Ganglion cyst

From Wikipedia, the free encyclopedia - View original article

Ganglion cyst
Classification and external resources
Cyst on dorsum of left hand
Jump to: navigation, search
Not to be confused with Ganglion (nervous tissue structure).
Ganglion cyst
Classification and external resources
Cyst on dorsum of left hand

A ganglion cyst or synovial cyst [1] or myxoid cyst,[2] also known as Gideon's Disease, a Bible Cyst or Bible Bump,[3] is a non-neoplastic soft tissue lump that may occur in any joint, but most often occurs on or around joints and tendons in the hands or feet.[4] It is caused by leakage of fluid from the joint into the surrounding tissue.[2]

Signs and symptoms[edit]

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


It is most frequently located around the dorsum of the wrist and on the fingers. A common site of 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 may also occur in the foot.[6]

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." [5] They are most often found around the wrist joint, especially at the scapho-lunate area, which accounts for 80% of all ganglion cysts.[citation needed]

In a 2007 study of patients whose foot lumps were being surgically removed in Glasgow, 39 of 101 cases were ganglion cysts. The study replicated an earlier result that 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." They also noted a marked female preponderance (85%) and that 11 of the other cases had been misdiagnosed as ganglion cysts before surgery.[7]

Ganglion cysts can also occur about the knee, commonly near the cruciate ligaments, also at the origins of the gastrocnemius tendon and anteriorly on Hoffa's infrapatellar fat pad.[8] At the shoulder, they typically occur at the acromioclavicular joint or along the biceps tendon.[9]

From their common origin at the joint or tendon, ganglion cysts can form in a wide range of locations. Rarely, intraosseous ganglion cysts occur, sometimes in combination with a cyst in the overlying soft tissue.[5][10] Very rare cases of intramuscular ganglion cysts in the gastrocnemius muscle have been reported.[11][12] It is possible for the 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 can remove the need for a riskier, more extensive surgery in the neural tissue of the thigh.[13] The cysts can even intrude into the spine, which can cause pain and dysesthesia in distant extremities.[14]

It has recently been proposed 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 spread within the peroneal nerve.[15]

Cysts have also been reported to occur nearby to shoulder joint, compressing one or more nerves and causing bone erosions.[16]


The most commonly accepted cause of ganglion cysts is the "herniation hypothesis", in which they occur as "an out-pouching or distention of a weakened portion of a joint capsule or tendon sheath." This is based on the observations that the cysts occur close to tendons and joints, the microscopic anatomy of the cyst resembles that of the tenosynovial tissue, the fluid is similar in composition to synovial fluid, and dye injected into the joint capsule frequently ends up in the cyst, which can become enlarged after activity. However, dye injected into the cyst rarely enters the joint, which has been attributed to the formation of an effective "check valve" allowing fluid out of the joint, but not back in.[5] Synovial cysts, posttraumatic degeneration of connective tissue and inflammation have been considered as the 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 cyst can develop independently from a joint.[14][17]


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

Radiographs in AP and lateral views are obtained to exclude any more serious underlying pathology.[18] Ultrasonography (US) may be done to increase diagnostic confidence in clinically suspected lesions or depict occult cysts.[19] Intratendinous ganglia are readily distinguished from extratendinous ganglia during dynamic US. Microscopically, ganglionic cysts are thin-walled cysts containing clear, mucinous fluid.[6]


Surgical treatments remain the primary option, other than doing nothing at all, for the treatment of ganglion cysts. The progression of ganglion surgery worldwide is to arthroscopic or mini-open wide awake excision of ganglion cysts.[20] Alternatively, a hypodermic needle may be used to drain the fluid from the cyst (aspiration) and a corticosteroid is injected after cyst is empty.[19] However, if the fluid has become thick owing to the passage of time, this treatment is not always effective.[citation needed]

One method for a ganglion cyst is to strike the lump with a large 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 commonly used; this led to the nickname of "Bible bumps" or "Gideon's disease."[21][3]


Complications of treatment include stiffness in hand and scar formation.[19]


Recurrence rate is higher in aspirated cysts than in excised ones.[18] Ganglion cysts have been found to recur following surgery in 12%[22] to 41%[23] of patients.

