The successful arthroscopic treatment of suprascapular 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.

Intraneural ganglion cyst of the lumbosacral plexus mimicking L5 radiculopathy: A case report

BACKGROUND

Intraneural ganglion cysts are benign gelatinous masses that form within the epineurium of a peripheral nerve. Only few cases of intraneural ganglion cyst arising from the hip joint have been reported.

CASE SUMMARY

A previously healthy 65-year-old woman who had been experiencing left buttock pain radiating to the dorsum of the foot for 2 years visited our clinic. Prior to visiting the clinic, she underwent lumbar spine magnetic resonance imaging and received physiotherapy, pain killers, and epidural injections based on a presumptive diagnosis of spinal stenosis for 2 years in other hospitals. Repeat magnetic resonance imaging revealed joint connection of the articular branch of the hip joint and rostral extension of the cyst along the L5 spinal nerve near the L5-S1 neural foramen. The patient was diagnosed with intraneural ganglion cyst arising from the articular branch of the hip joint based on high-resolution magnetic resonance neurography. Using the arthroscopic approach, a cystic opening within the intra-articular space was detected, and cyst decompression was then performed. The pain in the left leg was significantly relieved during the 6-mo follow-up.

CONCLUSION

Although intraneural ganglion cysts arising from the hip joint are rare, they can cause typical radicular pain and mimic common L5 radiculopathy. Typical cyst ascent phenomenon starting from the termination of the articular branch on magnetic resonance imaging is a crucial finding indicative of intraneural ganglion cysts arising from the hip joint.

Clinical Relevance and Immunohistochemical Patterns of Silent Pituitary Adenomas: 10 Years of Single-centre Experience

BACKGROUND

Silent pituitary adenomas are clinically non-functional (i.e., without clinically evident pituitary hormone production).

INTRODUCTION

The aim of this study was to investigate subjects with silent pituitary adenomas for possible variations in their clinical status.

METHODS

A total of 102 patients who had undergone surgery for pituitary adenoma and had been diagnosed with silent pituitary adenoma was included in the study. The patients' preoperative and postoperative hormonal parameters and magnetic resonance imaging (MRI) features were collected, and pathological specimens were re-evaluated.

RESULTS

Immunohistochemistry results of the 102 patients were as follows: hormone-negative adenomas (n=35) 35.5%; FSH+LH-positivity (n=32) 31.3%; ACTH-positivity (n=11) 10.7%; α-subunit- positivity (n= 9) 8.8%; prolactin-positivity (n=8) 7.8%; GH-positivity (n=6) 5.4%; and plurihormonal adenoma (n=1). The mean sizes of SGA, SGHA, and SCA were 28.0±12.7, 30.0±16.0, and 27.7±8.9mm (p>0.05), respectively. With the exception of silent gonadotroph adenomas (SGAs), female gender dominance was shown in patients with silent growth hormone adenoma (SGHA) and silent corticotroph adenoma (SCA). Although no clinical relevance was observed in relation to hormonal excess, preoperative GH (4.21±4.6, vs. 0.27±0.36 p=0.00) was slightly more elevated in SGHA than in GH-negative adenomas. Additionally, preoperative basal ACTH values (47.3±28.7 vs. 23.9±14.4, p=0.003) were also higher in SCA compared to the other types. Our findings revealed SCAs to be of more aggressive behaviour than SGHAs and SGAs due to invasiveness in radiological imaging, their elevated re-operation, and postoperative ACTH values.

CONCLUSION

Silent pituitary adenomas represent a challenging diagnostic tumour group. Careful initial evaluation of patients with pituitary adenomas should consider any mild signs and symptoms of functionality, particularly in cases of GH- and ACTH-secreting adenomas.

"Isolated" Suprascapular Neuropathy: Compression, Traction, or Inflammation?

BACKGROUND

Several hypotheses have been proposed for the pathophysiology of suprascapular nerve (SSN) palsy, including compression, traction, and nerve inflammation.

OBJECTIVE

To provide insight into the pathophysiology of isolated nontraumatic SSN palsy by performing critical reinterpretations of electrodiagnostic (EDX) studies and magnetic resonance (MR) images of patients with such diagnosis.

METHODS

We retrospectively reviewed all patients referred to our institution for the past 20 yr with a diagnosis of nontraumatic isolated suprascapular neuropathy who had an upper extremity EDX study and a shoulder or brachial plexus MR scan. Patient charts were reviewed to analyze their initial clinical examination, and their original EDX study and MR images were reinterpreted by an experienced neurologist and a musculoskeletal radiologist, respectively, both blinded from the authors' hypothesis and from each other's findings.

