Approach
Ganglion cysts are primarily a cosmetic deformity and conservative treatment is usually first-line.
Further intervention (aspiration or surgery) can be explored if cysts are cosmetically unpleasant or compromising local neurovascular structures secondary to mass effect. Patients with neurovascular compromise related to ganglia are typically treated with surgical resection. Completely devascularized fingers/hand are extremely rare, so surgical intervention can usually be performed in a nonemergent but timely manner.
Published randomized and pseudo-randomized trials lack methodological detail and sufficient outcome measures, and are not suitable to determine the relative effectiveness of clinical treatment against simple reassurance.[24]
Observation
Given that ganglia are the most common benign tumors of the hand and the wrist with no reported cases of malignant degeneration, the most appropriate initial line of treatment is observation or conservative measures such as activity modification to avoid painful wrist positions or volar wrist splinting for pain control.[11][25]
Observation can be continued indefinitely with more advanced treatment reserved for neurovascular compromise, pain, functional limitations, or cosmetic deformity. Conservative treatment results in spontaneous resolution in up to 58% of adults and up to 93% of children over a 9- to 12-month period.[26][27][28]
Analgesia
Patients may report some discomfort or aching, especially after activity. This can usually be alleviated by an nonsteroidal anti-inflammatory drug as well as activity modification. Compressive wraps or wrist supports worn during activities that exacerbate discomfort can also help.
Cyst aspiration
Cyst puncture and drainage, with or without corticosteroid injection, is the primary form of closed management of dorsal ganglia and can be curative as well as diagnostic.
Aspiration of volar ganglion cysts is not recommended due to the potential risk of injury to the radial artery.[22]
While aspiration can be done in the office, caution must be utilized given the direct extension of the cyst stalk into the wrist joint. Septic arthritis is a rare, but possible, complication of this procedure.
Dorsal ganglion cyst aspiration has been reported to have a 13% success rate with single puncture and drainage. This can be increased to approximately 40% if the wrist is splinted for 3 weeks afterward, and approximately 85% with up to 3 treatments.[26][29][30]
Evidence suggests simple aspiration yields similar success rates (33%) to aspiration and injection of corticosteroid.[31] Injection of corticosteroid may reduce inflammation and increase the success rate, but definitive benefit has not been demonstrated.[32]
Needling of dorsal cysts can lead to overall decompression and multiple needling of the base or stalk of the cyst can increase the rate of resolution to 42%.[26] Multiple needling can be painful or uncomfortable and injection with local anesthetic may be warranted.
Risk of recurrence following cyst aspiration.
One systematic review of studies that reported treatment outcomes for adult wrist ganglions found that 59% of patients who underwent aspiration experienced recurrence.[33] Aspiration was not associated with a significant reduction in recurrence compared with reassurance.[33]
Surgical excision
Cysts that are recalcitrant to conservative management may be addressed surgically if they are painful or cosmetically unpleasing and the patient desires excision of the mass. Surgery is recommended as a first line treatment when there are paresthesias, muscle weakness, or vascular insufficiency.
Surgery is the most successful treatment but it is not a guaranteed cure. Surgical options include formal open excision versus arthroscopic decompression and resection. Prior to surgery, patients should be advised that they will be trading cosmetic masses for surgical scars, and that complete excision may be prevented if the cyst encapsulates neurovascular structures.
Dorsal ganglion recurrence is reduced when a cuff of normal tissue is removed along with the stalk of the ganglia. However, care must be taken to avoid injury to the scapholunate interosseous ligament or a resultant scapholunate diastasis may develop. Volar wrist ganglia often intimately surround, or are attached to, the radial artery and have a slightly higher rate of recurrence. A cuff of the ganglion may remain after surgery in these patients to avoid injury or arteriotomy of the artery. Wrist immobilization following surgery may help to reduce the rate of recurrence, but motion should be initiated relatively soon postoperatively to reduce the risk of stiffness.
Risk of recurrence following surgical excision.
The risk of recurrence following open surgery varies. Typically, dorsal ganglia have a 3% to 9% recurrence rate and volar ganglia have a recurrence rate of 7% to 19%. Open surgical excision is associated with a significantly lower chance of recurrence compared with aspiration.[33] In pediatric patients with wrist ganglia, the patient’s age is an important factor in recurrence, with teenagers having higher recurrence rates.[34]
Arthroscopic debridement offers the benefit of treating any other intra-articular pathology that may be noticed on examination. One systematic review reported pooled recurrence rates of 9% and 20% for arthroscopic excision and open surgery of dorsal ganglion cysts, respectively.[35] When low quality studies and/or those with high risk of bias were excluded, recurrence rates were 7.9% for arthroscopic surgery and 9.8% for open surgery.[35] In a subset of studies, complication rates were reported to be similar between open and arthroscopic surgery (6% versus 4%, respectively).[35]
Other treatments
Closed rupture of ganglion cysts using forced massage or a sharp blow with a heavy object have been reported. These techniques are not recommended, and may lead to fracture of the distal radius or injury to surrounding structures.
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