Abstract
Background
While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood.
Materials
We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation.
Results
A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts.
Conclusion
Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.
Similar content being viewed by others
Abbreviations
- FS:
-
Fat suppression
- FSE:
-
Fast spin echo
- GRE:
-
Gradient recalled echo
- MIP:
-
Maximum intensity projection
- MRI:
-
Magnetic resonance imaging
References
Allieu Y, Cenac PE (1989) Peripheral nerve mucoid degeneration of the upper extremity. J Hand Surg Am 14:189–194
Allieu Y, Dersarkissian Y, Teissier J, Kassab A (1987) Neuf cas de dégénérescence mucoïde des nerfs. Complication d’un syndrome canalaire. Rev Chir Orthop 73(11 suppl):243–248 (Fr)
Artico M, Cervoni L, Carloia S, Stevanato G, Mastantuono N, Nucci F (1997) Synovial cysts: clinical and neuroradiological aspects. Acta Neurochir 139:176–181
Blitz NM, Prestridge J, Amrami KK, Spinner RJ (2008) A posttraumatic, joint-connected sural intraneural ganglion cyst-with anew mechanism of intraneural recurrence: a case report. J Foot Ankle Surg 47:199–205
Bowers WH, Doppelt SH (1979) Compression of the deep branch of the ulnar nerve by an intraneural cyst. Case report. J Bone Joint Surg Am 61:612–613
Bowlby AA (1889) Injuries and diseases of nerves and their surgical treatment. J and A Churchill, London
Campailla E (1967) On so-called cystic degeneration of peripheral nerve trunks. G Psichiatr Neuropatol 95:967–976 (It)
Chalidis BE, Sachinis NC, Dimitriou CG (2009) Ulnar nerve penetration by a volar ganglion in the Guyon canal. Plast Reconstr Surg 124:264e–266e
Chen WA, Barnwell JC, Li Y, Smith BP, Li ZJ (2011) An ulnar intraneural ganglion arising from the pisotriquetrial joint: case report. J Hand Surg Am 36:65–67
Chick G, Alnot JY, Silbermann-Hoffman O (2001) Intraneural mucoid pseudocysts. A report of ten cases. J Bone Joint Surg Br 83:1020–1022
Chodkow WN (1926) Ganglien der peripherischen nerven. Zentralbl Chir 53:680 (Ger)
Choi JS, Kim KH, Kwak JH, Park HG, Lee SW (2011) Intraneural ganglion cyst in foot and ankle. J Korean Foot Ankle Soc 15:223–231 (Kor)
Church WS, Langton J (eds) (1884) Saint Bartholomew’s Hospital reports, vol XX. Smith, Elder & Co, London, p 346
Colbert SH, Le MH (2011) Case report: intraneural ganglion cyst of the ulnar nerve at the wrist. Hand 6:317–320
Davis GA, Cox IH (2011) Tibial intraneural ganglia at the ankle and knee: incorporating the unified (articular) theory in adults and children. J Neurosurg 114:236–239
De Santis G, Villani M, Pederzini L, De Luca D, Soragni O, Luchetti R (1986) Su due casi di pseudocisti mucoidi nervei periferici. Chir Organi Mov 71:159–163 (It)
Dubs J (1922) Ganglion der Nervenscheide des n. ulnaris. Dtsch Med Wochenschr 48:68 (Ger)
Foucher G, Berard V, Snider G, Lenoble E, Constantinesco A (1993) Distal ulnar nerve entrapment due to tumors of Guyon’s canal. A series of ten cases. Handchir Mikrochir Plast Chir 25:61–65
Garcia F, Sampedro Costas JJ, Alonso Rodriguez A, Marin M (1976) Compresion motora cubital en el tunel de Guyon por ganglion secundariamente intraneural. Rev Esp Cir Mano 4:69–79 (Sp)
Giele H, Le Viet D (1997) Intraneural mucoid cysts of the upper limb. J Hand Surg Br 22:805–809
Gillies RM, Burrows C (1991) Nerve sheath ganglion of the superficial radial nerve. J Hand Surg Br 16:94–95
Gray DJ, Gardner E (1965) The innervation of the joints of the wrist and hand. Anat Rec 151:261–266
Gurdjian ES, Larsen RD, Lindner DW (1965) Intraneural cyst of the peroneal and ulnar nerves. Report of two cases. J Neurosurg 23:76–78
