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Sonographic evaluation of intramuscular ganglia
ClinicalRadiology(1995) 50, 235-236
Sonographic Evaluation of Intramuscular Ganglia S. BIANCHI, A. ZWASS*, I. F. ABDELWAHAB~', C. G. MAZZOLA:~, M. OLIVIERIw and F. RETTAGLIATAw
Department of Radiology, E.O. Ospedali Galliera, Genova, Italy, *Department of Radiology, Columbia Presbyterian Medical Center, New York, NY, USA, ~Department of Radiology, Mount Sinai Medical Center, New York, NY, USA, ~Department of Orthopaedics, Ospedale di Lavagna, Genova, Italy, and w of Orthopaedics, E.O. Ospedali Galliera, Genova, Italy The study presents the ultrasound appearance of the intramuscular ganglia arising from the superior tibio-fibular joint. An oval, anechoic septated mass with distal sound enhancement in the antero-lateral aspect of the leg was seen in five examined patients. In all the cases, ultrasound-guided needle aspiration was performed and viscous fluid characteristic of ganglia was obtained. All the patients were treated by surgical excision of mass. Local recurrence, which occurred in three cases, was confirmed by ultrasound. The study indicates that ultrasound is useful in diagnosing intramuscular ganglia, in planning the treatment, and in the follow-up examination. Ultrasound-guided needle aspiration is a helpful technique in confirming the diagnosis. Bianchi, S., Zwass, A., Abdelwahab, I.F., Mazzola, C.G., Olivieri, M. & Rettagliata, F. (1995). Clinical Radiology 50, 235-236. Sonographic Evaluation of Intramuscular Ganglia
Accepted for Publication 5 December 1994 Cystic masses around the knee are common and may present a diagnostic problem. Popliteal cysts are the most commonly seen of these lesions. Meniscal cysts and the ganglia are much less frequent. Our study presents the ultrasound (US) appearance of intramuscular ganglia (IMG) arising from the superior tibio-fibular joint. PATIENTS AND M E T H O D S Five patients, three males and two females, 23-60 years old, with an average age of 46 years, were referred for US with history of swelling on the lateral aspect of the leg. Swelling was painful in one and painless in four cases. There was no history of trauma. US was performed using a real-time linear array equipment with 7.5 MHz and 10MHz transducers. In every case, the affected leg was scanned in longitudinal and transverse planes. Plain radiographs were obtained in all cases. RESULTS Ultrasound features were of an oval, anechoic septated mass with distal acoustic enhancement in the anterolateral aspect of the leg, having a well defined, hyperechoic wall 1-2.5mm thick (Figs 1 and 2). The largest diameter of the lesions ranged between 1 and 9 cm. All the masses were connected to the superior tibio-fibular joint by a stalk. Two ganglia were located in the anterior tibialis and three in the peroneus longus muscle. In all the cases, US-guided needle aspiration was performed and 5-20 cm 3 of clear, viscous fluid characteristic of ganglia was obtained. Biochemical assessment of the fluid indicated a high concentration of hyaluronic acid. All the patients were treated by surgical excision of mass, including the stalk connecting to the superior tibioCorrespondence to: Alicia Zwass, MD, Department of Radiology, Columbia Presbyterian Medical Center, 630 West 168 Street, New York, NY 10032, USA.
fibular joint. Local recurrence, which occurred in three cases, was confirmed by US. DISCUSSION Ganglia, the most common soft tissue tumours of the hands and wrists, rarely occur near the superior tibiofibular joint [1]. In this location, ganglia involve the muscles, the tendon sheaths or the nerve sheaths [2]. Ganglia are often multiloculated, and they contain viscous, sticky, mucinous material, with a high concentration of hyaluronic acid. Clinically, ganglia present as a painless or, less commonly, a painful mass on the lateral aspect of the leg close to the superior tibio-fibular joint. The ganglia may be intramuscular, most commonly involving the tibialis anterior and the peroneus longus muscles [3-5]. The aetiology is unknown, but trauma, synovial herniation and mucoid tissue degeneration have been postulated as causes [1,6]. There have been reports of ganglia originating in the common peroneal nerve sheath. The nerve or its branches may also be involved secondary to compression or infiltration, causing weakness, foot drop or, less commonly, sensory impairment [5,7-10]. On US examination, IMG appears as an anechoic, well defined, septated mass with good through transmission. The wall is echogenic and slightly irregular, which distinguishes these ganglia from those of the hand and wrist [11,12]. The proximal aspect of the lesion is connected through the stalk with the superior tibio-fibular joint, without demonstrable communication with synovial cavity. Other imaging techniques such as CT [13,14] and magnetic resonance imaging [15] can be useful; however, they are more costly, not easily available, and ionizing radiation is involved in CT examination. The differential diagnosis includes: popliteal cyst, meniscal cyst (Fig. 3), intramuscular myxoma, vascular lesions, benign and malignant soft tissue tumours.
