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THE SIMPLE GANGLION
769
witling to use these services and to take proffered advice, the production of these foods could be much increased. The livestock potential is by no means fully developed. In some countries large numbers of unproductive animals are still maintained, either for religious reasons or for the prestige which they bring to their were
domestic animals could be controlled and prevented. Should the climate of opinion change-and the report has a long section on education-then the demands for the services owners; in many, much of the disease among
of veterinarians would be far greater than the present veterinary colleges could meet.
THE SIMPLE GANGLION
DIAGNOSIS of that common lesion, the simple ganglion, usually presents little difficulty, but its treatment remains a perplexing problem. The patient’s main worry is often the disfigurement caused by a visible swelling, commonly on the exposed surface near the wrist-joint. The question is how to rid the patient permanently of the lump and yet leave him with little or no resultant scarring. A ganglion may disappear spontaneously. More commonly it vanishes after a blow or aspiration or expression of the jelly-like contents. Such methods are simple, leave no scar, and can be used in the doctor’s surgery or the outpatient department; surgical excision, on the other hand, is more complex, often leaves ugly scars, and may be followed by recurrence. McEvedy 1 has dispelled some of the confusion about how these relatively trivial lesions should be
:
treated. The dorsum of the wrist is by far the commonest site; this is followed by the flexor aspect of the wrist, the finger, and the dorsum of the foot. Ganglia have been described in association with all other joints in the limbs, but not with those of the spinal column. The chance of spontaneous disappearance does not seem to be greater than I in 3. Of the many different causes that have been suggested, one is synovial herniation. But McEvedy studied over 40 cases radiographically after radio-opaque dye had been injected into the cyst, and found that in none were communications with joint cavities or tendon sheaths demonstrable. The X-rays revealed the lesion as " a main cyst with smaller out-pouchings or pseudopodia ". These pseudopodia are readily displayed during surgical excision, and failure to remove them completely is likely to be one cause of recurrence; but dissection of the main cyst with its pseudopodia is relatively simple, as there is a clean plane of cleavage between the cyst wall and surrounding tissues. On its deep aspect the ganglion is firmly adherent to the capsule of a joint or, in those arising in the fingers, to the fibrous flexor sheath. At this attachment, several small cysts are embedded in the fibrous tissue and communicate with the main cyst. Examination under the microscope shows that the wall of the main cyst is formed of fibrous tissue; but no true lining membrane is present. In the smaller cysts, however, McEvedy describes a well-defined lining layer of cubical cells; these flatten and fade away as the main cyst is approached. The mucoid content of a ganglion, being similar to that of synovial-lined cysts, is thought to be modified synovial fluid produced by the lining cells of these capsular cysts. McEvedy suggests that ganglia arise by distension of small burst in the joint capsule. These bursa: may be the result of trauma, direct or indirect; 1.
McEvedy,
B. V. Brit. J. Surg. 1962,
49, 585.
