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Mateusz Gładysz

Ganglion excision

· MD · FEBOPRAS · FEBHS

A ganglion is a mucin-filled cyst joined by a stalk to a joint capsule or tendon sheath; it is the commonest lump of the hand and wrist, accounting for 50 to 70 per cent of masses there.

Last clinically reviewed

1. Indications

  • A dorsal or volar wrist ganglion that is painful, limits function or troubles the patient by its appearance, after observation has been discussed. Observation is a sound first choice: in a prospective cohort of dorsal ganglia followed for a mean of 70 months, neither excision nor gave a significant long-term benefit over no treatment, although satisfaction was higher after excision even when the ganglion recurred1.
  • Recurrence after aspiration. Excision reduced recurrence by 76 per cent compared with aspiration in randomised trials2, and a ganglion that recurs after one aspiration rarely resolves with further aspirations3.
  • A volar wrist ganglion only after a frank discussion: at 2 and 5 years, symptoms did not differ whether a palmar ganglion was excised, aspirated or left alone, and 20 of 39 untreated ganglia disappeared4.
  • An occult dorsal ganglion — dorsal wrist pain with tenderness over the and no palpable mass. Limited dorsal capsulectomy relieved pain in 7 of 8 patients in the original series5; MRI supports the diagnosis but missed about one in six at surgery6.
  • A mucous cyst that is painful, deforms the nail, thins the overlying skin or drains. Surgery gave the highest cure rate of any treatment in a systematic review (95 per cent, against 61 per cent for corticosteroid injection)7. An infected mucous cyst can cause septic arthritis of the distal interphalangeal joint, which is an argument for excision8; in another series, complications occurred only in cysts with a previous fistula9.
  • A flexor sheath (seed) ganglion that is tender on grip. Recurrence was 89 per cent after multiple punctures and none after excision in a series of 12810.

2. Contraindications

  • Active infection of the hand or of the cyst. An infected mucous cyst with septic arthritis is treated as an infection, by debridement, open packing and antibiotics8.
  • An uncertain diagnosis. A firm, rapidly growing or atypical mass needs imaging first: radiography and ultrasound look for joint disease or a solid lesion, and MRI is kept for suspected occult ganglia or solid tumours, including sarcoma11. After a case of scaphoid subluxation, one group suggested a radiograph as part of the routine work-up of a dorsal ganglion12.
  • Relative: an asymptomatic ganglion in a patient who wants reassurance only. Many are found incidentally: radiopalmar ganglia were present on 29 per cent of wrist MRI scans, and 85 per cent of the patients had no radiopalmar symptoms13.

3. Relevant anatomy

Dorsal wrist
Dissection under magnification showed a one-way, valve-like communication between the scapholunate joint and the ganglion, and the classical operation excised all attachments to the scapholunate ligament14. The origin is not always there: 42.8 per cent of dorsal ganglia arose from the capitate–lunate joint in one series15. The terminal branch of the runs on the floor of the fourth extensor compartment, in the field of the deep dissection; excising the scapholunate interosseous ligament could lead to scapholunate dissociation16. Branches of the and the dorsal ulnar sensory nerve cross the superficial field.
Volar wrist
Of 104 anterior wrist ganglia, 68 arose from the radioscaphoid joint and 35 from the 17. On ultrasound, 63 per cent of all wrist ganglia lay between the radial artery and flexor carpi radialis18, and on MRI 168 of 308 radiopalmar ganglia were in direct contact with the radial vascular bundle13. The lies ulnar to the field and is at risk unless it is positively identified19.
Mucous cyst
The cyst lies on the dorsum of the distal interphalangeal joint between the joint and the nail fold. Osteophytes were found in all 20 digits in which the joint was explored, and the cyst lay over the in all but two of 26 digits20. Radiographic osteoarthritis of the joint was present in 74.5 per cent of patients in another series21; the form the clinical . The terminal extensor tendon inserts on the distal phalanx beside the cyst and is at risk during its excision.
Flexor sheath
In one series, 69 per cent of lay on the and A2 pulleys10, between the .