Ikeda K, Osamura N (2010) Intraneural ganglion of a peripheral nerve. Report of two cases (Japanese). Clin Plast Surg (Jpn) 45:189–191
Inaparthy PK, Anwar F, Botchu R, Jahnich H, Katchburian MV (2008) Compression of the deep branch of the ulnar nerve in Guyon’s canal by a ganglion: two cases. Arch Orthop Trauma Surg 128:641–643
Jaradeh S, Sanger JR, Maas EF (1995) Isolated sensory impairment of the thumb due to an intraneural ganglion cyst in the median nerve. J Hand Surg Br 20:475–478
Jenkins SA (1952) Solitary tumors of peripheral nerve trunks. J Bone Joint Surg Br 34:401–411
Kitamura T, Oda Y, Matsuda S, Kubota H, Iwamoto Y (2000) Nerve sheath ganglion of the ulnar nerve. Arch Orthop Trauma Surg 120:108–109
Matsuda K, Kojima T, Kohno T (1982) Three unusual cases of ganglion. Plast Surg 25:153–157 (Jpn)
Menge M, Tachibana S (1980) Intraneural compression of the ulnar nerve by a ganglion. Handchirurgie 12:15–17 (Ger)
Mohsenipour I, Twerdy K, Grunert V (1986) Intraneurales ganglion des n. ulnaris. Fallbeschreibung Zentralbl Neurochir 47:63–65 (Ger)
Müller G, Mijuz G, Scharfetter F (1971) Ube reine intraneruales ganglion des nervus ulnaris am handgelenk. Schweiz Arch Neurol Neurochir Psychiatr 109:99–105 (Ger)
Munera L, Ricoy JR (1972) Ganglion intraneural del nervio cubital. Rev Esp de Cir Ost 7:317–322 (Sp)
Nummi J, Solonen KA (1974) Intraneural ganglion of the ulnar nerve. Handchirurgie 6:20–22 (Ger)
Okada M, Sakaguchi K, Oebisu N, Takamatsu K, Nakamura H (2011) A ganglion within the ulnar nerve and communication with the distal radioulnar joint via an articular branch: case report. J Hand Surg Am 36:2024–2026
Patel MR, Naik AN, Mody K, Pollack M (1997) Intraneural mucous cysts of peripheral nerves. Am J Orthop 26:562–564
Rezzouk J, Durandeau A (2004) Nerve compression by mucoid pseudocysts: arguments favoring an articular cause in 23 patients. Rev Chir Orthop Reparatrice Appar Mot 90:143–146 (Fr)
Schmidt HM, Lanz U (2004) Surgical anatomy of the hand. Thieme, Stuttgart, New York, pp 80–81
Sekiguchi A, Kiyotsugu O, Yousuke T (1981) A case of intraneural ganglion cyst of ulnar nerve deep branch. Saitama Med Univ J 8:297 (Jpn)
Spinner RJ, Atkinson JL, Tiel RL (2003) Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory. J Neurosurg 99:330–343
Spinner RJ, Hébert-Blouin MN, Amrami KK (2010) Complex cysts: shared pathogenesis from the superior tibiofibular joint. J Surg Orthop Adv 19:143–148
Spinner RJ, Scheithauer BW, Amrami KK (2009) The unifying articular (synovial) origin of intraneural ganglia: evolution-revelation-revolution. Neurosurgery 65:A115–A124
Spinner RJ, Wang H (2011) The first described joint-associated intraneural ganglion cyst. Neurosurgery 69:1291–1298
Strickland JW, Steichen JB (1977) Nerve tumors of the hand and forearm. J Hand Surg Am 2:285–291
Takahashi M, Yabe Y (1978) Paralysis of peripheral nerves by ganglion cysts. Chubu Orthop Trauma J 21:1301–1303 (Jpn)
Wang H, Terrill RQ, Tanaka S, Amrami KK, Spinner RJ (2009) Adherence of intraneural ganglia of the upper extremity to the principles of the unifying articular (synovial) theory. Neurosurg Focus 26:E10
Zielinski CJ (2003) Intraneural ganglion of the ulnar nerve at the wrist. Orthopedics 26:429–430
Conflicts of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Spinner, R.J., Wang, H., Howe, B.M. et al. Deep ulnar intraneural ganglia in the palm. Acta Neurochir 154, 1755–1763 (2012). https://doi.org/10.1007/s00701-012-1422-1
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00701-012-1422-1