Deep ulnar intraneural ganglia in the palm

Ganglion cysts of the wrist: A bibliometric analysis review of the top 50 highly cited publications

Introduction

Ganglion cysts (GCs) are a form of benign soft tissue mass commonly seen on the dorsum of the wrist that could also form in the hand. They can cause pain and impede physical activities. Despite extensive studies, there has not been a thorough analysis of the top 50 GC articles. This bibliometric analysis examines the most cited research on GC of the wrist with the aim of uncovering existing trends and future directions in the field.

Methods

The authors conducted a comprehensive search utilizing the Web of Science Core Collection on November 16, 2023, to identify the top 50 cited articles on wrist GC published between 1988 and 2023. Subsequently, data were extracted from each article encompassing details such as the title, authors, first/senior authors, publication year, country, journal, total citations, annual average citations, research setting, funding, study design, level of evidence, and primary outcome.

Results

The predominant publication venue was identified as The Journal of Hand Surgery, with (44 %) originating from the United States, followed by contributions from the United Kingdom (14 %), South Korea (8 %), and China (4 %). Key findings included surgical techniques, diagnostic investigations, patient outcomes, treatment plans, epidemiology, and comparative analyses. Notably, there was a peak in citations in the early 2010s.

Conclusion

In recent decades, significant progress has been made in the study of wrist GC, mostly driven by the United States with an emphasis on surgical techniques and diagnostic investigations.

Cubital Tunnel Syndrome Due to Intraneural Ganglion Cysts of the Ulnar Nerve With Joint-Cyst Connection at the Elbow

BACKGROUND AND OBJECTIVES

The unifying articular theory suggests that intraneural ganglion cysts in the cubital tunnel arise from the elbow joint and are connected to the ulnar nerve through an articular branch. This study aimed to report our clinical experience with these cysts and our surgical findings and outcomes.

METHODS

We retrospectively analyzed 13 patients who underwent surgery for cubital tunnel syndrome caused by an intraneural ganglion cyst of the ulnar nerve. Clinical symptoms, physical examination findings, nerve conduction testing electromyography, plain radiography, and ultrasonography were evaluated before and after surgery. MRI was performed in 2 patients. Cyst decompression, disconnection of the articular branch, and ulnar nerve transposition were performed in all.

RESULTS

The mean follow-up was 29 months. After surgery, local elbow pain and Tinel sign disappeared in all patients, and the average Numerical Rating Scale dropped from 3.7 (2-5) to 0 (0-0). Two-point discrimination testing was normal (<5.0 mm) in 12 patients. Wartenberg sign and "claw hand" deformity became negative, and muscle function and motor nerve conduction velocity were improved in 12 patients. The Medical Research Council muscle strength grade was M4 or M5 in the flexor carpi ulnaris, flexor digitorum profundus of the 4th and 5th digits, and first dorsal interosseous muscle in 12 patients. Postoperative spontaneous potentials including fibrillation and sharp waves, and motor unit recruitment in the first dorsal interosseous muscle were obviously improved. A cystic articular branch was confirmed during surgery in all patients. No cyst recurred clinically or on follow-up ultrasonography.

CONCLUSION

The unifying articular theory of intraneural ganglion cysts applies to those located in the ulnar nerve at the elbow. Surgical disconnection of the articular nerve branch from the ulnar nerve eliminated the pathway for cyst recurrence and achieved good long-term outcomes.

Does complete regression of intraneural ganglion cysts occur without surgery?

PURPOSE

The dynamic nature of intraneural ganglion cysts, including spontaneous expansion and regression, has been described. However, whether these cysts can regress completely in the absence of surgical management has important therapeutic implications. Therefore, we aim to review the literature for cyst regression without surgical intervention.

METHODS

We reviewed our database of 970 intraneural ganglion cysts in the literature to search for evidence of complete regression based on strict radiologic confirmation, either spontaneously, or after percutaneous cyst aspiration or steroid injection.

RESULTS

We did not find any examples of complete regression without surgical treatment that met inclusion criteria. Spontaneous regression was reported in four cases; however, only two cases had follow-up imaging, both of which demonstrated residual cysts. Nineteen cases of percutaneous intervention were found in the literature, 13 of which reported clinical improvement following aspiration/steroid injection; however, only seven cases had available imaging. Only two cases reported complete resolution of cyst on MR imaging at follow-up, but reinterpretation found residual intraneural cyst in both cases.

