A ganglion cyst is the most common type of benign soft tissue mass in the hand. These typically occur on the top side of the wrist, and may cause wrist pain,particularly when the wrist is extended. In many cases, the cyst develops idiopathically (without a cause), but it can also develop in the setting of an injury to the scapholunate ligament.
If a cyst is large enough to allow aspiration of it gelatinous content, this is an option, however recurrence occurs around 60-70% of the time because the cyst membrane or exterior lining itself is not removed. Alternatively, for small cysts or dorsal wrist pain felt to be caused by "occult' ganglia" (too small to be seen externally), a cortisone injection is an option-- which might releive the pain from dorsal impingement accompanying wrist extention.
Either injection or aspiration are always options, but they are not mandatory prerequistes to surgical treatment because, as has been stated, they are often temporary measures, at best. Indeed, a recent meta-analysis makes the point that compared to reassurance alone, aspiration does not appear to provide significant benefit with respect to ganglion resolution. Aspiration offers definitive confirmation of the diagnosis for a concerned patient or when they occur in atypical locations, however.
If a patient prefers to have the ganglion removed either because of pain, size, chronicity or recurrence, surgical removal is feasible and efficacious; recurrence rates reported in a recent meta-analysis of arthroscopic removal, open excision, and aspiration were 6%, 21% and 59%, respectively. Complication rates were 4%, 14%, and 3%, respectively.
While ganglion excision has utilized an open incision historically, so that the cyst and its stalk can be removed, the meta-analysis reveals the validity of arthroscopic treatment in terms of yielding promising results. As a minimally invasive alternative, arthroscopic removal is a good option, which may be accompanied by less pain and earlier restoration of motion. I have been performing arthroscopic ganglion removals since around 2005 and have witnessed recurrence in approximately 2%. The vast majority of patients have been pleased. The video below shows the type of early outcome that can be expected in the absence of complications.
Complications include portal scar sensitivity, infection, and recurrence. Clinical series have not indicated a risk of extensor tendon injury, but I have had one patient present with a mild index finger extensor lag in the postoperative period. The extensor tendons are located external to the capsule so with some mild postoperative bleeding and/or inflammation, this rare complication may develop, however, such a finding can be addressed surgically if functional disability persists despite therapy.
When recurrence develops, both open and arthroscopic options may be feasible.