the
accumulate, and then burst
out into the lax form the main surrounding cyst. Seddon2 also held that trauma was a likely xtiological factor. Rupture by firm pressure or a sudden blow appears to be possible in about 50% of ganglia; but, of these, less than half are permanently cured. Aspiration alone only occasionally leads to cure, but McEvedy reports a recurrence-rate of only 18% where aspiration is followed by injection of a sclerosant solution such as ethanolamine. Such treatment has its dangers: firstly, the sclerosant may enter a joint or tendon sheath; and, secondly, leakage of the solution into the surrounding tissues may lead to sloughing of the overlying skin or fibrosis around the neighbouring tendons. No such complications were encountered in McEvedy’s series, and he has never been able to demonstrate any direct communication with joints or tendon sheaths. This method must, however, be used with caution, and X-ray examination after the injection of radio-opaque dye is a wise preliminary measure, although it complicates a simple outpatient procedure; if a sclerosant is to be injected into a lesion arising close to a major joint, this precaution is essential. The injection of hyaluronidase or hydrocortisone seems to be of no value, and the use of radiotherapy 3for such harmless lesions can only be condemned. Excision, which remains the mainstay of treatment, should be planned and executed with the utmost care. A bloodless field is essential for what must be delicate and painstaking dissection. The whole of the cyst, the pseudopodia, and the fibrous capsule from which the ganglion arises must be removed. The area of joint capsule to be excised depends on the amount involved by the capsular cysts. Complications, such as postoperative heematoma, wound infection, and damage to cutaneous nerves and tendons, should not arise when these operations are performed under the best conditions, with full operating-theatre ritual, good lighting, and a bloodless field. Ugly and keloid scarring will be reduced if the incision is planned to coincide with a skin crease. Recurrence-rates after excision have varied from 0 to 50% in different reports. Hand and Patey5 reported a rate of 28% after excisions performed on a series of inpatients, and this seems to be an average figure for treatment carried out under good conditions. The results of different therapeutic measures show that excision remains the treatment of choice, particularly when other methods have been tried without success. But aspiration followed by the injection of a sclerosant solution seems worth trying in view of the low recurrencerate reported by McEvedy. The simpler methods of temporary immobilisation of the related joint or tendons by splints, rupture by a blow, or aspiration produce some diminution in size or temporary improvement but are unlikely to lead to permanent cure. Ganglia related to the larger limb joints are more deeply placed and may present difficulties in diagnosis. When the cyst lies in muscle, a sarcoma is often suspected before operation. Pressure on nerves in the vicinity may lead to areas of paresis or hyposesthesia. Surgical exploration is essential in these cases, and cure by excision seldom difficult. The tissue excised at any operation should be examined histologically, since, rarely, the lesion is found to be a contents
tissue
to
myxosarcoma. 2. 3. 4. 5.
Seddon, H. J. J. Bone Jt Surg. 1952, 34B, 386. Reeves, R. J. Sth. med. J., Alabama, 1944, 37, 584. Woodburne, A. R. Arch. Derm., Chicago, 1947, 56, 407. Hand, B. H., Patey, D. H. Practitioner, 1952, 169, 195.
witling to use these services and to take proffered advice, the production of these foods could be much increased. The livestock potential is by no means fully developed. In some countries large numbers of unproductive animals are still maintained, either for religious reasons or for the prestige which they bring to their were
domestic animals could be controlled and prevented. Should the climate of opinion change-and the report has a long section on education-then the demands for the services owners; in many, much of the disease among
of veterinarians would be far greater than the present veterinary colleges could meet.
THE SIMPLE GANGLION
DIAGNOSIS of that common lesion, the simple ganglion, usually presents little difficulty, but its treatment remains a perplexing problem. The patient’s main worry is often the disfigurement caused by a visible swelling, commonly on the exposed surface near the wrist-joint. The question is how to rid the patient permanently of the lump and yet leave him with little or no resultant scarring. A ganglion may disappear spontaneously. More commonly it vanishes after a blow or aspiration or expression of the jelly-like contents. Such methods are simple, leave no scar, and can be used in the doctor’s surgery or the outpatient department; surgical excision, on the other hand, is more complex, often leaves ugly scars, and may be followed by recurrence. McEvedy 1 has dispelled some of the confusion about how these relatively trivial lesions should be
:
treated. The dorsum of the wrist is by far the commonest site; this is followed by the flexor aspect of the wrist, the finger, and the dorsum of the foot. Ganglia have been described in association with all other joints in the limbs, but not with those of the spinal column. The chance of spontaneous disappearance does not seem to be greater than I in 3. Of the many different causes that have been suggested, one is synovial herniation. But McEvedy studied over 40 cases radiographically after radio-opaque dye had been injected into the cyst, and found that in none were communications with joint cavities or tendon sheaths demonstrable. The X-rays revealed the lesion as " a main cyst with smaller out-pouchings or pseudopodia ". These pseudopodia are readily displayed during surgical excision, and failure to remove them completely is likely to be one cause of recurrence; but dissection of the main cyst with its pseudopodia is relatively simple, as there is a clean plane of cleavage between the cyst wall and surrounding tissues. On its deep aspect the ganglion is firmly adherent to the capsule of a joint or, in those arising in the fingers, to the fibrous flexor sheath. At this attachment, several small cysts are embedded in the fibrous tissue and communicate with the main cyst. Examination under the microscope shows that the wall of the main cyst is formed of fibrous tissue; but no true lining membrane is present. In the smaller cysts, however, McEvedy describes a well-defined lining layer of cubical cells; these flatten and fade away as the main cyst is approached. The mucoid content of a ganglion, being similar to that of synovial-lined cysts, is thought to be modified synovial fluid produced by the lining cells of these capsular cysts. McEvedy suggests that ganglia arise by distension of small burst in the joint capsule. These bursa: may be the result of trauma, direct or indirect; 1.