CONCLUSION

We believe that pathology (structural abnormalities and/or increased joint fluid) always exists at the joint origin of intraneural ganglion cysts which persist even with regression of the cyst. The persistence of a capsular abnormality or defect can lead to recurrence of the cyst in the future, and while imaging may show dramatic decreases in cyst size, truly focused assessment of images will show a tiny focus of persistent intraneural cyst at the joint origin. Thus, expectant management or percutaneous intervention may lead to regression, but not complete resolution, of intraneural ganglion cysts.

Intraneural or extraneural ganglion cysts as a cause of cubital tunnel syndrome: A retrospective observational study

Purpose

Cubital tunnel syndrome caused by ganglion cysts has rarely been reported. The purpose of this study was to evaluate the surgical treatment outcomes of a patient diagnosed with cubital tunnel syndrome caused by intraneural or extraneural cysts and to summarize our experience.

Method

In total, 34 patients were evaluated retrospectively from January 2011 to January 2020 with a follow-up of more than 24 months. Preoperative data, such as demographic data, clinical symptoms, physical examination findings, and laboratory tests, were all recorded and pre-operative and post-operative data were compared. The function was evaluated by the modified Bishop scoring system and the McGowan grade at the last follow-up.

Results

Improvement of interosseous muscle strength, the Visual Analog Scale (VAS), 2-point discrimination (2-PD), electromyogram (EMG) result, Wartenberg sign, claw hand, and weakness could be clearly observed in all patients. Extraneural cysts were completely removed and the pedicles of the cysts were ligated. Intraneural cysts were incised and drained, and part of their cyst walls were removed using a microsurgical technique. All patients underwent anterior subcutaneous transposition (AST). At the last follow-up, McGowan's (0-IIa) grade increased from seven patients (20.6%) preoperatively to 27 patients (79.4%); the excellent and good rate according to the modified Bishop scoring system was 82.4% (28 patients), and all patients had no symptoms of recurrence after surgery.

Conclusion

The treatment of cubital tunnel syndrome caused by intraneural or extraneural cysts achieved good long-term results through extraneural cyst resection or intraneural cyst incision and drainage combined with subcutaneous transposition. Early diagnosis and surgical treatment are essential for the patient's postoperative recovery.

Influential factors of surgical decompression for ulnar nerve neuropathy in Guyon's canal

BACKGROUND

Guyon's canal syndrome is nerve compressive pathology which can lead to sensory and/or motor function deficits. This problem is usually difficult to distinguish from cubital tunnel syndrome and relatively less common than cubital tunnel syndrome. This study evaluated the functional results and patient-reported outcomes following decompression of the ulnar nerve in Guyon's canal.

METHODS

Patients who were diagnosed with Guyon's canal syndrome confirmed by electrodiagnostic studies and underwent nerve decompression surgery were included in this study. The functional improvement by examining the Froment's sign, Wartenberg's sign, static two-point discrimination, and Semmes Weinstein monofilament examination as physical examination scores was evaluated. The visual analogue scale of satisfaction and the disabilities of the arm, shoulder, and hand questionnaire were used for the postoperative patient-reported outcome evaluation.

RESULTS

From 2003 to 2019, 38 cases had been enrolled with a mean age of 53 years, ranging from 19 to 85 years. There were seven patients with comorbidity of diabetes mellitus and 28 patients who received additional neurolysis combined with the Guyon's release procedure. There were 19 patients with a good response to surgery and 10 patients with a poor surgical outcome due to persistent paresthesia or weakness. After statistical analysis, it was revealed that several influential factors could have been related to a compromised functional outcome, including a symptom duration of more than 3 months, combination with additional neurolysis of ipsilateral extremity, and/or comorbidity with diabetes mellitus.

CONCLUSION

It was concluded that promising functional outcomes after surgical release of ulnar neuropathy in Guyon's canal could be achieved if the patients did not need additional neurolysis or the symptom duration was within 3 months.

Acute Ulnar Neurapraxia and Carpal Tunnel Syndrome in the Context of a Distal Radius Fracture

Distal radius fractures, carpal tunnel syndrome, and ulnar nerve compression are common causes of symptoms that result in patients presenting for hand evaluation. This is a unique case of a distal radius fracture leading to both carpal tunnel syndrome and ulnar nerve compression requiring urgent operative management.