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CLINICAL RADIOLOGY
(a) Fig. 3 Longitudinal sonogram at the proximal-lateral aspect of the leg, showing a cystic mass (curved arrow) located in the subcutaneous soft tissues. Arthroscopy revealed presence of a meniscal cyst. Note that the lesion is located superficially to the fascia of the anterior tibialis tendon (straight arrow).
CONCLUSIONS
US has proven a very useful tool in diagnosing IMG. It gives an exact location and size of the lesion, and shows its relation with adjacent neurovascular structures. US-guided needle aspiration is a helpful technique in confirming the diagnosis of IMG. US was also employed as a follow-up examination after surgical excision to rule out local recurrence. REFERENCES
(b) Fig. 1 - (a) Longitudinal sonogram on the anterio-lateral aspect of the leg, showing an anechoic, multiloculated, septated lesion with good through transmission consistent with ganglion. (b) Transverse sonogram at the level of the superior tibio-fibular joint, demonstrating a stalk (arrows) connecting the joint with the ganglion. TIBIA, Tibia; PER, fibula; G, ganglion.
Fig. 2 - Longitudinal sonogram showing relationship between the ganglion (GANGL), the peroneal nerve (arrow), and the tibialis anterior artery (ART). Note the characreristic location of the lesion.
1 McEvedy B. Simple ganglion. British Journal of Surgery 1962;49: 585 593. 2 Friedlander HL. Intraneural ganglion of the tibial nerve. Journal of Bone and Joint Surgery (Am) 1967;48:519 522. 3 Muckart RD. Compression of the common peroneal nerve by intramuscular ganglion from the superior tibio-fibular joint. Journal of Bone and Joint Surgery (Br) 1976;58:241-244. 4 Grooks DM. Nerve compression by simple ganglia. Journal of Bone and Joint Surgery (Br) 1952;34:391-400. 5 Stener B. Unusual ganglion cysts in the neighbourhood of the knee joint. Acta Orthopaedica Scandinavica 1969;40:392-401. 6 Barrie HJ, Barrington W, Colwill JC et al. Ganglion migrans of the proximal tibio-fibular joint causing lesions in the subcutaneous tissue, muscle, bone or peroneal nerve: report of three cases and review of the literature. Clinical Orthopaedics 1980;149:211-216. 7 Stack RE, Bianco A J, MacCarty CS. Compression of the common peroneal nerve ganglion cyst. Journal of Bone and Joint Surgery (Am) 1965;47:773-778. 8 Barret R, Cramer F. Tumors of the peripheral nerves and so-called "Ganglia" of the peroneal nerve. Clinical Orthopaedics 1963;27: 135-146. 9 Clark K. Ganglion of the lateral popliteal nerve. Journal of Bone and Joint Surgery (Br) 1961;43:460-468. 10 Parkes A. Iutraneural ganglion of the lateral popliteal nerve. Journal of Bone and Joint Surgery (Br) 1961;43:784-790. 11 Bianchi S, Abdelwahab IF, Zwass A e t al. Sonographic findings in examination of digital ganglia: retrospective study. Clinical Radiology 1993;48:392-401. 12 Bianchi S, Abdelwahab IF, Zwass A et al. Ultrasonographic evaluation of wrist ganglia. Skeletal Radiology 1994;23:201-203. 13 Burk DL, Dalinka MK, Kanal E et al. Meniscal and ganglion cysts of the knee: MR evaluation. American Journal of Roentgenology 1988;150:331-336. 14 Lee KR, Cox GG, Neff JR et aL Cystic masses of the knee: arthrographic and CT evaluation. American Journal of Roentgenology 1987;148:329-334. 15 Feldman F, Singson RD, Staron RB. Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiology 1989;18:353-358.
