Ganglion cyst

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Ganglion cyst
Other names: Ganglia, synovial cyst,[1] Gideon's disease, Olamide's cyst, Bible cyst, Bible bump[2]
Cyst on dorsum of left hand close to the wrist
SpecialtyPlastic surgery
SymptomsSmall soft lump associated with a joint[3]
ComplicationsCarpal tunnel syndrome, compression of the radial artery[4]
Usual onset15 to 40 years old[3]
Diagnostic methodTypically based on signs[4]
Differential diagnosisLipoma, epidermoid inclusion cyst, gout, hemangioma[4]
TreatmentWatchful waiting, splinting the affected joint, needle aspiration, surgery[3]
PrognosisNot serious[3]
Frequency~3 per 10,000 per year (wrist and hand)[5]

A ganglion cyst is a fluid-filled bump associated with a joint or tendon sheath.[3] They most often occur at the back of the wrist followed by the front of the wrist.[3][4] Onset is often over months.[4] Typically there are no further symptoms.[3] Occasionally pain or numbness may occur.[3] Complications may include carpal tunnel syndrome.[4]

The cause is unknown.[3] The underlying mechanism is believed to involve an outpouching of the synovial membrane.[4] Risk factors include gymnastics.[3] Diagnosis is typically based on examination with light shining through the lesion being supportive.[4] Medical imaging may be done to rule out other potential causes.[3][4]

Treatment options include watchful waiting, splinting the affected joint, needle aspiration, or surgery.[3] About half the time they resolve on their own.[4] About 3 per 10,000 people newly develop ganglion of the wrist or hand a year.[5] They most commonly occur in young and middle aged females.[3] Trying to treat the lesion by hitting it with a book is discouraged.[4]

Signs and symptoms

The average size of these cysts is 2.0 cm, but excised cysts of more than 5 cm have been reported.[6] The size of the cyst may vary over time and may increase after activity.


These cysts most frequently occur around the dorsum of the wrist and on the fingers. A common site of the occurrence is along the extensor carpi radialis brevis, as it passes over the dorsum of the wrist joint. Although most commonly found in the wrist, ganglion cysts also may occur in the foot.[7]

Ganglion cysts are "commonly observed in association with the joints and tendons of the appendicular skeleton, with 88% 'in communication with the multiple small joints of the hand and wrist' and 11% with those of the foot and ankle."[6] They commonly are found near the wrist joint, especially at the scapho-lunate area.[8]

In a study were foot lumps were being removed surgically, 39 of 101 cases were ganglion cysts. No ganglion cysts were found on the sole or heel of the foot; the authors wrote that "Although lumps in these areas may be ganglia, the surgeon should probably consider other diagnoses in the first instance." The researchers also noted a marked preponderance of occurrence among females (85%) and that 11 of the other cases had been misdiagnosed as ganglion cysts before surgery.[9]

Ganglion cysts are not limited to the hands and feet. They may occur near the knee, commonly near the cruciate ligaments, but also they may occur at the origins of the gastrocnemius tendon and, anteriorly, on Hoffa's infrapatellar fat pad.[10] At the shoulder, they typically occur at the acromioclavicular joint or along the biceps tendon.[11]

From their common origin at a joint or tendon, ganglion cysts may form in a wide range of locations. Rarely, intraosseous ganglion cysts occur, sometimes in combination with a cyst in the overlying soft tissue.[6][12] Very rare cases of intramuscular ganglion cysts in the gastrocnemius muscle of the calf have been reported.[13][14] It is possible for a cyst to be displaced considerably from its connection to the joint. In one extreme case, a ganglion cyst was observed to propagate extensively via the conduit of the common peroneal nerve sheath to a location in the thigh; in such cases surgery to the proximal joint to remove the articular connection may remove the need for a riskier, more extensive surgery in the neural tissue of the thigh.[15] The cysts may intrude into the spine, which may cause pain and dysesthesia in distant extremities.[16]