A novel mechanism for the formation and propagation of neural tumors and lesions through neural highways

By recognizing anatomic and radiologic patterns of rare and often misdiagnosed peripheral nerve tumors/lesions, we have defined mechanisms for the propagation of neural diseases. The novel concept of the nervous system serving as a complex system of "highways" driving the neural and perineural spread of these lesions is described in three examples: Intraneural dissection of joint fluid in intraneural ganglion cysts, perineural spread of cancer cells, and dissemination of unknown concentrations of neurotrophic/inhibitory factors for growth in hamartomas/choristomas of nerve. Further mapping of these pathways to identify the natural history of diseases, the spectrum of disease evolution, the role of genetic mutations, and how these neural pathways interface with the lymphatic, vascular, and cerebrospinal systems may lead to advances in targeted treatments.

An intraneural ganglion cyst of the ulnar nerve at the wrist: a case report and literature review

Background

Intraneural ganglion cysts of the ulnar nerve at the wrist are rare and poorly understood. We report a case of an intraneural ganglion cyst at the level of the wrist.

Case presentation: A 48-year-old man presented with the complaints of weakness for 6 months and serious aggravation for 1 month in his right hand. After examinations, including ultrasound, the patient was diagnosed with an intraneural ganglion cyst. Intraoperatively, with exposure of the ulnar nerve, we found that the intraneural ganglion cyst was at the level of Guyon’s canal and extended approximately 6 cm proximally. Postoperatively, sensation of the fingers was normal, but atrophy of his muscles and limited straightening of his ring and little fingers were similar to those preoperatively.

Conclusions

Diagnosis of an intraneural cyst before surgery is mostly based on ultrasound and magnetic resonance imaging. Transection of the articular branch is an important measure to prevent recurrence of this cyst. If the ulnar nerve is compressed and causes symptoms, nerve decompression, including removal/aspiration of the cyst, and sometimes external neurolysis of the nerve, are necessary to relieve the symptoms and allow regeneration of the nerve. However, these should be performed without damaging the nerve fascicles.

Isolated compression of the ulnar motor branch due to carpal joint ganglia: clinical series, surgical technique and postoperative outcomes

The entrapment of the ulnar nerve in Guyon's canal (GC) is a well-known wrist canalicular syndrome which is usually followed by a gradual combination of both sensitive and motor symptomatology. However, GC nerve compression could also cause a pure hand motor dysfunction. This condition, less frequent than the classic Guyon's syndrome, can be difficult to diagnose. Authors report a case series of eight patients affected by isolated compression of the ulnar nerve motor branch, due to piso-triquetrum or triquetro-hamate joint ganglia. Surgical technique and postoperative outcomes are discussed in this paper. The isolated compression of the ulnar nerve motor branch is a very rare clinical condition which is often linked to several causes. The rarity of the pathology is probably due to lack of knowledge and therefore to the difficulty in formulating a correct diagnosis. Surgical treatment appears to be decisive in most cases, although late diagnosis often leads to incomplete functional recovery.

Peripheral nerve tumors of the hand: Clinical features, diagnosis, and treatment

The majority of the tumors arising from the peripheral nerves of the hand are relatively benign. However, a tumor diagnosed as malignant peripheral nerve sheath tumor (MPNST) has destructive consequences. Clinical signs and symptoms are usually caused by direct and indirect effects of the tumor, such as nerve invasion or compression and infiltration of surrounding tissues. Definitive diagnosis is made by tumor biopsy. Complete surgical removal with maximum reservation of residual neurologic function is the most appropriate intervention for most symptomatic benign peripheral nerve tumors (PNTs) of the hand; however, MPNSTs require surgical resection with a sufficiently wide margin or even amputation to improve prognosis. In this article, we review the clinical presentation and radiographic features, summarize the evidence for an accurate diagnosis, and discuss the available treatment options for PNTs of the hand.

Surgical Treatment of Intraneural Ganglion Cysts of the Ulnar Nerve at the Elbow: Long-Term Follow-up of 9 Cases

BACKGROUND

Intraneural ganglion (IG) cysts have been considered curiosities and their pathogenesis remains controversial.

