Treatment of Ganglion Cysts

Ganglion cysts are soft tissue swellings occurring most commonly in the hand or wrist. Apart from swelling, most cysts are asymptomatic. Other symptoms include pain, weakness, or paraesthesia. The two main concerns patients have are the cosmetic appearance of the cysts and the fear of future malignant growth. It has been shown that 58% of cysts will resolve spontaneously over time. Treatment can be either conservative or through surgical excision. This review concluded that nonsurgical treatment is largely ineffective in treating ganglion cysts. However, it advised to patients who do not surgical treatment but would like symptomatic relief. Compared to surgery, which has a lower recurrence rate but have a higher complication rate with longer recovery period. It has been shown that surgical interventions do not provide better symptomatic relief compared to conservative treatment. If symptomatic relief is the patient's primary concern, a conservative approach is preferred, whilst surgical intervention will decrease the likelihood of recurrence.


Introduction
Ganglion cyst is the most common soft tissue swelling in hand and wrist. It occurs most commonly on the dorsal side of the wrist (70%), followed by volar side (20%) of wrist and tendon sheath of fingers. Most of the ganglion cysts are asymptomatic besides swelling. Most patients sought advice and treatment because of the cosmetic appearance or they were concerned that their ganglion was a malignant growth [1]. Treatment options include reassurance, nonsurgical means like aspiration with or without steroid injections or hyaluronidase and surgical excision. We review the treatment outcome of ganglion in the literature and compare their recurrence and complication rates.

Reassurance
Majority of patients with ganglion do not have symptoms besides swelling, while others may present with pain, weakness, or paresthesia. Barnes et al. reported in their review that only 19.5% had symptoms other than a mass [2]. Westbrook et al. also reported majority of patients sought advice and treatment because of the cosmetic appearance or they were concerned that their ganglion was a malignant growth, while only 26% consulted because of pain and 8% consulted altered sensation or restricted hand function [1].
Many may not opt for any treatment if they are reassured of the benign nature of the disease. Also, even for painful ganglions, they cause less pain compared to other common orthopaedic problems, like carpal tunnel syndrome and osteoarthritis, in terms of Mean Visual Analogue Pain Scores [3].

Steroid.
Becker suggested the use of steroid injection in treating ganglion, with 87% resolution rate, based on the initial theory that chronic inflammatory may take part in the pathogenesis of ganglion. Subsequent studies showed variable successful rate. Varley et al. conducted a randomized controlled trial to aspiration with or without steroid and concluded that additional injection of steroid is of no benefit and subcutaneous fat atrophy and skin depigmentation can be the potential complications [11].

Sclerotherapy.
Sclerotherapy has been proposed to treat ganglion. Sclerosant was injected into ganglion sac to damage the intimal lining and cause fibrosis to reduce the recurrence rate. Initial study showed high successful rate ranging 78-100%. Mackie et al., however, confirmed ganglion had no intimal lining by histological studies and reported a failure rate as high as 94%. Since there is communication between ganglion and synovial joint, sclerosant might pass from ganglion to the joint and tendon and cause damage to them [16].
Since the publication of these reports, the use of sclerotherapy had declined. New technique had been developed with the aim of causing ganglion sclerosis without the risk of damage to the joints. Gümüş used electrocautery to cause ganglion sclerosis and showed favorite results. This technique had not been widely adopted [18].

4.4.
Hyaluronidase. The content of ganglion may be too vigorous to be drawn, and thus aspiration may not be complete. Some advocated the use of hyaluronidase, which depolymerizes the hyaluronic acid present in ganglion content. Otu reported a 95% cure rate after a follow-up period of 6 months [19]. Paul and Sochart also showed that the use of hyaluronidase in conjunction with steroid has resulted in significantly higher resolution rate compared to the use of steroid alone, but only 49% of their patients treated by hyaluronidase and steroid had complete resolution, compared to 20% in those treated with steroid [15]. Akkerhuis et al., however, reported a recurrence rate of 77%, for treatment of ganglion with hyaluronidase [20]. Thus, the successful rate had been variable, and hyaluronidase may cause allergic reaction.
4.5. Immobilization. Immobilization following aspiration had showed conflicting results. Richman et al. showed that 3week immobilization after aspiration and multiple puncture had a significantly higher successful rate for dorsal carpal ganglion, but the result for palmar ganglion was inconclusive [21]. On the other hand, Korman et al. concluded that immobilization did not significantly improve the successful treatment of ganglions over perforation and aspiration alone and had the potential adverse effects of inconvenience, economic repercussions, and stiffness [22].

