Intraneural ganglion cysts of the lower limb

Abstract

Background Intraneural ganglion cysts are rare. They affect the peripheral nerves. According to the most widely accepted theory (articular/synovial theory), the cysts are formed from a capsular defect of an adjacent joint, so that synovial fluid spreads along the epineurium of a nerve branch. This leads to diverse neurological symptoms. We will illustrate this disease based on three of our own cases.

Methods Patients were examined between 2011 and 2018 using lower limb MRI. MRI scans were also performed for the follow-up examinations.

Case studies and Discussion The patients had many symptoms. We were able to accurately detect the intraneural ganglion cysts on MRI and provide the treating surgeons with the basis for the operation to be performed. The success of surgical therapy depends on the resection of the nerve endings supplying the joint as the only way to treat the origin of the disease and prevent recurrence. Based on our case studies, we can support the commonly favored articular/synovial theory.

Key Points:

• Intraneural ganglion cysts can cause diverse neurological symptoms depending on their location.

• The pathogenesis is reasonably explained by the articular/synovial theory, which states that cysts are the result of a capsular defect of a joint.

• MRI is the method of choice for diagnosing intraneural ganglion cysts. However, ultrasound is also important.

• Surgery is the only curative treatment with treatment success being dependent on ligature of the nerve endings supplying the articular branch.

Citation Format

• Fricke T, Schmitt AD, Jansen O. Intraneural ganglion cysts of the lower limb. Fortschr Röntgenstr 2019; 191: 732 – 738

Key words

nervous-peripheral - muscular - intraneural ganglion cyst - neuropathy - MR imaging

• References

• 1 Kim DH, Ryu S. et al. Surgical management and results of 135 tibial nerve lesions at the Louisiana State University Health Sciences Center. Neurosurgery 2003; 53: 1114-1124
• 2 Patel P, Schucany WG. A rare case of intraneural ganglion cyst involving the tibial nerve. Proc (Bayl Univ Med Cent) 2012; 25: 132-135
• 3 Desy NM, Wang H. et al. Intraneural ganglion cysts: a systematic review and reinterpretation of the world's literature. J Neurosurg 2016; 125: 615-630
• 4 Konttinen YT, Tiainen VM. et al. Innervation of the joint and role of neuropeptides. Ann N Y Acad Sci 2006; 1069: 149-154
• 5 Wilson TJ, Hebert-Blouin MN. et al. The nearly invisible intraneural cyst: a new and emerging part of the spectrum. Neurosurg Focus 2017; 42: E10
• 6 Spinner RJ, Hebert-Blouin MN. et al. Extreme intraneural ganglion cysts. J Neurosurg 2011; 114: 217-224
• 7 Spinner RJ, Amrami KK. et al. Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory. J Neurosurg 2007; 107: 296-307
• 8 Silveira CRS, Vieira CGM. et al. Cystic degeneration of the tibial nerve: magnetic resonance neurography and sonography appearances of an intraneural ganglion cyst. Skeletal Radiol 2017; 46: 1763-1767
• 9 Robbins NM, Shah V. et al. Magnetic resonance neurography in the diagnosis of neuropathies of the lumbosacral plexus: a pictorial review. Clin Imaging 2016; 40: 1118-1130
• 10 Scherman BM, Bilbao JM. et al. Intraneural ganglion: a case report with electron microscopic observations. Neurosurgery 1981; 8: 487-490
• 11 Adn M, Hamlat A. et al. Intraneural ganglion cyst of the tibial nerve. Acta Neurochir (Wien) 2006; 148: 885-889 ; discussion 889–890
• 12 Koltzenburg M, Bendszus M. Imaging of peripheral nerve lesions. Curr Opin Neurol 2004; 17 (05) 621-626
• 13 Bendszus M, Koltzenburg M. et al. Sequential MR imaging of denervated muscle: experimental study. AJNR Am J Neuroradiol 2002; 23: 1427-1431
• 14 Lüllmann-Rauch R. Taschenlehrbuch Histologie. Stuttgart: Thieme; 2009
• 15 Kraychete DC, Sakata RK. Painful peripheral neuropathies. Rev Bras Anestesiol 2011; 61: 641-648
• 16 Akcakaya MO, Shapira Y. et al. Peroneal and tibial intraneural ganglion cysts in children. Pediatr Neurosurg 2013; 49: 347-352
• 17 Keser N, Akpinar P. et al. Irreversible Foot Drop as a Consequence of Neglected Knee Pain in an Adolescent with a Peroneal Intraneural Ganglion Cyst. World Neurosurg 2018; 111: 307-310
• 18 Hochman MG, Zilberfarb JL. Nerves in a pinch: imaging of nerve compression syndromes. Radiol Clin North Am 2004; 42: 221-245
• 19 Desy NM, Lipinski LJ. et al. Recurrent intraneural ganglion cysts: Pathoanatomic patterns and treatment implications. Clin Anat 2015; 28: 1058-1069
• 20 Moore KL, Agur AMR. et al. Essential clinical anatomy. Baltimore, MD: Lippincott Williams & Wilkins; 2011
• 21 Roger J, Chauvin F. et al. Synovial cyst of the knee: A rare case of acute sciatic neuropathy. Ann Phys Rehabil Med 2017; 60: 274-276
• 22 Wilson TJ, Amrami KK. et al. Intraneural ganglion cysts: A predictable method to their madness. Ann Phys Rehabil Med 2017; 60: 414-415
• 23 Petchprapa CN, Rosenberg ZS. et al. MR imaging of entrapment neuropathies of the lower extremity. Part 1. The pelvis and hip. Radiographics 2010; 30: 983-1000
• 24 Chhabra A, Flammang A. et al. Magnetic resonance neurography: technical considerations. Neuroimaging Clin N Am 2014; 24: 67-78
• 25 Ahlawat S, Chhabra A. et al. Magnetic resonance neurography of peripheral nerve tumors and tumorlike conditions. Neuroimaging Clin N Am 2014; 24: 171-192
• 26 Chung WJ, Chung HW. et al. MRI to differentiate benign from malignant soft-tissue tumours of the extremities: a simplified systematic imaging approach using depth, size and heterogeneity of signal intensity. Br J Radiol 2012; 85: e831-e836