The use of MR arthrography to document an occult joint communication in a recurrent peroneal intraneural ganglion

• Published in: Skeletal radiology Vol. 35; no. 3; pp. 172 - 179
• Main Authors: SPINNER, Robert J, AMRAMI, Kimberly K, ROCK, Michael G
• Format: Journal Article
• Language: English
• Published: Berlin Springer 01.03.2006; Springer Nature B.V
• Subjects: Adult; Biological and medical sciences; Diagnosis, Differential; Ganglion Cysts - diagnosis; Ganglion Cysts - pathology; Ganglion Cysts - surgery; Humans; Imaging, Three-Dimensional; Investigative techniques, diagnostic techniques (general aspects); Magnetic Resonance Imaging; Male; Medical sciences; Osteoarticular system. Muscles; Peroneal Nerve; Radiodiagnosis. Nmr imagery. Nmr spectrometry; Reoperation; Human; Peroneal nerve; Fibula; Relapse; Radiodiagnosis; Pathogenesis; Articular branch; Peroneal nerve ganglion; Joint; Nuclear magnetic resonance imaging; Surgeon; Case study; Treatment; Arthrography; Surgery; Cyst; Medical imagery; Benign neoplasm; Neck; Preoperative; Proximal tibio-fibular joint; Communication; MR arthrography
• ISSN: 0364-2348; 1432-2161
• DOI: 10.1007/s00256-005-0036-6

The pathogenesis of intraneural ganglia remains controversial. Only half of the reported cases of the most common type, the peroneal nerve at the fibular neck, have been found to have pedicles connecting the cysts to neighboring joints detected with preoperative imaging or intraoperatively. We believe that all intraneural ganglia arise from joints, and that radiologists and surgeons need to look closely preoperatively and intraoperatively for connections. Not identifying these connections with imaging and surgical exploration has led not only to skepticism about an articular origin of the cyst, but also to a high recurrence rate after surgery. We present a patient who had two recurrences of a peroneal intraneural ganglion in whom a joint connection was not detected on previous MRIs and operations. Reinterpretation of the original films and high-resolution MRI demonstrated an "occult" joint connection to the superior tibiofibular joint. MR arthrography performed after exercise and 1 h delay, however, clearly showed the connection and communication. The joint connection was then confirmed at surgery through an articular branch. Postoperatively the patient regained nearly normal neurologic function, and follow-up MRI showed no cyst recurrence. MR arthrography with delayed imaging should be considered in cases of intraneural ganglia when a joint connection is not obvious on MRI.