It has been proposed recently that cystic adventitial disease, in which a cyst occurs within the popliteal artery near the knee, may occur by an articular mechanism, with a conduit leading from the joint, similar to the development of ganglion cysts, that spreads within the peroneal nerve.[17]

Cysts that were compressing one or more nerves and causing bone erosions have been reported to occur near the shoulder joint.[18]


The most commonly accepted probable cause of ganglion cysts is the "herniation hypothesis", by which they are thought to occur as "an out-pouching or distention of a weakened portion of a joint capsule or tendon sheath." This description is based on the observations that the cysts occur close to tendons and joints. The microscopic anatomy of the cyst resembles that of tenosynovial tissue, the fluid being similar in composition to synovial fluid. Dye injected into the joint capsule frequently ends up in the cyst, which may become enlarged after activity. Dye injected into the cyst rarely enters the joint, however, which has been attributed to the apparent formation of an effective and one-way "check valve", allowing fluid out of the joint, but not back in.[6]

In synovials, posttraumatic degeneration of connective tissue and inflammation have been considered as causes. Other possible mechanisms for the development of ganglion cysts include repeated mechanical stress, facet arthrosis, myxoid degeneration of periarticular fibrous tissues and liquefaction with chronic damage, increased production of hyaluronic acid by fibroblasts, and a proliferation of mesenchymal cells. Ganglion cysts also may develop independently from a joint.[16][19]


Ganglion cyst of the hand with multiple cystic chambers containing glairy material - the walls are composed of bland fibrous tissue with no specialized lining

Ganglion cysts are diagnosed easily, as they are visible and pliable to touch.

Radiographs in AP and lateral views should be obtained to exclude any more serious underlying pathology.[20] Ultrasonography (US) may be used to increase diagnostic confidence in clinically suspected lesions or to depict occult cysts,[21] because intratendinous ganglia are readily distinguished from extratendinous ganglia during dynamic ultrasonography, as microscopically, ganglionic cysts are thin-walled cysts containing clear, mucinous fluid.[7]


If a person is not in pain, they should simply be reassured that the lump is not cancerous, and wait for the lump to disappear on its own.[22] At least 33% resolve without treatment within six years, and 50% within 10 years.[22]

Surgical treatments remain the primary elective option for treatment of ganglion cysts. The progression of ganglion surgery worldwide is to use an arthroscopic or mini-opening method.[23] Alternatively, a hypodermic needle may be used to drain the fluid from the cyst (via aspiration) and a corticosteroid may be injected after the cyst is empty;[21] however, if the fluid has thickened, owing to the passage of time, this treatment is not always effective.[citation needed] There is a recurrence rate of approximately 50% following needle drainage (via aspiration) of ganglion cysts.

A historical method of treatment for a ganglion cyst was to strike the lump with a large and heavy book, causing the cyst to rupture and drain into the surrounding tissues. Historically, a Bible was the largest or only book in any given household, and was employed for this treatment. This led to the former nickname of "Bible bumps" or "Gideon's disease" for these cysts.[2][24] This treatment risks injuring the person and thus is not recommended.[25]


Complications of treatment may include joint stiffness and scar formation.[21] Recurrence of the lesion is more common following excision of a volar ganglion cyst in the wrist. Incomplete excision that fails to include the stalk or pedicle also may lead to recurrence, as will failing to execute a layered closure of the incision.[26]


Recurrence rate is higher in aspirated cysts than in excised ones.[20] Ganglion cysts have been found to recur following surgery in 12%[27] to 41%[28] of patients.

