Ganglion Cyst Treatment & Management

Because the hand and wrist are very visible in day-to-day activity, aesthetics can be an indication for treatment but may favor a less invasive intervention, ^[3] whereas pain, limitation of movement, and nerve palsies are indications for surgical excision. ^[2]

There are few contraindications for ganglion excision. Caution is advised, however, for those few patients who have only one upper extremity and desire elective removal of a cyst. Any postoperative complication will create a substantially larger impact on such patients.

When the ganglion wall is thin, in the early stages, the cyst can be manually compressed until it bursts, and fluid is absorbed; this is the least invasive treatment. ^[3] A slightly more invasive approach, with a cure rate of 40%, is aspiration; cure rate is 85% when a minimum of three aspirations are performed. ^[2]

Corticosteroid injection with aspiration has been indicated by some authors, ^[5] but Thornburg ^[2] asserted that it has not proved beneficial and that it should be avoided in cases of mucous cysts because it can cause further thinning of overlying skin. ^[5] Although 70% of volar retinacular cysts are successfully treated with aspiration, ^[2] radial volar wrist ganglia are often in close contact with the radial artery and are therefore contraindicated for aspiration. ^[5]  Ultrasound-guided aspiration/injection appears to be safe and effective for symptomatic lower-extremity ganglion cysts. ^[15]

Another moderately invasive procedure is cyst puncture. Although it has a 95% cure rate, it is not widely used. In this treatment procedure, a suture is passed through the skin perpendicularly through the cyst and is left there for 3 weeks, increasing the risk of infection. ^[2]

Kim et al cited two case reports in which the application of electroacupuncture for 20 minutes once a week for 8 weeks reduced the size of the wrist ganglion on follow-up ultrasonography while also relieving the accompanying pain. ^[16]

Choice of operation

Open removal has been the surgical treatment of choice for ganglion cyst removal, with arthroscopy offering some benefits, including a reduction in intraoperative risks and postoperative complications. Recurrence is seen with all treatment modalities and has been reported to be as high as 40% following open excision of dorsal wrist ganglia. ^{[4, 6]}

Regardless of whether the ganglion is removed via open surgery or via arthroscopic excision, when a stalk is visualized, it should be completely removed, or the cyst should be removed at the origin to reduce the risk of recurrence. A recurrence rate of 13-40% has been observed following removal of entire cysts, but when a portion of the capsule is removed as well, recurrence rates decrease to as low as 4%. ^[2] Some surgeons close the capsule; however, this can lead to reduced, or loss of, wrist flexion, so most surgeons do not close the resulting defect. ^[2]

Brief splinting of 3-7 days is recommended for both open and arthroscopic ganglionectomy, but it seems that wrist motion within 3-5 days after the procedure can prevent stiffness. ^{[2, 5, 10]} A volar ganglion cyst is much more likely to recur than a dorsal ganglion cyst, ^[4] and care must be taken to protect the radial and ulnar neurovascular bundles because radial artery laceration is the most common vascular complication in volar carpal excision of ganglia. ^[2] (See the images below.)

Compared to an open ganglionectomy, arthroscopy uses smaller incisions and therefore leaves smaller scars; arthroscopy also allows better visualization and easier identification of other intra-articular pathologies, such as triangular fibrocartilage complex (TFCC) tears or ligament injuries. ^[4] The scapholunate interosseous ligament is of concern with open dorsal ganglionectomy, and the arthroscopic procedure provides protection of this ligament and allows for better control of excision. ^[10]

Although arthroscopic excision can be performed for radiocarpal volar ganglia, an open procedure is usually used. ^[9] When surgery is indicated for a mucous cyst, as it would be if there is nail deformity, pain, or skin thinning, it is important to also remove the osteophytes in an effort to significantly reduce the rate of recurrence. ^[2]

Procedure

A local block is not sufficient, and an intravenous regional or axillary block is recommended. Prior to an open procedure, an Allen test is performed to ensure collateral blood flow of radial and ulnar arteries. ^{[2, 10]} Thornburg also recommends the use of loupe magnification, a tourniquet, and bipolar cautery for open volar ganglionectomy. Because of the possibility of radial artery lacerations during volar carpal ganglion excision, careful protection and retraction of the radial artery are important for volar ganglionectomy following a careful dissection of the artery. If during dissection the cyst wall is not easily freed from the artery, it can be left and the remaining cyst and stalk removed. ^[2]

A distraction tower and 2.7-mm arthroscope are used for dorsal ganglion excision. ^[10] The 6R portal and 3-4 or 4-5 portals are most often used, whereas the 1-2 portal is rarely if ever used. ^{[2, 10]} In the Rizzo cohort, the average tourniquet time was 30 minutes, with one case of 18 minutes. ^[10] Aggressive excision, including removal of the stalk and even part of the joint capsule, is important in both surgical techniques for the wrist, but injury to ligaments needs to be avoided. Closure of the capsule is not recommended because of loss of wrist flexion.

A curved transverse incision, as well as T, H, and inverted U incisions, are all appropriate for mucous cyst removal; however, the H incision tends to provide the best visualization of osteophytes, which are recommended to be debrided along with cyst removal. ^[2] Because mucous cysts are intimately associated with the germinal matrix, care should be taken to avoid damaging this structure, which can extend 5 mm proximal to eponychial fold. ^[2]

For both open and arthroscopic wrist procedures, brief immobilization in slight extension for volar ganglion excision and slight flexion for dorsal ganglion excision, ^[5]  followed by early motion, provide the patient with comfort and prevent wrist stiffness. ^[2]  Following mucous cyst removal, immobilization is unnecessary unless debridement harmed the extensor tendon. ^[2]

In open and arthroscopic procedures, wrist stiffness is the most common postoperative complication; however, leaving the capsule open during an open procedure tends to reduce the risk of this complication, as does early motion. ^[2]  Neurovascular injury, especially radial artery laceration, is a possible complication, along with infection, decreased motion, and ligament instability in open excision—namely, of the scapholunate ligament. ^{[2, 4]}