Aspiration of Ganglion Cyst on Right Wrist

Abstract 

Ganglion cysts are mucinous-filled lumps that most commonly appear over tendons and joints. They are the most frequently observed soft tissue mass in the hand and wrist, but they are also frequently found in the knee and foot. These cysts present as a palpable lump and remain asymptomatic until they impinge on local nerves and blood vessels, leading to pain, numbness, tingling, and/or motor impairments. The most common treatment for ganglion cysts is observation, given that they have about 50% chance of resolving on their own over time.^6,7 However, physical activity can cause the cyst to grow, making more aggressive treatment often preferable. If the cyst starts to cause pain or restricts activity due to its large size, aspiration can be performed to reduce pressure. If the cyst reappears or symptoms persist, surgical excision is advised. We report the case of a 51-year-old woman with a steadily growing ganglion cyst on her right wrist. After discussing the treatment options, she opted for aspiration as it is a less invasive procedure.

Keywords

Benign tumors, connective tissue diseases, wrist.

Case Overview

Background

Ganglion cysts are mucin-filled cysts that are most commonly found on the dorsum of wrists. They arise from trauma and/or mucoid degeneration of the periarticular structures that present as a firm, well-circumscribed knot.¹ The size of the cyst increases with activity and can impinge on local nerves, resulting in motor and/or sensory loss. Diagnosis of ganglion cyst is usually clinical and can be determined with transillumination. First-line treatment for most patients is observation as about 50% resolve gradually, but aspiration of ganglion cysts can immediately relieve impingement on neurovascular structures, improve joint pain, and decrease rate of recurrence.²

Focused History of the Patient

This 51-year-old, healthy-appearing woman presented with a firm, smooth, unilateral ganglion cyst on the dorsum of her right wrist that has had noticeable growth in size over the last 2–3 months. Patients’ primary reason for treatment is to decrease wrist pain and the probability of the growing cyst to further impinge on nearby neurovascular structures. There were no known allergies or contraindications for the procedure.

Imaging

No imaging was necessary for aspiration of the ganglion cyst.

Natural History

Ganglion cyst is the most common soft tissue tumor of the hand. 60–70% of ganglion cysts are found in the dorsal aspect of the wrist. They may affect any age group; however they are more common in the twenties to forties.⁵ Ganglion cysts are the most common soft tissue hand and wrist mass.¹ Its origin and pathogenesis remains enigmatic, however, they are thought to result from the mucoid degeneration causing herniation of connective tissue from the tendon sheaths, ligaments, joints capsules, bursae, and menisci with no true overlying epithelial lining.^1.5 This swelling contains a gelatinous fluid that overlies the joint and can be found anywhere in the body. Most commonly located on the dorsal side of the wrist involving the radiolunate ligament, they can also be found on the volar surface of the wrist, dorsal DIP joints, and dorsum of the foot.³ Recurrence of ganglion cyst is approximately 50% with aspiration and 10% with excision surgery.⁴

Options and Rationale for Treatment

Before the procedure was initiated, the patient was presented with several treatment options. Given that she had a substantial cyst causing her discomfort and negatively affecting her appearance, the option of observation was disregarded. The patient chose aspiration over excision due to the less invasive nature of the procedure. The first-line approach for ganglion cyst is observation, as over 50% of the time they regress over time with no intervention.² When the cyst recurs  following a period of observation, aspiration and excision are frequently preferred. Aspiration, while far less invasive than excision of the cyst, has a much higher recurrence rate of 50% within the next year compared to excision.² For severe neurological or vascular impingement, excision is the preferred method. While there is a higher chance of complications with the more invasive procedure, the recurrence rate is also far lower at 10%.⁴ Despite the patient having a ganglion cyst on the dorsal side of the wrist, cysts on the volar side of the wrist tend to have more complications and a higher chance of recurrence due to the intricate neurovascular structure of the volar wrist. If the patient’s main goal is to alleviate symptoms, a less invasive approach is recommended. However, to reduce the chance of the cyst returning, surgical removal is more effective.

Special Considerations

No special considerations were indicated for this patient.

Discussion

The procedure starts with sanitizing the insertion site. The needle is then inserted transversely to avoid any vasculature. If angled toward the underlying carpal bones, the risk for complications is much higher, so it is best to take precaution with the angle of the needle. Once inside the cyst, pressure from the surgeon’s fingers was applied to the outer rim to assist in evacuation of the gel-like substance inside. Once all the fluid inside the cyst is aspirated, the needle is retracted and a bandage is applied.

This procedure is completed in a matter of minutes so it is done in an outpatient setting with the patient discharged soon after. Her only postoperative instructions were to take pain medication on an as needed basis. Prognosis for ganglion cyst aspiration is excellent, providing immediate pain and cosmetic relief. The time frame of another ganglion cyst developing varies from patient to patient from months to years to never. In rural locations and settings, these procedures can be applied to improve the quality of life for patients who might otherwise face a wait of several months for elective surgery.

Equipment

Minimal equipment is necessary for ganglion cyst aspiration, but includes:

• Alcohol pads
• Large bore needle with syringe
• Sterile supplies: bandages, drapes, gauze, gloves

Disclosures

Nothing to disclose.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.