A six-year outcome study of the treatment of ganglion cysts on the dorsum (back) of the wrist compared excision, aspiration, and no treatment. Neither excision nor aspiration provided long-term benefit better than no treatment. Of the untreated ganglion cysts, 58% resolved spontaneously; the post-surgery recurrence rate in this study was 39%.[29] A similar study in 2003 of ganglion cysts occurring on the palmar surface of the wrist states: "At 2 and 5 year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated or left alone."[30]


Being a misnomer that has persisted into modern times,[31] the ganglion cyst is unrelated to the neural "ganglion" or "ganglion cell"; its etymology traces back to the ancient Greek γάγγλιον, a "knot" or "swelling beneath the skin",[32] which extends to the neural masses by analogy. Generally, Hippocrates is credited with the description of these cysts.[6][33]

The term "Bible cyst" (or "Bible bump") is derived from an urban legend or historical effort to hit the cyst with a Bible.[34][35] Trying to treat the lesion by hitting it with a book is however discouraged.[4]

See also


  1. "National Library of Medicine - Medical Subject Headings (MeSH) - Ganglion Cyst". Archived from the original on March 10, 2016. Retrieved August 27, 2013.
  2. 2.0 2.1 " The Electronic Textbook of Hand Surgery". The American Society for Surgery of the Hand Archived from the original on March 9, 2014. Retrieved April 12, 2014.
  3. 3.00 3.01 3.02 3.03 3.04 3.05 3.06 3.07 3.08 3.09 3.10 3.11 3.12 3.13 "Ganglion Cyst of the Wrist and Hand-OrthoInfo". March 2013. Archived from the original on 6 July 2017. Retrieved 10 June 2017.
  4. 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Ferri, Fred F. (2014). Ferri's Clinical Advisor 2015 E-Book: 5 Books in 1. Elsevier Health Sciences. p. 472. ISBN 9780323084307. Archived from the original on 2017-09-10.
  5. 5.0 5.1 Cooney, William P. (2011). The Wrist: Diagnosis and Operative Treatment. Lippincott Williams & Wilkins. p. 1089. ISBN 9781451148268. Archived from the original on 2017-09-10.
  6. 6.0 6.1 6.2 6.3 6.4 Craig A. Camasta, DPM (1993). "excision of the ganglion cyst" (PDF). Podiatry Institute. Archived (PDF) from the original on 2013-11-01.
  7. 7.0 7.1 McNabb, J. W. (2005). Practical Guide to Joint and Soft Tissue Injection and Aspiration. Lippincott Williams & Wilkins. pp. 62–65. ISBN 9780781753630.
  8. "Ganglion cysts". The British Society for Surgery of the hand. BSSH. Archived from the original on April 7, 2017. Retrieved April 6, 2017.
  9. Duncan JM Macdonald; et al. (August 2007). "The Differential Diagnosis of Foot Lumps: 101 Cases Treated Surgically in North Glasgow Over 4 Years". Annals of the Royal College of Surgeons of England. 89 (3): 272–275. doi:10.1308/003588407x168235. PMC 1964714. PMID 17394713.
  10. Jon Arthur Jacobson (2007). Fundamentals of Musculoskeletal Ultrasound. Elsevier Health Sciences. ISBN 978-1416035930. Archived from the original on 2014-07-04.
  11. Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Sample chapter available on acromioclavicular joint ganglion Archived 2014-05-18 at the Wayback Machine.
  12. Muir B, Kissel JA, Yedon DF (December 2011). "Intraosseous ganglion cyst of the humeral head in a competitive flat water paddler: case report". J Can Chiropr Assoc. 55 (4): 294–301. PMC 3222705. PMID 22131566. (includes MRI images)
  13. Jae Jeong Park; et al. (2010). "Case Report : Intramuscular Ganglion Cyst of the Gastrocnemius Muscle". Korean Journal of Dermatology. Archived from the original on 2013-06-17.
  14. Park S, Jin W, Chun YS, Park SY, Kim HC, Kim GY, Park JS, Ryu KN (October 2009). "Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: sonographic appearance". Journal of Clinical Ultrasound. 37 (8): 478–81. doi:10.1002/jcu.20609. PMID 19618443.