Sonographic Evaluation of Intramuscular Ganglia S. BIANCHI, A. ZWASS*, I. F. ABDELWAHAB~', C. G. MAZZOLA:~, M. OLIVIERIw and F. RETTAGLIATAw
Department of Radiology, E.O. Ospedali Galliera, Genova, Italy, *Department of Radiology, Columbia Presbyterian Medical Center, New York, NY, USA, ~Department of Radiology, Mount Sinai Medical Center, New York, NY, USA, ~Department of Orthopaedics, Ospedale di Lavagna, Genova, Italy, and w of Orthopaedics, E.O. Ospedali Galliera, Genova, Italy The study presents the ultrasound appearance of the intramuscular ganglia arising from the superior tibio-fibular joint. An oval, anechoic septated mass with distal sound enhancement in the antero-lateral aspect of the leg was seen in five examined patients. In all the cases, ultrasound-guided needle aspiration was performed and viscous fluid characteristic of ganglia was obtained. All the patients were treated by surgical excision of mass. Local recurrence, which occurred in three cases, was confirmed by ultrasound. The study indicates that ultrasound is useful in diagnosing intramuscular ganglia, in planning the treatment, and in the follow-up examination. Ultrasound-guided needle aspiration is a helpful technique in confirming the diagnosis. Bianchi, S., Zwass, A., Abdelwahab, I.F., Mazzola, C.G., Olivieri, M. & Rettagliata, F. (1995). Clinical Radiology 50, 235-236. Sonographic Evaluation of Intramuscular Ganglia
Accepted for Publication 5 December 1994 Cystic masses around the knee are common and may present a diagnostic problem. Popliteal cysts are the most commonly seen of these lesions. Meniscal cysts and the ganglia are much less frequent. Our study presents the ultrasound (US) appearance of intramuscular ganglia (IMG) arising from the superior tibio-fibular joint. PATIENTS AND M E T H O D S Five patients, three males and two females, 23-60 years old, with an average age of 46 years, were referred for US with history of swelling on the lateral aspect of the leg. Swelling was painful in one and painless in four cases. There was no history of trauma. US was performed using a real-time linear array equipment with 7.5 MHz and 10MHz transducers. In every case, the affected leg was scanned in longitudinal and transverse planes. Plain radiographs were obtained in all cases. RESULTS Ultrasound features were of an oval, anechoic septated mass with distal acoustic enhancement in the anterolateral aspect of the leg, having a well defined, hyperechoic wall 1-2.5mm thick (Figs 1 and 2). The largest diameter of the lesions ranged between 1 and 9 cm. All the masses were connected to the superior tibio-fibular joint by a stalk. Two ganglia were located in the anterior tibialis and three in the peroneus longus muscle. In all the cases, US-guided needle aspiration was performed and 5-20 cm 3 of clear, viscous fluid characteristic of ganglia was obtained. Biochemical assessment of the fluid indicated a high concentration of hyaluronic acid. All the patients were treated by surgical excision of mass, including the stalk connecting to the superior tibioCorrespondence to: Alicia Zwass, MD, Department of Radiology, Columbia Presbyterian Medical Center, 630 West 168 Street, New York, NY 10032, USA.
fibular joint. Local recurrence, which occurred in three cases, was confirmed by US. DISCUSSION Ganglia, the most common soft tissue tumours of the hands and wrists, rarely occur near the superior tibiofibular joint [1]. In this location, ganglia involve the muscles, the tendon sheaths or the nerve sheaths [2]. Ganglia are often multiloculated, and they contain viscous, sticky, mucinous material, with a high concentration of hyaluronic acid. Clinically, ganglia present as a painless or, less commonly, a painful mass on the lateral aspect of the leg close to the superior tibio-fibular joint. The ganglia may be intramuscular, most commonly involving the tibialis anterior and the peroneus longus muscles [3-5]. The aetiology is unknown, but trauma, synovial herniation and mucoid tissue degeneration have been postulated as causes [1,6]. There have been reports of ganglia originating in the common peroneal nerve sheath. The nerve or its branches may also be involved secondary to compression or infiltration, causing weakness, foot drop or, less commonly, sensory impairment [5,7-10]. On US examination, IMG appears as an anechoic, well defined, septated mass with good through transmission. The wall is echogenic and slightly irregular, which distinguishes these ganglia from those of the hand and wrist [11,12]. The proximal aspect of the lesion is connected through the stalk with the superior tibio-fibular joint, without demonstrable communication with synovial cavity. Other imaging techniques such as CT [13,14] and magnetic resonance imaging [15] can be useful; however, they are more costly, not easily available, and ionizing radiation is involved in CT examination. The differential diagnosis includes: popliteal cyst, meniscal cyst (Fig. 3), intramuscular myxoma, vascular lesions, benign and malignant soft tissue tumours.