Threat Technique.
Gang and Makhlouf introduce the thread technique, by which two sutures were passed through the ganglion at right angles to each other, and each was tied in a loop. The contents of ganglion were expelled by massage at interval. They reported a recurrence rate of 4.8%. However, 11% of the patients had positive culture swabs [24]. Singhal et al. described a similar technique, but the complete resolution rate was only 50% [25]. Taking into account that nearly half of the ganglion would resolve spontaneously, with such a high failure rate, nonsurgical treatment of ganglion was generally ineffective. However, the complications were considered less (Table 3) [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25]. Some reported zero percent of complication rates, while others reported minor complications like transient pain and swelling. Therefore, nonsurgical treatment can be considered to be an alternative way for symptomatic relief if the patients do not want surgery.
Another advantage of conservative treatment is that aspiration of ganglion contents confirms a benign diagnosis and allays the patients' fear and desire for further treatment.

Surgery
In 1976, Angelides and Wallace [26] introduced the techniques of excising the whole ganglion including the cyst, its attachments to the scapholunate ligament, and the involved segment of joint capsule, to reduce the recurrence rate. It is now considered to be the most effective technique.

Mobility and Other
Outcomes. Surgery may not result in favourable outcomes. Angelides et al. reported 1.2% of patients had 0-10 degree loss of volar flexion after surgery, although this had no functional significant [26]. Sanders studied nine patients with occult dorsal ganglion. One out of eight who attended followup had residual pain after surgery, while three out of eight had limited motion [48]. Clay and Clement reported that while surgery resulted in improvement of pain in 79%, it worsen the pain in 8% of patients. 17% of patients complained of weakened grip with 2% demonstrating loss of grip strength of more than 20% compared with opposite hand [28]. Residual pain, limited range of motion, and weaken grip were also reported in other studies ( Table 6).   [47] Dorsal and palmar 15.3 months 1/15 (6.7%) Table 5 Complication rate Open excision Angelides and Wallace 1976 [26] Dorsal 0/346 (0%) 1.2% had 0-10 degree loss of volar flexion Janzon and Niechajev 1981 [27] N o t r e p o r t e d Clay and Clement 1988 [28] Dorsal 0/51 (0%) 1 had evidence of scapholunate dissociation   [29,30] D o r s a l a n d p a l m a r N o t r e p o r t e d  [47] Dorsal and palmar 1/15 (6.7%) 1 case of transient paresthesia Table 6 Residual  Dias conducted two prospective cohort comparing the outcomes of dorsal and palmar ganglions, respectively, treated by surgery with those treated by reassurance and aspiration. No significant difference was found in persistent symptoms and symptom relief among three groups. However, those treated with surgery had significantly higher recovery times, with averaged 14.1 days and 10.9 days off work for palmar and dorsal wrist ganglion excision, respectively, compared to averaged 3.5 days and 3.2 days for aspiration of palmar and dorsal wrist ganglion [5,6] (Table 7).

Arthroscopic Excision.
In 1995, Osterman and Raphael described a technique of arthroscopic excision of dorsal wrist ganglia. Arthroscopic resection has the potential advantages of minimizing the surgical scar and permits evaluation of any intra-articular pathologic condition of either midcarpal or radiocarpal joints [38].
Majority of initial reports on recurrence rate look more favourable than open excision (Tables 4 and 5). However, a prospective, randomized study in 2008 showed rates of recurrence with arthroscopic dorsal ganglion excision (3/28) are comparable with and not superior to those of open excision (2/23). Additional long-term comparative studies are needed to accurately differentiate the efficacy of open and arthroscopic techniques [36].

Conclusion
Majority of patients with ganglion do not have symptoms. Given that the spontaneous resolution rate of ganglion can be as high as 58%. Reassurance and observation can be the option if the patients are asymptomatic or do not want any intervention. Nonsurgical treatments of ganglion including aspiration, steroid injection sclerotherapy, and hyaluronidase were generally ineffective. However, since they had lower complication rates, they can be used for symptomatic relief if the patients do not want surgery. Surgery had a lower recurrence rate than conservative treatment. However it has higher rates of complication and longer recovery period, and the rate of symptomatic relief may not be higher than other treatments.