RESULTS

Fifty-nine patients were included. Fifty of them (85%) presented with at least 1 finding that was inconsistent with an isolated SSN palsy. Forty patients (68%) had signs on physical examination beyond the SSN distribution. Thirty-one patients (53%) had abnormalities on their EDX studies not related to the SSN. Twenty-two patients (37%) had denervation atrophy in other muscles than the spinati, or neural hyperintensity in other nerves than the SSN on their MR scans, without any evidence of SSN extrinsic compression.

CONCLUSION

The great majority of patients with presumed isolated SSN palsy had clinical, electrophysiological, and/or imaging evidence of a more diffuse pattern of neuromuscular involvement. These data strongly support an inflammatory pathophysiology in many cases of "isolated" SSN palsy.

Obturator Intraneural Ganglion Cysts: Joint Connected and Underdiagnosed

BACKGROUND

Intraneural ganglion cysts of the obturator nerve are rare. Our aim is to review cases of obturator intraneural ganglion cysts at our institution and those reported in the literature.

METHODS

We reviewed all cases evaluated by the senior author. A literature search was performed using the PubMed database and Google Scholar with the following terms: "obturator cyst," "obturator intraneural ganglion cyst," and "obturator intraneural ganglia." All cases underwent a retrospective review. Patient demographic data, including age, sex, and presenting signs and symptoms were recorded. Imaging studies were re-evaluated by 2 musculoskeletal radiologists experienced in the diagnosis of intraneural ganglion cysts.

RESULTS

We identified 2 cases of obturator intraneural ganglia at our institution; both were connected to the hip joint. We found 4 cases that were clearly diagnosed as intraneural ganglia in the literature, of which only 1 was recognized by the original authors as being joint connected, but based on our reinterpretation, 3 of 4 were joint connected. An additional 9 cases identified in the literature did not definitely report the nerve-cyst relationship, but based on our reinterpretation, were believed to be intraneural; 8 were joint connected.

CONCLUSIONS

We believe that obturator intraneural ganglion cysts adhere to the principles of the unifying articular theory. They arise from the anteromedial hip joint and extend into an articular branch and can reach the parent obturator nerve. Surgery should address the hip disease and/or the articular branch connection. Not appreciating the pathoanatomy of these cysts can lead to persistent or recurrent cysts.

Paralabral cysts of the shoulder treated with isolated labral repair: effect on pain and radiologic findings

BACKGROUND

Paralabral cysts emanating from posterosuperior labral tears may compress the suprascapular nerve and induce neuropathy. This study prospectively assessed patients with labral tears and symptomatic paralabral cysts treated with isolated labral repair. Pain relief, time to cyst resolution, reversibility of muscular edema, atrophy, fatty infiltration, and bone erosion were evaluated.

METHODS

Forty-seven patients with symptomatic posterosuperior paralabral cysts were treated with isolated labral repair. Magnetic resonance imaging (MRI) was repeated 6 and 12 weeks postoperatively or until cyst resolution. In a subgroup of 15 patients, MRI was performed the day before the operation, the first postoperative day, and at 2 weeks.

RESULTS

Median cyst size was 6.8 cm³ (range, 2.1-88.9; standard deviation [SD], 18.3 cm³). Preoperatively, 20 patients (43%) presented clinical muscle atrophy and radiologic edema on MRI, 8 had fatty infiltration, and 3 presented bony scapular erosion caused by cyst compression. Median time to cyst resolution and regression of muscular edema was 11 weeks (range, 3-20; SD, 8.8 weeks) and 14 weeks (range, 3-52; SD 10.6 weeks), respectively. Preoperative fatty infiltration grade I and II of the supraspinatus and infraspinatus muscles was reduced in two patients. Bony erosions remodeled after cyst resolution. Mean pain ratings (1-10 scale) improved from 7.7 (SD, 1.8) to 1.3 (SD, 1.3; 95% confidence interval of difference, 5.5-6.8; P < .001).

CONCLUSION

Labral repair leads to significant pain relief with cyst resolution within 2 to 3 months in most patients. Secondary muscle pathology (ie, edema, atrophy and fatty infiltration) may be partially or completely reversed. Bony erosion caused by cyst compression may be remodeled after cyst resolution.

Use of a Total Shoulder Arthroplasty in a Patient with Minimally Painful Severe Glenohumeral Arthritis and a Progressive Plexopathy: A Case Report

CASE

A 70-year-old woman presented with severe but minimally painful right glenohumeral osteoarthritis (OA), with progressive weakness and numbness radiating to the right hand. Imaging revealed a large fluid collection extending from the joint to the subcoracoid space, with a mass effect on the brachial plexus. A total shoulder arthroplasty (TSA) and decompression of a ganglion cyst were performed. Follow-up with serial electromyography demonstrated resolution of the brachial plexopathy and restoration of function.

CONCLUSION

Ganglion cysts may arise secondary to severe glenohumeral OA and may compress the surrounding structures, producing a progressive plexopathy. Treatment of the underlying pathology with a TSA may be effective.

