Ganglion cyst

What are Ganglion cysts?

Ganglion cysts are the commonest type of lumps and bumps that occur in hand and wrist. They are non-cancerous sacs filled with jelly like substance and develops in joints and tendons (tissue that joins muscle to bone). They are also known as bible cysts as in the past these lesions were hit with the bible. They commonly affect wrist or hand and in older patients’ fingers (commonly on back side) are affected. They are round or oval shaped. The fluid inside the sac is clear, colourless, thick, sticky and jelly like material.. Some ganglions occur in the base of fingers (A1 pulley or pearl ganglion). The ganglions that occur in the end joints of finger are also called as mucous cysts.

Ganglion cysts are more common in women than men, usually in the age between 15 to 40 years. The exact cause of their appearance is not known. Injury, trauma, arthritis, overuse, and repeated stress on the wrist like gymnasts can cause these cysts. Its most common in hand (60-70%) mostly located in dorsal carpal (70%), volar carpal (20 %), and volar retinacula (10%).

 

What are the symptoms of Ganglion cyst?

Ganglion cysts are harmless and are usually asymptomatic. They appear as a small lump or swelling in the wrist, and their sizes keep on changing. They are usually painless but can cause slight discomfort in extremes of movement.  If they appear on the areas where it can compress a nerve, then they may cause pain, tingling and weakness in the muscle.

 

How is it diagnosed?

Your orthopaedic surgeon will ask you for your symptoms and duration of the lumps. He will perform a physical check to find out the type of lump you are having. He may ask you for X-rays, CT, MRI and ultrasound to study the extent of the lump and its relationship to the bone, joints or soft tissues.

 

What happens if nothing is done?

If they are left untreated, they may disappear by themselves. But it may take years for this. However, in some these lumps could be painful, causing restriction of movements and function of the hand.

 

How is it treated?

Many ganglion cysts disappear on its own and may need few years to do so. . It requires treatment only when your ganglion cause pain, mechanical symptoms or size large enough to interfere with your normal activities It can be treated non-surgically or surgically. The non-surgical treatment involves observation, splint application or aspiration.

Surgery is indicated in –

  • Severe pain
  • Failure of conservative treatment
  • Nerve compression
  • Failure of aspiration procedure – multilobulated
  • Pressure symptoms in adjacent structures

 

What are the non-operative treatments?

The non-operative treatment includes the following-

  • Reassurance
  • Splint- repeated activity may lead to an increase in the size of the cyst and your surgeon may give you a wrist brace or splint to relieve your symptoms. As the pain reduces, hand therapy is recommended to regain the strength of the wrist and improve range of motion.
  • Aspiration– in case your ganglion cyst is symptomatic, your surgeon may aspirate the ganglion. He will puncture the cyst with a needle and fluid is withdrawn out of the sac through a syringe. He might inject steroid after aspiration. In selected patients your surgeon may refer you for an ultrasound guided procedure
  • Medicines- painkillers are often used to relieve pain and tenderness caused by the lump. Anti-inflammatory medicines are prescribed to relieve pain and size of the lump of the hand.
  • Hand therapy– your therapist will teach you exercises to maximize the function of the affected arm.

 

What does the operation involve?

The surgical treatment aims at the removal of the ganglion from its site to confirm the diagnosis from pathologist, to enhance the function and reduce any discomfort and pain resulting from the ganglion.

  • You are admitted to the hospital and the operation is usually performed as a day case.
  • The operation is performed under general anaesthesia or local anaesthesia (nerve block). In general anaesthesia, the patient does not feel anything and sleeps throughout the operation. In local anaesthesia, the patient remains awake during the operation but he cannot feel whatever is happening in the surgical area. Your anaesthetist can select a combination of both local and general anaesthetic.
  • The skin is cut and cyst is removed along with its stalk and the involved part of capsule or tendon sheath which is the root of cyst.
  • In selected cases the surgery is performed as using arthroscopy (Key hole).
  • The Skin is closed using absorbable sutures. The operation takes usually 1 hour, and the majority of the patients are discharged on the same day.

 

What happens after surgery?

  • The local anaesthetic wears off in 4 to 12 hours after surgery. Patients are given painkillers before the pain starts i.e. on return to home. It is continued for at least 48 hours after the first dose. Thus, most of our patients report little or any pain.
  • You will have a bulky bandage when you wake up, that usually needs to be reduced in 24-48 hrs. You will have spare dressings to take home and have to keep the wound dry and clean for 2 weeks
  • You have to keep your hand and wrist elevated (above the level of your heart) and keep moving your fingers, elbow and shoulder to maintain the flexibility and prevent stiffness of the joints.
  • You are reviewed again after the period of two weeks to check the wound and physical therapy are advised for rehabilitation.
  • The wound should be massaged (typically after 2 weeks) using moisturising cream by the patient 3 times a day for 3 months once the wound is well healed. This reduces the scar sensitivity and scar-related complications (tenderness; helps scar to mature).
  • Physical therapy of hand is essential to restore the range of motion, normal function and strength of the hand.

 

Are there any risks?

  • Bleeding
  • Infection
  • Damage to nerves vessels and tendons
  • Neuroma
  • Stiffness
  • Persistence of symptoms
  • Injury to scapholunate interosseous ligament
  • Reoccurrence (15%)
  • Permanent scarring
  • Need for revision surgery
  • CRPS (Complex Regional Pain Syndrome)

 

What are the results of the operation?

The results of the operation are excellent with a success rate of > 97% and few complications. The results are more predictable under the author’s experiences.

 

When can I return to driving and work?

You can get back to work in few days if you have a desk job, however might take 2-4 weeks if your job involves physical work. You should be able to resume driving in 2 weeks. The above time line could vary based on the severity of problem and the treatment modality.  Your surgeon can give you the correct estimation for this.

Ganglion cyst

  1. Volar Ganglion – It lies close to radial artery and blind aspiration is not advisable
  2. Dorsal ganglion
  3. Finger ganglion (mucous cyst) – The cyst compresses the nailbed leading to ridge in the finger nail.

 

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