  15. Robert J. Spinner; et al. (2012). "Re: Pure Peroneal Intraneural Ganglion Cyst: Hindsight is 20/20" (PDF). Turkish Neurosurgery. pp. 527–528. Archived (PDF) from the original on 2013-10-14.
  16. 16.0 16.1 Sang Woo Kim; et al. (April 2011). "A Ganglion Cyst in the Second Lumbar Intervertebral Foramen". J Korean Neurosurg Soc. 49 (4): 237–240. doi:10.3340/jkns.2011.49.4.237. PMC 3098430. PMID 21607185. (original source cites eight additional references for the quoted paragraph)
  17. R. J. Spinner; et al. (2012-08-29). "Evidence to support that adventitial cysts, analogous to intraneural ganglion cysts, are also joint-connected". Clin. Anat. 26 (2): 267–81. doi:10.1002/ca.22152. PMID 22933403.
  18. Field, Larry D. (2003). MasterCases: Shoulder and Elbow Surgery. Thieme. p. 241. ISBN 9780865778733.
  19. Ribes, Ramón (2010). Learning Musculoskeletal Imaging. Springer. p. 197. ISBN 9783540880004.
  20. 20.0 20.1 Pocket Guide to Musculoskeletal Diagnosis. Springer. 2005. p. 63. ISBN 9781597450096.
  21. 21.0 21.1 21.2 The Gale encyclopedia of surgery: a guide for patients and caregivers, Volume 1. Gale. 2003. pp. 560. ISBN 9780787677213.
  22. 22.0 22.1 "Clinical treatments for wrist ganglia" (PDF). ROYAL AUSTRALASIAN COLLEGE OF SURGEONS. Archived from the original (PDF) on 27 March 2018.
  23. Bismil MSK, Bismil QMK. The wide awake approach to hand and wrist ganglia: Ten-year experience, technical tips and review of macroscopic pathology and outcomes of 300 cases. OA Case Reports 2013 Nov 15;2(13):129.
  24. Dacombe, PJ; Robinson, J (Mar 27, 2012). "Falling Up the Stairs: the Equivalent of 'Bashing it with a Bible' for an ACL Ganglion Cyst of the Knee". BMJ Case Reports. 2012: bcr0120125591. doi:10.1136/bcr.01.2012.5591. PMC 3316796. PMID 22605799.
  25. Hammond, Claudia. "Should you bash a 'bible bump'?". Archived from the original on 2013-02-07. Retrieved 2018-08-09.
  26. Camasta, Craig A., DPM, Excision of the Ganglion Cyst Archived 2013-11-01 at the Wayback Machine,, update 1993, 1993 33 pdf, pages 181–5
  27. Gallego S, Mathoulin C (2010). "Arthroscopic resection of dorsal wrist ganglia: 114 cases with minimum follow-up of 2 years". Arthroscopy. 26 (12): 1675–1682. doi:10.1016/j.arthro.2010.05.008. PMID 20952152.
  28. Lidder S, Ranawat V, Ahrens P (2009). "Surgical excision of wrist ganglia; literature review and nine-year retrospective study of recurrence and patient satisfaction". Orthop Rev. 1 (1): e5. doi:10.4081/or.2009.e5. PMC 3143961. PMID 21808669.
  29. Dias JJ, Dhukaram V, Kumar P (October 2007). "The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention". The Journal of Hand Surgery, European Volume. 32 (5): 502–8. doi:10.1016/J.JHSE.2007.05.007. PMID 17950209.
  30. Dias J, Buch K (Apr 2003). "Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes". J Hand Surg Br Vol. 28 (2): 172–6. doi:10.1016/s0266-7681(02)00365-0. PMID 12631492.
  31. J.C. Segen (1992). The Dictionary of Modern Medicine. ISBN 9781850703211. Archived from the original on 2017-09-10. (see the entry for aneurysmal bone cyst, which "like pyogenic granuloma and ganglion cyst, a misnomer that has withstood the sands of time and the dint of logic")
  32. "Etymology of the Greek word ganglion (γάγγλιον)". Archived from the original on 2013-10-06.
  33. See Hippocrates' "On the Articulations" (part 40) at Wikisource
  34. "Ganglions". Archived from the original on 2009-04-15. Retrieved 2009-05-27.
  35. Hammond, Claudia. "Should you bash a 'bible bump'?". Archived from the original on 7 February 2013. Retrieved 24 November 2018.

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