4. Patient positioning

Supine, with the arm on a hand table. For a dorsal ganglion the forearm is pronated; for a volar ganglion it is supinated; for a finger cyst the hand lies flat on the table. The ganglion and the incision are marked before infiltration.
Wrist ganglia are excised under local infiltration of 0.4 per cent lignocaine with 1:250,000 adrenaline, within 1 to 1.5 mL/kg, injected along the incision and around the ganglion but not into it, with an upper-arm tourniquet at 250 mmHg. with buffered 1 per cent lignocaine and 1:100,000 adrenaline, without a tourniquet, and general anaesthesia are the alternatives. In a prospective comparison, WALANT gave a shorter operation, less diathermy use and lower pain scores than general anaesthesia with a tourniquet, with no difference in stalk visualisation22; in a retrospective series, recurrence and complications did not differ between local anaesthesia without a tourniquet and tourniquet-controlled regional or general anaesthesia23. Mucous cysts and flexor sheath ganglia are excised under digital WALANT with the buffered mix, without a finger tourniquet.
No antibiotic prophylaxis is given: this is a clean elective operation without an implant.

5. Approach

  • Dorsal wrist: a transverse incision in a wrist crease over the ganglion, with a longitudinal incision as the alternative; the published technique uses either16.
  • Volar wrist: a longitudinal or zigzag incision over the ganglion on the radial side of the flexor carpi radialis.
  • Mucous cyst: a curvilinear or H-shaped incision over the dorsum of the distal interphalangeal joint, planned to include or spare the thinned skin over the cyst.
  • Flexor sheath ganglion: a transverse or Bruner incision over the cyst at the A1 or A2 pulley.

6. Key steps

  1. 1. Dorsal exposure

    The subcutaneous tissue is spread bluntly. Branches of the superficial radial nerve and the dorsal ulnar sensory branches are protected, the extensor retinaculum is preserved, and the extensor tendons are retracted through the interval in which the cyst presents, such as between extensor pollicis longus and extensor digitorum communis.

  2. 2. Tracing the stalk

    The ganglion is dissected intact from the surrounding tissue and its stalk is traced to its origin at the scapholunate interval or, often, the capitolunate joint or another part of the capsule1415. Identifying the stalk allows the whole ganglion complex to be excised and is meant to prevent recurrence16.

  3. 3. Capsular window and the scapholunate ligament

    The stalk is excised with a window of dorsal capsule about 1 to 2 cm around its base. Scapholunate interosseous ligament fibres are identified and preserved, the joint is inspected and satellite cysts are excised. The capsular window is left open. Of 124 wrist ganglia excised with a 1–2 cm window that was not repaired, 66 patients were followed for a mean of 42 months: recurrence was 10.6 per cent and none developed scapholunate or other instability15. In a retrospective cohort of 189 cysts, capsular closure alone was followed by recurrence in 6 of 44, and its authors suggest that closing the capsule may increase the risk24. The terminal posterior interosseous nerve is not divided routinely; in a retrospective comparison, neurectomy did not change pain, satisfaction or recurrence significantly25.

  4. 4. Volar ganglion

    Through the volar incision the radial artery and its superficial palmar branch are identified, mobilised and protected throughout, and the palmar cutaneous branch of the median nerve is identified and protected. The wall of the ganglion is separated from the radial artery adventitia under direct vision, and the stalk is traced to the radioscaphoid joint, the scaphotrapeziotrapezoid joint, the flexor carpi radialis sheath or the midcarpal joint and excised with a cuff of capsule; the joint is inspected. In a randomised comparison, open excision of 20 radiocarpal volar ganglia was followed by four injuries to a branch of the radial artery; its authors advise that midcarpal volar ganglia be treated by open operation rather than arthroscopically26. Before a volar excision the radial pulse is felt and its relation to the swelling recorded, and an may be recorded; no study of its value before ganglion surgery specifically was found.