OBJECTIVE

To clarify ulnar nerve at the elbow (UNE) pathogenesis and long-term surgical outcomes by presenting 9 rare cases of IG of the UNE.

METHODS

Surgical treatment of IG was performed. Clinical symptoms, physical examinations, and electromyogram were evaluated pre- and postoperatively. At least 4 yr of follow-up was performed.

RESULTS

The Tinel's sign became negative and local elbow pain disappeared in all 9 patients after surgery, and the average visual analog scale/score dropped from 4.9 (3-8) to 0 (0-0) after 6.2 d (2-10) on average. Two patients retained positive Froment test, “claw hand” and paresthesias with the 2-point discrimination much different from the contralateral little finger. Postoperative the UK Medical Research Council muscle strength score (MRC) grades of the flexor carpi ulnaris and the flexor digitorum profundus muscle of the fourth and fifth digits recovered to M4-M5 from M0-M2 in all 9 patients. The postoperative MRC grades of the third to fourth lumbrical muscles, the interossei, and the hypothenar recovered to M3-M5 from M0-M2 in 7 patients. Cystic articular branch (CAB) was found in all 9 patients intraoperatively. No symptomatic recurrence of IG was seen. The mean motor nerve conduction velocity of ulnar nerve across the elbow recovered from 5.3 to 41.2 m/s.

CONCLUSION

A unifying articular theory is responsible for the pathogenesis of IG of UNE and disconnection of the CAB would prevent recurrence. The long-term outcome is good after surgical treatment of IG of UNE.

Superficial radial intraneural ganglion cysts at the wrist

Superficial radial intraneural ganglion cysts are rare. Only nine previous cases have been described. We provide two examples with a wrist joint connection and review the literature to provide further support for the unifying articular (synovial) theory for the pathogenesis and treatment of intraneural ganglia.

Intraneural ganglion cyst of the ulnar nerve in an unusual location: A case report

INTRODUCTION

Intraneural ganglion cysts are benign, mucinous, non-neoplastic lesions of the peripheral nerves. While the most common location of intraneural ganglion cysts is the ulnar nerve and its branches, intraneural ganglion cyst involving the superficial branch of the ulnar nerve has not yet been reported.

PRESENTATION OF CASE

A-25-year-old woman presented with pain and a palpable mass in the hypothenar region of the volar side of her right hand. Her neuromuscular examination was normal. The pain was unresponsive to nonsurgical treatments. After confirming with imaging modalities, the initial diagnosis was considered as an intraneural ganglion cyst arising from superficial ulnar nerve. Excision of the ganglion and exploration of the articular branch (if seen in operation) decision was undertaken by the senior author. Whether MRI or intraoperative exploration, not identified an articular branch.

DISCUSSION

Intraneural ganglion cysts of peripheral nerves may be seen in miscellaneous locations in the body. However, to our knowledge, an intraneural ganglion cyst involving the superficial branch of the ulnar nerve is unique. While a variety of theories have been proposed to enlighten the etiopathogenesis of intraneural ganglia, the latest and most affirmed is the unifying articular (synovial) theory.

CONCLUSION

Intraneural ganglion cysts may be seen on the hypothenar side of the palm. The etiology and treatment of choice are closely associated with each other in this rare disorder. It is important to realize a related articular branch, otherwise the origin of cyst formation remains, and this may cause other para-articular cysts.

Intraneural ganglion cysts: a systematic review and reinterpretation of the world's literature