A six-year outcome study of treatment of ganglia on the back (dorsum) of the wrist compared excision, aspiration and no treatment. Neither excision nor aspiration provided long-term benefit better than no treatment. Of the untreated ganglia, 58% resolved spontaneously; the post-surgery recurrence rate in this study was 39%.[24] A similar study in 2003 of palmar wrist ganglion 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."[25]

Additional images[edit]


An apparent misnomer,[26] 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",[27] which extends to the neural masses by analogy. Hippocrates is generally credited with their description.[5][28]

The term "Bible cyst" (or "Bible bump") is derived from a common treatment in the past that consisted of hitting the cyst with a Bible or similarly large book.[29] Striking the ganglion cyst with a large tome is usually sufficient to rupture the cyst, and re-accumulation is uncommon.[inconsistent]

See also[edit]


  1. ^ Retrieved August 27, 2013.  Missing or empty |title= (help)
  2. ^ a b Lawrence C (December 2005). "Skin excision and osteophyte removal is not required in the surgical treatment of digital myxoid cysts". Archives of dermatology 141 (12): 1560–4. doi:10.1001/archderm.141.12.1560. PMID 16365258. Retrieved 2008-10-13. 
  3. ^ a b " The Electronic Textbook of Hand Surgery". The American Society for Surgery of the Hand Retrieved April 12, 2014. 
  4. ^ McDonald, RE; Mullens, DJ (May 2013). "Ganglion cyst treatment using the ganglion suture technique". Osteopathic Family Physician 5 (3): 123–127. doi:10.1016/j.osfp.2013.01.006. 
  5. ^ a b c d e Craig A. Camasta, DPM (1993). "excision of the ganglion cyst". Podiatry Institute. 
  6. ^ a b McNabb, J. W. (2005). Practical Guide to Joint and Soft Tissue Injection and Aspiration. Lippincott Williams & Wilkins. pp. 62–65. ISBN 9780781753630. 
  7. ^ 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. 
  8. ^ Jon Arthur Jacobson (2007). Fundamentals of Musculoskeletal Ultrasound. Elsevier Health Sciences. 
  9. ^ Arend CF. Ultrasound of the Shoulder. Master Medical Books, 2013. Sample chapter available on acromioclavicular joint ganglion.
  10. ^ 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)
  11. ^ Jae Jeong Park et al. (2010). "Case Report : Intramuscular Ganglion Cyst of the Gastrocnemius Muscle". Korean Journal of Dermatology. 
  12. ^ Soonchan Park MD et al. (October 2009). "Ruptured intramuscular ganglion cyst in the gastrocnemius medialis muscle: Sonographic appearance". Journal of Clinical Ultrasound 37 (8). pp. 478–481. 
  13. ^ Robert J. Spinner et al. (2012). "Re: Pure Peroneal Intraneural Ganglion Cyst: Hindsight is 20/20" 22 (4). Turkish Neurosurgery. pp. 527–528. 
  14. ^ a b Sang Woo Kim et al. (April 2011). "A Ganglion Cyst in the Second Lumbar Intervertebral Foramen". J Korean Neurosurg Soc. 49 (4). pp. 237–240. doi:10.3340/jkns.2011.49.4.237.  (original source cites eight additional references for the quoted paragraph)
  15. ^ 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. 
  16. ^ Field, Larry D. (2003). MasterCases: Shoulder and Elbow Surgery. Thieme. p. 241. ISBN 9780865778733. 
  17. ^ Ribes, Ramón (2010). Learning Musculoskeletal Imaging. Springer. p. 197. ISBN 9783540880004. 
  18. ^ a b Pocket Guide to Musculoskeletal Diagnosis. Springer. 2005. p. 63. ISBN 9781597450096. 
  19. ^ a b c The Gale encyclopedia of surgery: a guide for patients and caregivers, Volume 1. Gale. 2003. p. 560. ISBN 9780787677213. 
  20. ^ 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.
  21. ^ 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. doi:10.1136/bcr.01.2012.5591. PMID 22605799. 
  22. ^ 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. 
  23. ^ 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. 
  24. ^ Dias JJ, Dhukaram V, Kumar P, The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. J Hand Surg Eur Vol. 2007 Oct;32(5) 502-8.
  25. ^ Dias J, Buch K. Palmar wrist ganglion: does intervention improve outcome? A prospective study of the natural history and patient-reported treatment outcomes. J Hand Surg Br. 2003 Apr;28(2) 172-6.
  26. ^ J.C. Segen (1992). The Dictionary of Modern Medicine.  (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")
  27. ^ "Etymology of the Greek word ganglion (γάγγλιον)". 
  28. ^ See Hippocrates' "On the Articulations" (part 40) at Wikisource
  29. ^

External links[edit]