  5. 5. Mucous cyst

    The terminal extensor tendon and the germinal matrix are identified and protected. The cyst is excised with its tract to the joint, the dorsal capsule is debrided and the osteophytes are excised with a rongeur, and the joint is irrigated. Subcutaneous excision with osteophyte resection and no skin procedure was followed by recurrence in 1.5 per cent at a mean of 6.6 years, and all nail deformities resolved9. Leaving the osteophytes is an alternative (the brief's "capsule and tract only" option): an osteophyte-sparing technique using a dorsally based flap recurred in 2 of 143 cysts (1.4 per cent)27; simple excision of the cyst alone recurred in 7 of 2528. Where thinned skin is excised, the defect is closed directly or, if it will not close, by a or a ; recurrence after a graft did not differ significantly from primary closure29.

  6. 6. Flexor sheath ganglion

    The digital neurovascular bundles are identified and protected. The cyst is excised with a small window of the sheath or pulley, and the flexor tendons are inspected and their gliding confirmed.

  7. 7. Haemostasis and the specimen

    At the wrist the tourniquet is released (under WALANT there is none), haemostasis is secured with bipolar diathermy and the wound is irrigated. The specimen is not sent for histology when its content is typical clear gelatinous mucin. Pathology agreed with the clinical diagnosis in 98.6 per cent of 429 wrist ganglia, and its authors recommend histology only when the typical fluid is not found30; a second series found 99.6 per cent concordance and reached the same conclusion31.

7. Closure

At the wrist the skin is closed with a 4-0 Monocryl subcuticular suture and Steri-Strips, under a soft non-adherent dressing, wool and crepe, without a splint; a short wrist splint for comfort is an option. A systematic review found no compelling evidence that immobilisation after dorsal ganglion excision improves function32, and after volar excision a plaster slab seemed to be followed by wrist stiffness19.
On the finger the skin is closed with interrupted 5-0 nylon sutures, or the defect is covered by a flap or a full-thickness graft with a tie-over bolster, under a non-adherent and light finger dressing with the distal interphalangeal joint free. A distal interphalangeal extension splint is optional after a mucous cyst; in 394 excisions, splinting did not reduce recurrence33.

8. Aftercare

  • Day case. Elevation when comfortable; immediate finger and wrist movement and light use of the hand from day 1.
  • Paracetamol and an anti-inflammatory regularly for 48 to 72 hours.
  • Wrist: wound check and Steri-Strip removal at 10 to 14 days (GP or dressings clinic).
  • Finger: sutures out at 10 to 14 days; after a mucous cyst, keep the finger dry until review; after a graft the bolster is removed at the planned review.
  • Driving when the wheel can be gripped comfortably and strong analgesics have stopped, usually within 1 to 2 weeks.
  • Desk work when comfortable, usually within the first week; manual work at about 2 weeks.
  • A recurrence usually appears within the first year or two, and the patient returns if the lump comes back.
  • Return advice: increasing pain, swelling, redness, discharge or fever — GP or emergency department.
  • Clinic review at 6 weeks, with histology reviewed there if a specimen was sent.

9. Complications

Recurrence, by approach
Other complications
  • Overall: complications followed 14 per cent of open wrist excisions in pooled data, against 4 per cent after arthroscopic excision2; 8 of 103 patients had a complication after dorsal excision1 and 20 per cent after volar excision4.
  • Radial artery (volar): four injuries to a branch of the radial artery among 20 open radiocarpal excisions26; the palmar superficial branch was lacerated and ligated in two of 16 volar excisions37; partial radial artery injury occurred in 8.9 per cent of 45 arthroscopic volar resections41.
  • Cutaneous nerves: 28 per cent of patients had evidence of damage to the palmar cutaneous branch of the median nerve after volar excision19.
  • Stiffness: transient stiffness is one of the commonest complications after dorsal excision; manipulation is rarely if ever indicated, and in one report it caused rotatory subluxation of the scaphoid12. One in four wrists remained weak after a volar ganglion, whatever the treatment4.
  • Scapholunate instability after excision is almost never seen; Duncan and Lewis reported a single case after dorsal excision42. A painful positive before excision became negative afterwards in 17 of 19 wrists43, so the pre-operative test is recorded.
  • Mucous cyst: residual loss of extension of 5 to 20 degrees at the interphalangeal or distal interphalangeal joint in 17 per cent of digits, a new nail deformity in 7 per cent and pyarthrosis needing arthrodesis in two of 79 patients; a pre-existing nail deformity resolved in 60 per cent40. Infection followed 10.4 per cent of in-office excisions44.

