The clinico-anatomic explanation for tibial intraneural ganglion cysts arising from the superior tibiofibular joint
- 377 Downloads
To demonstrate that tibial intraneural ganglia in the popliteal fossa are derived from the posterior portion of the superior tibiofibular joint, in a mechanism similar to that of peroneal intraneural ganglia, which have recently been shown to arise from the anterior portion of the same joint.
Retrospective clinical study and prospective anatomic study.
The clinical records and MRI findings of three patients with tibial intraneural ganglion cysts were analyzed and compared with those of one patient with a tibial extraneural ganglion cyst and one volunteer. Seven cadaveric limbs were dissected to define the articular anatomy of the posterior aspect of the superior tibiofibular joint.
The condition of the three patients with intraneural ganglia recurred because their joint connections were not identified initially. In two patients there was no cyst recurrence when the joint connection was treated at revision surgery; the third patient did not wish to undergo additional surgery. The one patient with an extraneural ganglion had the joint connection identified at initial assessment and had successful surgery addressing the cyst and the joint connection. Retrospective evaluation of the tibial intraneural ganglion cysts revealed stereotypic features, which allowed their accurate diagnosis and distinction from extraneural cases. The intraneural cysts had tubular (rather than globular) appearances. They derived from the postero-inferior portion of the superior tibiofibular joint and followed the expected course of the articular branch on the posterior surface of the popliteus muscle. The cysts then extended intra-epineurially into the parent tibial nerves, where they contained displaced nerve fascicles. The extraneural cyst extrinsically compressed the tibial nerve but did not directly involve it. All cadaveric specimens demonstrated a small single articular branch, which derived from the tibial nerve to the popliteus. The branch coursed obliquely across the posterior surface of the popliteus muscle before innervating the postero-inferior aspect of the superior tibiofibular joint.
The clinical, MRI and anatomic features of tibial intraneural ganglion cysts are the posterior counterpart of the peroneal intraneural ganglion cysts arising from the anterior portion of the superior tibiofibular joint. These predictable features can be exploited and have implications for the pathogenesis of these intraneural cysts and treatment outcomes. These ganglion cysts are joint-related and provide further evidence to support the unifying articular theory. In each case the joint connection needs to be identified preoperatively, and the articular branches and the superior tibiofibular joint should be addressed operatively to prevent cyst recurrence.
KeywordsMRI Intraneural ganglion Extraneural cyst Tibial nerve Unified theory Articular branch
magnetic resonance imaging
fast spin echo
maximum intensity projection
- 2.Mahaley MS Jr. Ganglion of the posterior tibial nerve. Case report. J Neurosurg 1990;40:120–4.Google Scholar
- 7.Tseng K-F, Hsu H-C, Wang F-C, Fong Y-C. Nerve sheath ganglion of the tibial nerve presenting as a Baker’s cyst: a case report. Knee Surg Sports Traumatol Arthrosc 2006;14:880–4.Google Scholar
- 11.Wadstein T. Two cases of ganglia in the sheath of the peroneal nerve. Acta Orthop Scand 1931;2:221–30.Google Scholar
- 14.Anson BJ. Morris’ human anatomy, 11th ed. New York: McGraw-Hill; 1966, p. 378.Google Scholar
- 15.Hollinshead WH. Anatomy for surgeons: the back and limbs, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1982. p. 789Google Scholar
- 16.Standring S. Gray’s anatomy: the anatomical basis of clinical practice. 39th ed. New York, Edinburgh: Elsevier Churchill Livingstone; 2005. p. 1484.Google Scholar
- 19.Sunderland S. Nerves and nerve Injuries, 2nd ed. Churchill Livingstone, Edinburgh; 1978. p. 946–7.Google Scholar
- 25.Spinner RJ, Dellon AL, Rosson GD, Amrami KK. Tibial intraneural ganglia in the tarsal tunnel? Is there a joint connection. Clin Anat 2005;18:640–1.Google Scholar
- 29.Spinner RJ, Scheithauer BW, Desy NM, Rock MG, Holdt FC, Amrami KK. Coexisting secondary intraneural and vascular adventitial ganglion cyst of joint origin: a causal rather than a coincidental relationship supporting an articular theory. Skeletal Radiol 2006;35:734–44.Google Scholar
- 31.Spinner RJ, Edwards PK, Amrami KK. Application of three-dimensional rendering in joint-related ganglia. Clin Anat 2006;19:312–22.Google Scholar