236
CLINICAL RADIOLOGY
(a) Fig. 3 Longitudinal sonogram at the proximal-lateral aspect of the leg, showing a cystic mass (curved arrow) located in the subcutaneous soft tissues. Arthroscopy revealed presence of a meniscal cyst. Note that the lesion is located superficially to the fascia of the anterior tibialis tendon (straight arrow).
CONCLUSIONS
US has proven a very useful tool in diagnosing IMG. It gives an exact location and size of the lesion, and shows its relation with adjacent neurovascular structures. US-guided needle aspiration is a helpful technique in confirming the diagnosis of IMG. US was also employed as a follow-up examination after surgical excision to rule out local recurrence. REFERENCES
(b) Fig. 1 - (a) Longitudinal sonogram on the anterio-lateral aspect of the leg, showing an anechoic, multiloculated, septated lesion with good through transmission consistent with ganglion. (b) Transverse sonogram at the level of the superior tibio-fibular joint, demonstrating a stalk (arrows) connecting the joint with the ganglion. TIBIA, Tibia; PER, fibula; G, ganglion.
Fig. 2 - Longitudinal sonogram showing relationship between the ganglion (GANGL), the peroneal nerve (arrow), and the tibialis anterior artery (ART). Note the characreristic location of the lesion.
1 McEvedy B. Simple ganglion. British Journal of Surgery 1962;49: 585 593. 2 Friedlander HL. Intraneural ganglion of the tibial nerve. Journal of Bone and Joint Surgery (Am) 1967;48:519 522. 3 Muckart RD. Compression of the common peroneal nerve by intramuscular ganglion from the superior tibio-fibular joint. Journal of Bone and Joint Surgery (Br) 1976;58:241-244. 4 Grooks DM. Nerve compression by simple ganglia. Journal of Bone and Joint Surgery (Br) 1952;34:391-400. 5 Stener B. Unusual ganglion cysts in the neighbourhood of the knee joint. Acta Orthopaedica Scandinavica 1969;40:392-401. 6 Barrie HJ, Barrington W, Colwill JC et al. Ganglion migrans of the proximal tibio-fibular joint causing lesions in the subcutaneous tissue, muscle, bone or peroneal nerve: report of three cases and review of the literature. Clinical Orthopaedics 1980;149:211-216. 7 Stack RE, Bianco A J, MacCarty CS. Compression of the common peroneal nerve ganglion cyst. Journal of Bone and Joint Surgery (Am) 1965;47:773-778. 8 Barret R, Cramer F. Tumors of the peripheral nerves and so-called "Ganglia" of the peroneal nerve. Clinical Orthopaedics 1963;27: 135-146. 9 Clark K. Ganglion of the lateral popliteal nerve. Journal of Bone and Joint Surgery (Br) 1961;43:460-468. 10 Parkes A. Iutraneural ganglion of the lateral popliteal nerve. Journal of Bone and Joint Surgery (Br) 1961;43:784-790. 11 Bianchi S, Abdelwahab IF, Zwass A e t al. Sonographic findings in examination of digital ganglia: retrospective study. Clinical Radiology 1993;48:392-401. 12 Bianchi S, Abdelwahab IF, Zwass A et al. Ultrasonographic evaluation of wrist ganglia. Skeletal Radiology 1994;23:201-203. 13 Burk DL, Dalinka MK, Kanal E et al. Meniscal and ganglion cysts of the knee: MR evaluation. American Journal of Roentgenology 1988;150:331-336. 14 Lee KR, Cox GG, Neff JR et aL Cystic masses of the knee: arthrographic and CT evaluation. American Journal of Roentgenology 1987;148:329-334. 15 Feldman F, Singson RD, Staron RB. Magnetic resonance imaging of para-articular and ectopic ganglia. Skeletal Radiology 1989;18:353-358.