McEvedy,
B. V. Brit. J. Surg. 1962,
49, 585.
the
accumulate, and then burst
out into the lax form the main surrounding cyst. Seddon2 also held that trauma was a likely xtiological factor. Rupture by firm pressure or a sudden blow appears to be possible in about 50% of ganglia; but, of these, less than half are permanently cured. Aspiration alone only occasionally leads to cure, but McEvedy reports a recurrence-rate of only 18% where aspiration is followed by injection of a sclerosant solution such as ethanolamine. Such treatment has its dangers: firstly, the sclerosant may enter a joint or tendon sheath; and, secondly, leakage of the solution into the surrounding tissues may lead to sloughing of the overlying skin or fibrosis around the neighbouring tendons. No such complications were encountered in McEvedy’s series, and he has never been able to demonstrate any direct communication with joints or tendon sheaths. This method must, however, be used with caution, and X-ray examination after the injection of radio-opaque dye is a wise preliminary measure, although it complicates a simple outpatient procedure; if a sclerosant is to be injected into a lesion arising close to a major joint, this precaution is essential. The injection of hyaluronidase or hydrocortisone seems to be of no value, and the use of radiotherapy 3for such harmless lesions can only be condemned. Excision, which remains the mainstay of treatment, should be planned and executed with the utmost care. A bloodless field is essential for what must be delicate and painstaking dissection. The whole of the cyst, the pseudopodia, and the fibrous capsule from which the ganglion arises must be removed. The area of joint capsule to be excised depends on the amount involved by the capsular cysts. Complications, such as postoperative heematoma, wound infection, and damage to cutaneous nerves and tendons, should not arise when these operations are performed under the best conditions, with full operating-theatre ritual, good lighting, and a bloodless field. Ugly and keloid scarring will be reduced if the incision is planned to coincide with a skin crease. Recurrence-rates after excision have varied from 0 to 50% in different reports. Hand and Patey5 reported a rate of 28% after excisions performed on a series of inpatients, and this seems to be an average figure for treatment carried out under good conditions. The results of different therapeutic measures show that excision remains the treatment of choice, particularly when other methods have been tried without success. But aspiration followed by the injection of a sclerosant solution seems worth trying in view of the low recurrencerate reported by McEvedy. The simpler methods of temporary immobilisation of the related joint or tendons by splints, rupture by a blow, or aspiration produce some diminution in size or temporary improvement but are unlikely to lead to permanent cure. Ganglia related to the larger limb joints are more deeply placed and may present difficulties in diagnosis. When the cyst lies in muscle, a sarcoma is often suspected before operation. Pressure on nerves in the vicinity may lead to areas of paresis or hyposesthesia. Surgical exploration is essential in these cases, and cure by excision seldom difficult. The tissue excised at any operation should be examined histologically, since, rarely, the lesion is found to be a contents
tissue
to
myxosarcoma. 2. 3. 4. 5.
Seddon, H. J. J. Bone Jt Surg. 1952, 34B, 386. Reeves, R. J. Sth. med. J., Alabama, 1944, 37, 584. Woodburne, A. R. Arch. Derm., Chicago, 1947, 56, 407. Hand, B. H., Patey, D. H. Practitioner, 1952, 169, 195.