OBJECTIVE The etiology of intraneural ganglion cysts has been controversial. In recent years, substantial evidence has been presented to support the articular (synovial) theory for their pathogenesis. The authors sought to 1) perform a systematic review of the world's literature on intraneural cysts, and 2) reinterpret available published MR images in articles by other authors to identify unrecognized joint connections. METHODS In Part 1, all cases were analyzed for demographic data, duration of symptoms, the presence of a history of trauma, whether electromyography or nerve conduction studies were performed, the type of imaging, surgical treatment, presence of a joint connection, intraneural cyst recurrence, and postoperative imaging. Two univariate analyses were completed: 1) to compare the proportion of intraneural ganglion cyst publications per decade and 2) to assess the number of recurrences from 1914 to 2003 compared with the years 2004-2015. Three multivariate regression models were used to identify risk factors for intraneural cyst recurrence. In Part 2, the authors analyzed all available published MR images and obtained MR images from selected cases in which joint connections were not identified by the original authors, specifically looking for unrecognized joint connections. Two univariate analyses were done: 1) to determine a possible association between the identification of a joint connection and obtaining an MRI and 2) to assess the number of joint connections reported from 1914 to 2003 compared with 2004 to 2015. RESULTS In Part 1, 417 articles (645 patients) were selected for analysis. Joint connections were identified in 313 intraneural cysts (48%). Both intraneural ganglion cyst cases and cyst recurrences were more frequently reported since 2004 (statistically significant difference for both). There was a statistically significant association between cyst recurrence and percutaneous aspiration as well as failure to disconnect the articular branch or address the joint. In Part 2, the authors identified 43 examples of joint connections that initially went unrecognized: 27 based on their retrospective MR image reinterpretation of published cases and 16 of 16 cases from their sampling of original MR images from published cases. Overall, joint connections were more commonly found in patients who received an MRI examination and were more frequently reported during the years 2004 to 2015 (statistically significant difference for both). CONCLUSIONS This comprehensive review of the world's literature and the MR images further supports the articular (synovial) theory and provides baseline data for future investigators.

MR Imaging of the Nerves of the Upper Extremity: Elbow to Wrist

The peripheral nervous system is susceptible to a diverse array of pathologic insults, broadly categorizable into those entities intrinsic to the nerves themselves, either primarily arising within the nerve(s) or direct involvement of the nerve(s) secondary to a systemic process, and those processes external to the nerve(s) proper but affecting them extrinsically via mass effect, such as entrapment neuropathies. The soft tissue contrast inherent to high-quality MR imaging allows for outstanding visualization of the peripheral nervous system and surrounding structures. This review focuses on the use of MR imaging in the diagnosis and management of peripheral nerve disorders of the upper extremity.

Ulnar nerve entrapment at the wrist

Presentation of ulnar nerve entrapment at the wrist varies based on differential anatomy and the site or sites of compression. Therefore, an understanding of the anatomy of the Guyon canal is essential for diagnosis in patients presenting with motor and/or sensory deficits in the hand. The etiologies of ulnar nerve compression include soft-tissue tumors; repetitive or acute trauma; the presence of anomalous muscles and fibrous bands; arthritic, synovial, endocrine, and metabolic conditions; and iatrogenic injury. In addition to a thorough history and physical examination, which includes motor, sensory, and vascular assessments, imaging and electrodiagnostic studies facilitate the diagnosis of ulnar nerve lesions at the wrist. Nonsurgical management is appropriate for a distal compression lesion caused by repetitive activity, but surgical decompression is indicated if symptoms persist or worsen over 2 to 4 months.

Unusual peroneal nerve palsy caused by intraneural ganglion cyst: pathological mechanism and appropriate treatment

The origin of the peroneal intraneural ganglion and the outcome of treatment are still controversial. We report here three cases with peroneal intraneural ganglion and discuss the appropriate treatment. In our cases, 58-, 62-, and 65-year-old patients were operated on with extraneural decompression and epineurotomy within 4 months after onset of drop foot. Two cases demonstrated intraneural ganglion connecting to the articular branch and traversing to the deep and common peroneal nerve. At the 1-year follow-up, paralyzed peroneal nerve could be recovered in all patients even with residual ganglion. We propose correct early diagnosis, simple exoneural dissection, and atraumatic epineurotomy for the successful treatment of peroneal intraneural ganglion. Disruption of the stalk in the articular branch is a key point to prevent recurrence. For early diagnosis, clinicians should be aware of the existence of this rare lesion.

Severe ulnar nerve palsy caused by synovial chondromatosis arising from the pisotriquetral joint: a case report and review of literature

We report here the unique case of 60-year-old man with severe ulnar nerve palsy caused by synovial chondromatosis arising from the pisotriquetral joint. At operation, the tumor entrapped the ulnar nerve proximal to the Guyon canal so that it was severely paralyzed. The ulnar neurovascular bundle could be separated safely under the microscope. To our knowledge, this type of severe neuropathy has not been reported before. Although synovial chondromatosis associated with peripheral nerve neuropathy is extremely rare, we should be aware of the existence of this type of compression neuropathy in the upper limb.