Ganglion cyst removal

Definition

Ganglion cyst removal, or ganglionectomy, is the removal of a fluid-filled sac on the skin of the wrist, finger, or sole of the foot. The cyst is attached to a tendon or a joint through its fibers and contains synovial fluid, which is the clear liquid that lubricates the joints and tendons of the body. The surgical procedure is performed in a doc tor's office. It entails aspiration, or draining fluid from the cyst with a large hypodermic needle. The cyst may also be excised (removed by cutting).

Purpose

Ganglion cysts are sacs that contain the synovial fluid found in joints and tendons. They are the most common forms of soft tissue growth on the hand and are distinguished by their sticky liquid contents. The cystic structures are attached to tendon sheaths via a long thin tube-like arm. About 65% of ganglion cysts occur on the upper surface of the wrist, with another 20%–25% on the volar (palm) surface of the hand. Most of the remaining 10%–15% of ganglion cysts occur on the sheath of the flexor tendon. In a few cases, the cysts emerge on the sole of the foot.

Ganglion cysts have appeared in medical writing from the time of Hippocrates (c. 460–c. 375 B . C .). Their exact cause is unknown. There are some indications, however, that ganglion cysts result from trauma to or deterioration of the tissue lining in the joints that secretes synovial fluid.

A ganglion cyst is usually attached to a tendon or muscle in the wrist or finger (A). To remove it, the skin is cut open (B), the growth is removed (C), and the skin is sutured closed (D). (

Illustration by GGS Inc.

)

Ganglion cysts can emerge quite quickly, and can disappear just as fast. They are benign growths, usually causing problems in the functioning of the joints or tendons of the hand or finger only when they are large. Many people do not seek medical attention for ganglion cysts unless they cause pain, affect the movement of the nearby tendons, or become particularly unsightly.

An old traditional treatment for a ganglion cyst was to hit it with a Bible, since the cysts can burst when struck. Today, cysts are removed surgically by aspiration but often reappear. Surgical excision is the most reliable treatment for ganglion cysts, but aspiration is the more common form of therapy.

Demographics

Ganglion cysts account for 50%–70% of all soft tissue tumors of the hand and wrist. They are most likely to occur in adults between the ages of 20 and 50, with the female: male ratio being about 3: 1. Most ganglion cysts are visible; however, some are occult (hidden). Occult cysts may be diagnosed because the patient feels pain in that part of the hand or has noticed that the tendon cannot move normally. In about 10% of cases, there is associated trauma.

Description

Patients are given a local or regional anesthetic in a doctor's office. Two methods are used to remove the cysts. Most physicians use the more conservative procedure, which is known as aspiration.

Aspiration

• An 18- or 22-gauge needle attached to a 20–30-mL syringe is inserted into the cyst. The doctor removes the fluid slowly by suction.
• The doctor may inject a corticosteroid medication into the joint after the fluid has been withdrawn.
• A compression dressing is applied to the site.
• The patient remains in the office for about 30 minutes.

Excision

Some ganglion cysts are so large that the doctor recommends excision. This procedure also takes place in the physician's office with local or regional anesthetic.

Excision of a ganglion cyst is performed as follows:

• The physician palpates, or feels, the borders of the sac with the fingers and marks the sac and its periphery.
• The sac is cut away with a scalpel.
• The doctor closes the incision with sutures and applies a bandage.
• The patient is asked to remain in the office for at least 30 minutes.

Diagnosis/Preparation

Ganglion cysts are fairly easy to diagnose because they are usually visible and pliable to the touch. They are distinguished from other growths by their location near tendons or joints and by their fluid consistency. Ganglion cysts are sometimes confused with a carpal boss (a bony, non-mobile spur on the top of the wrist), but can usually be distinguished by the fact that they can be moved and are usually less painful for the patient.

The doctor may schedule one or more imaging studies of the hand and wrist. An x-ray may reveal bone or joint abnormalities. Ultrasound may be used to diagnose the presence of occult cysts.

Aftercare

Patients should avoid strenuous physical activity for at least 48 hours after surgery and report any signs of infection or inflammation to their physician. A follow-up appointment should be scheduled within three weeks of aspiration or excision. Excision may result in some stiffness after the surgery and some difficulties in flexing the hand because of scar tissue formation.

Risks

Aspiration has very few complications as a treatment for ganglion cysts; the most common aftereffects are infection or a reaction to the cortisone injection. Complications of excision include some stiffness in the hand and scar formation. Ganglion cysts recur after excision in about 5–15% of cases, usually because the cyst was not completely removed.

Normal results

Aspirated ganglion cysts disappear and cause no further symptoms in 27–67% of cases. They may, however, reoccur and require repeated aspiration. Aspiration combined with an injection of cortisone has more success than aspiration by itself. Excision is a much more reliable procedure, however, and the stiffness that the patient may experience after the procedure eventually goes away. The formation of a small scar is normal.

Morbidity and mortality rates

The only risks for ganglion cyst removal are infections or inflammation due to the cortisone injection. There is a small risk of damage to nearby nerves or blood vessels.

Alternatives

Alternatives to aspiration and excision in the treatment of ganglion cysts include watchful waiting and resting the affected hand or foot. It is quite common for ganglion cysts to fade away without any surgical treatment.

Resources

BOOKS

"Common Hand Disorders." Section 5, Chapter 61 in The Merck Manual of Diagnosis and Therapy , edited by Mark H. Beers, MD, and Robert Berkow, MD. Whitehouse Station, NJ: Merck Research Laboratories, 1999.

Ferri, Fred F. Ferri's Clinical Advisor: Instant Diagnosis and Treatment . St. Louis, MO: Mosby, Inc., 2003.

Ruddy, Shaun, et al. Kelly's Textbook of Rheumatology , 6th ed. Philadelphia, PA: W.B. Saunders, 2001.

PERIODICALS

Tallia, A. F., and D. A. Cardone. "Diagnostic and Therapeutic Injection of the Wrist and Hand Region." American Family Physician 67 (February 15, 2003): 745-750.

OTHER

MDConsult.com. Ganglion Cyst Removal (Ganglionectomy) . http://www.mdconsult.com.

Nancy McKenzie, PhD

WHO PERFORMS THE PROCEDURE AND WHERE IS IT PERFORMED?

Aspiration or excision to treat ganglion cysts is done by primary care doctors as well as orthopedic surgeons. The procedures may be performed in the doctor's office or at an outpatient clinic.

QUESTIONS TO ASK THE DOCTOR

• May I continue to exercise and continue my other regular activities with this cyst?
• Would you recommend removal rather than aspiration?
• How effective is aspiration in preventing these cysts from recurring?
• How successful have excisions been with your patients?