclusion of patients with heterogenous etiologies for pain, variable needle placement techniques, and lack of measurement of functional outcomes. LIMITATIONS: Case report and low quality studies in existing literature. CONCLUSIONS: Hip joint radiofrequency denervation is a promising avenue for adjunctive treatment of hip pain. Further cadaveric studies are required to clarify a multitude of technical parameters. Once these are well defined, future clinical studies should consider pain, functional, and economic outcomes in their design.

Hilton's law revisited.

Hilton's Law, put forth 150 years ago, is well known and frequently taught in anatomy courses. We critically analyzed the complex description of associated muscular, cutaneous, and articular innervations in order to assess the general applicability of Hilton's Law. We applied rules for interpretation of the Law extrapolated upon but based on Hilton's original writings, and excluded obscure supplementary clauses not considered as part of the Law. We found the Law, as originally written and as we interpreted with some latitude, to be reliable and applicable to all cranial and peripheral nerves. Hilton's Law is a powerful springboard to understand articular anatomy and pathophysiology.

Intraneural Ganglion Cyst in Foot and Ankle / 대한족부족관절학회지

PURPOSE: Pathogenesis of intraneural ganglion is controversial, however, the synovial theory that the intraarticular region is the origination of disease has come into the spotlight nowadays. But there are a few researches about intraneural ganglion in foot and ankle. We studied 7cases of intraneural ganglion. We are going to prove the synovial theory by indentifying articular branch of intraneural ganglion. MATERIALS AND METHODS: From August 2003 to May 2011, we evaluated 7 ouf of 8 patients diagnosed as a intraneural ganglion in foot and ankle. The gender ratio were 4 male and 3 female, and the mean age at the time of surgery was 52.9 years. Clinically, we checked pre and post operative symptom, muscle tone and whether loss of muscle tone and sensation exists. We analyzed surgical records and preoperative MRI and compared those with intra-operative finding. RESULTS: In MRI analysis of 7cases, the connection around the joints were confirmed, and 1 case was confirmed in the retrospective analysis of MRI. Intraneural ganglions occurred in medial plantar nerve 3 cases, lateral plantar nerve 1 case, superficial peroneal nerve 1 case and sural nerve 1 case. We could not found recurrence during the follow up periods. Most patients relieved pain after operation, but recovery of sensation was unsatisfactory. We could find some cases pathological finding of the nerve intraoperatively, and clinical result of that cases was poor. CONCLUSION: Intraneural ganglion can occur in various parts in foot and ankle. We concluded that the intranneural ganglion originated from joint by identifying the artichlar branch of ganglion. Due to its small size, it is difficult to find articular branch in operation field. But we do our best to find and remove articular branch. Currently, considering the small amount of research in foot and ankle, more research about articular brach is needed.