Arthroscopic management of suprascapular neuropathy of the shoulder improves pain and functional outcomes with minimal complication rates

PURPOSE

The purpose of this study was to systematically assess the arthroscopic management of suprascapular neuropathy, including the aetiology, surgical decision-making, clinical outcomes, and complications associated with the procedure.

METHODS

Three databases [PubMed, Ovid (Medline), and Embase] were searched. Systematic literature screening and data abstraction was performed in duplicate to present a review of studies reporting on arthroscopic management of suprascapular neuropathy. The quality of the included studies was assessed using level of evidence and the MINORS (Methodological Index for Nonrandomized Studies) checklist.

RESULTS

In total, 40 studies (17 case reports, 20 case series, 2 retrospective comparative studies, and 1 prospective comparative study) were identified, including 259 patients (261 shoulders) treated arthroscopically for suprascapular neuropathy. The most common aetiology of suprascapular neuropathy was suprascapular nerve compression by a cyst at the spinoglenoid notch (42%), and the decision to pursue arthroscopic surgery was most commonly based on the results of clinical findings and investigations (47%). Overall, 97% of patients reported significant improvement in or complete resolution of their pre-operative symptoms (including pain, strength, and subjective function of the shoulder) over a mean follow-up period of 23.7 months. Further, there was a low overall complication rate (4%) associated with the arthroscopic procedures.

CONCLUSION

While most studies evaluating arthroscopic management of suprascapular neuropathy are uncontrolled studies with lower levels of evidence, results indicate that such management provides patients with significant improvements in pain, strength, and subjective function of the shoulder, and has a low incidence of complications. Patients managed arthroscopically for suprascapular neuropathy may expect significant improvements in pain, strength, and subjective function of the shoulder.

LEVEL OF EVIDENCE

Level IV, systematic review of level II to IV studies.

Intraneural cyst of the supraescapular nerve: Atypical cause of peripheral nerve entrapment syndrome. Case report and literature review

OBJECTIVE

Intraneural cysts are benign lesions located within the epineurium of some peripheral nerves and their aetiopathogenesis is controversial. Most are located at the level of the lower limbs. In the upper limbs, the most frequently affected nerve is the ulnar nerve. Suprascapular nerve entrapment syndrome due to the formation of an intraneural cyst is rare. In this article, we show a new case and perform a literature review of intraneural cysts located in the suprascapular nerve.

METHODS

We present a 49-year-old woman with pain in the lateral shoulder region of several months' evolution. A brachial plexus MR showed a tumour of approximately 2×1.5cm, with a cystic appearance, in relation to the upper trunk of the right brachial plexus.

RESULTS

We used a supra-infraclavicular approach. The cystic tumour affected the suprascapular nerve. After locating a zone on the surface without nervous fascicles, we performed a partial resection of the capsule and emptying of the cyst, with a xanthochromic gelatinous content. The anatomopathological examination confirmed the diagnosis of intraneural cyst.

CONCLUSION

The suprascapular nerve is a mixed nerve, coming from the upper trunk. It provides the motor branches to the supraspinatus and infraspinatus muscle. Compression of the suprascapular nerve leads to atrophy of these muscles. This entity is one of the differential diagnoses in a patient with pain irradiating to the shoulder, and its correct treatment often results in complete remission of symptoms.

The cubital tunnel syndrome caused by the intraneural or extraneural ganglion cysts: Case report and review of the literature

Cubital tunnel syndrome is the second most common nerve compression syndrome in peripheral nerve compression disease. Although potential ulnar nerve entrapment can occur at multiple points along its course, such as the arcade of struthers, the medial intermuscular septum, the medial epicondyle, the cubital tunnel, and the deep flexor pronator aponeurosis, the most common site of entrapment is the cubital tunnel. However, cubital tunnel syndrome could also be caused by the occupying masses along the course of ulnar nerve, such as intraneural or extraneural ganglia. The cubital tunnel syndrome caused by intraneural or extraneural ganglion cysts has been rarely reported. In our hospital, there were 184 patients with cubital tunnel syndrome who underwent surgical treatment from January 2010 to January 2014. Of these patients, 16 had extraneural cysts and 3 had intraneural ganglion cysts. The incidence rate of cysts in the cubital tunnel was 10.33%. Electromyography was used as routine examination. Ultrasound was used only in some patients in whom elbow mass was suspected. In the surgery of the cubital tunnel syndrome combined with cyst, if any other cysts were found, we should be remove completely the cyts and decompress the ulnar nerve thoroughly with the ulnar nerve being anterior transposition. These cysts were confirmed by histopathological examination. Finally, we compared the clinical features of patients who had a medial elbow ganglion with those of patients who had only cubital tunnel syndrome. B ultrasound can significantly improve the diagnosis. All patients were followed up for 4 months to 2 years, and the curative effect was good.