10. Evidence

Observation, aspiration and excision
The two prospective cohorts of Dias and colleagues describe the natural history: about half of untreated palmar ganglia disappeared, symptoms at 2 and 5 years did not depend on treatment, and excision gave no significant long-term benefit for dorsal ganglia over no treatment, although patients who had excision were more satisfied41. In randomised trials excision reduced recurrence by 76 per cent compared with aspiration2; adding a steroid to aspiration did not change the 33 per cent success rate3.
Open or arthroscopic
Pooled data across all studies favour arthroscopy (recurrence 6 against 21 per cent)2, but the randomised trial and a meta-analysis restricted to comparative studies found no difference in recurrence3536. Arthroscopy shortens time off work after volar excision (10 against 23 days in one trial)26 and carries its own risks, including partial radial artery injury; complications were associated with ganglia lying distal to the arterial bifurcation and reaching the superficial fascia41.
Technique
No randomised trial of the capsular window, capsular repair or posterior interosseous neurectomy was found. Leaving a 1–2 cm window unrepaired produced no instability in a long-term series15; capsular closure alone was followed by more recurrences in one retrospective series (6 of 44), without a statistical test24; neurectomy showed no significant effect25. Recurrence varies with the surgeon: in 628 excisions it ranged from 2 to 11 per cent between three surgeons38.
Mucous cyst
Surgery gave the highest cure rate of any treatment7, and the lowest recurrence follows techniques that deal with the joint — osteophyte resection with debridement9 or an osteophyte-sparing dorsally based flap27 — rather than simple excision of the cyst28. The cyst is associated with osteoarthritis of the joint, probably driven by its osteophytes, and joint debridement with cyst removal is the most effective way to prevent recurrence45.
For patients — plain-language summary
A ganglion is a lump of jelly joined to a joint or tendon lining by a thin stalk; it is not a cancer. About half go away without treatment, and leaving one alone is usually safe. Draining it with a needle is quick, but the lump often returns. If it is painful or troublesome, it can be removed as a day case: a wrist ganglion under local anaesthetic with a cuff on the upper arm, and a finger cyst with numbing medicine alone. The stalk is followed to the joint and removed with a small window of the joint lining. For a mucous cyst on a finger, the small bony spurs of the worn end joint are trimmed as well. You can use the hand for light tasks from the first day, usually without a splint, and most people return to desk work within a week and to manual work after about 2 weeks. The lump can still come back — after about 1 in 5 open operations on the wrist in pooled studies — and ganglions on the front of the wrist, close to the radial artery, carry more risk of complications.

FAQ Frequently asked questions

Am I awake for the operation?
Yes, usually. A wrist ganglion is removed under local anaesthetic injected around the lump, with a cuff on the upper arm; general anaesthesia or WALANT are alternatives. A finger cyst is removed with numbing medicine containing adrenaline and no cuff. You go home the same day.
Will the ganglion come back?
It can. In pooled studies, about 1 in 5 wrist ganglia came back after open excision, against about 6 in 10 after needle drainage. In two series, only 1 to 3 in 100 mucous cysts came back after excision. A recurrence usually appears within the first year or two.
Is keyhole surgery better?
Not clearly. In a randomised trial and a review of comparative studies, recurrence after keyhole (arthroscopic) excision was similar to open excision. Keyhole surgery allowed a faster return to work but took longer. It is an alternative to discuss; this page describes the open operation.
Is a ganglion on the front of the wrist different?
Yes. It often lies against the radial artery, which is protected throughout the operation. In one study, complications and recurrence were more common than for back-of-wrist ganglia, and in one study symptoms at 5 years were the same whether the lump was removed, drained or left alone.
When can I use my hand?
Straight away for light tasks, usually without a splint. Most people return to desk work within the first week and to manual work after about 2 weeks. The wound is checked at 10 to 14 days and you are seen in clinic at 6 weeks.

References

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