Skeletal Radiology

, Volume 36, Issue 4, pp 281–292 | Cite as

The clinico-anatomic explanation for tibial intraneural ganglion cysts arising from the superior tibiofibular joint

  • Robert J. Spinner
  • Ali Mokhtarzadeh
  • Terry K. Schiefer
  • Kartik G. Krishnan
  • Michel Kliot
  • Kimberly K. Amrami
Scientific Article

Abstract

Objective

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.

Design

Retrospective clinical study and prospective anatomic study.

Materials

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.

Results

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.

Conclusions

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.

Keywords

MRI Intraneural ganglion Extraneural cyst Tibial nerve Unified theory Articular branch 

Abbreviations

MRI

magnetic resonance imaging

CT

computerized tomography

FSE

fast spin echo

MIP

maximum intensity projection

References

  1. 1.
    Friedlander HL. Intraneural ganglion of the tibial nerve. J Bone Joint Surg Am 1967; 49:519–22.PubMedGoogle Scholar
  2. 2.
    Mahaley MS Jr. Ganglion of the posterior tibial nerve. Case report. J Neurosurg 1990;40:120–4.Google Scholar
  3. 3.
    Malghem J, Vande Berg BC, Lebon CH, Lecouvet FE, Maldague BE. Ganglion cysts of the knee: articular communication revealed by delayed radiography and CT after arthrography. AJR Am J Roentgenol 1998;170:1579–83.PubMedGoogle Scholar
  4. 4.
    Spinner RJ, Atkinson JLD, Harper CM Jr, Wenger DE. Recurrent intraneural ganglion cyst of the tibial nerve. J Neurosurg 2000;92:334–7.PubMedCrossRefGoogle Scholar
  5. 5.
    Malghem J, Vande BB, Lecouvet F, Lebon Ch, Maldague B. Atypical ganglion cysts. JBR-BTR 2002;85:34–42.PubMedGoogle Scholar
  6. 6.
    Rezzouk J, Durandeau A. Compression nerveuse par pseudo-kyste mucoide: a propos de 23 cas. Rev Chir Orthop 2004;90:143–6.PubMedGoogle Scholar
  7. 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
  8. 8.
    Spinner RJ, Atkinson JLD, Tiel RL. Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory. J Neurosurg 2003;99:330–3.PubMedGoogle Scholar
  9. 9.
    Spinner RJ, Atkinson JLD, Scheithauer BW, Rock MG, Birch R, Kim TA, Kliot M, Kline DG, Tiel RL. Peroneal intraneural ganglia: the importance of the articular branch. Clinical series. J Neurosurg 2003;99:319–29.PubMedGoogle Scholar
  10. 10.
    De Seze MP, Rezzouk J, de Seze M, Uzel M, Lavingnolle B, Durandeau A, Casoli V, Midy D. Anterior innervation of the proximal tibiofibular joint. Surg Radiol Anat 2005;27:30–2.CrossRefGoogle Scholar
  11. 11.
    Wadstein T. Two cases of ganglia in the sheath of the peroneal nerve. Acta Orthop Scand 1931;2:221–30.Google Scholar
  12. 12.
    Harbaugh KS, Tiel RL, Kline DG. Ganglion cyst involvement of peripheral nerves. J Neurosurg 1997;87:403–8.PubMedCrossRefGoogle Scholar
  13. 13.
    Spinner RJ, Desy NM, Amrami KK. Cystic transverse limb of the articular branch: a pathognomonic sign for peroneal intraneural ganglia at the superior tibiofibular joint. Neurosurgery 2006;59:157–66.PubMedCrossRefGoogle Scholar
  14. 14.
    Anson BJ. Morris’ human anatomy, 11th ed. New York: McGraw-Hill; 1966, p. 378.Google Scholar
  15. 15.
    Hollinshead WH. Anatomy for surgeons: the back and limbs, 3rd ed. Philadelphia: Lippincott Williams & Wilkins; 1982. p. 789Google Scholar
  16. 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
  17. 17.
    Kennedy JC, Alexander IJ, Hayes KC. Nerve supply of the human knee and its functional importance. Am J Sports Med 1982;10:329–35.PubMedGoogle Scholar
  18. 18.
    Sunderland S, Hughes E. Metrical and non-metrical features of the muscular branches of the sciatic nerve and its medial and lateral popliteal divisions. J Comp Neurol 1946;85:205–22.CrossRefGoogle Scholar
  19. 19.
    Sunderland S. Nerves and nerve Injuries, 2nd ed. Churchill Livingstone, Edinburgh; 1978. p. 946–7.Google Scholar
  20. 20.
    Krishnan KG, Schackert G. Intraneural ganglion cysts: a case of sciatic nerve involvement. Br J Plast Surg 2003;56:183–6.PubMedCrossRefGoogle Scholar
  21. 21.
    Lang CJG, Neubauer U, Qaiyumi S, Fahlbusch R. Intraneural ganglion of the sciatic nerve: detection by ultrasound. J Neurol Neurosurg Psychiatry 1994;57:870–1.PubMedCrossRefGoogle Scholar
  22. 22.
    Groulier P, Benaim JL, Curvale G, Guillermet R. Compression of the posterior tibial nerve by a synovial cyst arising from the superior tibio-fibular joint. Report of a case. Rev Chir Orthop 1987;73:67–79.PubMedGoogle Scholar
  23. 23.
    Sansone V, Sosio C, da Gama Malchèr M, De Ponti A. Two cases of tibial nerve compression caused by uncommon popliteal cysts. Arthroscopy 2002;18:E8.PubMedCrossRefGoogle Scholar
  24. 24.
    Adn M, Hamlat A, Morandi X, Guegan Y. Intraneural ganglion cyst of the tibial nerve. Acta Neurochir (Wien) 2006;148:885–90.CrossRefGoogle Scholar
  25. 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
  26. 26.
    Sun JCL, Wallace C, Zochodne DW. Tibial mononeuropathy from a lower limb synovial cyst. Can J Neurol Sci 1995;22:312–5.PubMedGoogle Scholar
  27. 27.
    Deluca PF, Bartolozzi AR. Tibial neuroma presenting as a Baker cyst. A case report. J Bone Joint Surg Am 1999;81:856–8.PubMedGoogle Scholar
  28. 28.
    Monllau JC, Oriol A, Diago C, Marimón I. Histological diagnosis and tibial neuromas. To the editor. J Bone Joint Surg Am 2001;83:461.PubMedGoogle Scholar
  29. 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
  30. 30.
    Spinner RJ, Amrami KK, Rock MG. The use of MR arthrography to detect occult joint communication in a recurrent peroneal intraneural ganglion. Skeletal Radiol 2006;35:172–9.PubMedCrossRefGoogle Scholar
  31. 31.
    Spinner RJ, Edwards PK, Amrami KK. Application of three-dimensional rendering in joint-related ganglia. Clin Anat 2006;19:312–22.Google Scholar

Copyright information

© ISS 2006

Authors and Affiliations

  • Robert J. Spinner
    • 1
    • 2
    • 3
  • Ali Mokhtarzadeh
    • 4
  • Terry K. Schiefer
    • 4
  • Kartik G. Krishnan
    • 5
  • Michel Kliot
    • 6
  • Kimberly K. Amrami
    • 7
  1. 1.Department of Neurologic SurgeryMayo ClinicRochesterUSA
  2. 2.Department of Orthopedic SurgeryMayo ClinicRochesterUSA
  3. 3.Department of AnatomyMayo ClinicRochesterUSA
  4. 4.Mayo Clinic College of MedicineRochesterUSA
  5. 5.Department of Neurological SurgeryCarl Gustav Carus University HospitalDresdenGermany
  6. 6.Department of NeurosurgeryUniversity of WashingtonSeattleUSA
  7. 7.Department of RadiologyMayo ClinicRochesterUSA

Personalised recommendations