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Deep ulnar intraneural ganglia in the palm

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Abstract

Background

While extraneural ganglion cysts are common and well known, intraneural ganglia are rare and misunderstood.

Materials

We describe a patient with an intraneural ganglion in an unusual location, the deep branch of the ulnar nerve in the palm. We confirmed a connection to the triquetral-hamate joint on preoperative high-resolution MRI and intraoperatively, and observed distal extension of the cyst, a variant pattern of propagation. We wondered if these intraneural cysts followed the principles of the unifying articular (synovial) theory rather than the de novo (degenerative) theory suggested by others. We reviewed patients with ulnar intraneural ganglia at the wrist for joint connections and the pattern of propagation.

Results

A total of 35 cases of ulnar intraneural ganglia at the wrist were identified, of which only 10 were joint connected. In 14 cases involving the deep ulnar branch, only 4 had joint connections. We hypothesized and proved that an unrecognized joint connection would be identified in the most recently reported case of a deep ulnar intraneural cyst in which a joint connection had not been identified. Propagation patterns supported descent in all cases involving the deep branch and proximal ascent in those of the main ulnar nerve (n = 18) or the dorsal cutaneous branch (n = 3). We believe that the orientation of the articular branches may play an important role in directionality in these intraneural cysts.

Conclusion

Contrary to popular opinion, our analysis of the literature would suggest that intraneural ganglia at this rare site obey the common principles of the articular theory described at more common sites for intraneural ganglia.

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Abbreviations

FS:

Fat suppression

FSE:

Fast spin echo

GRE:

Gradient recalled echo

MIP:

Maximum intensity projection

MRI:

Magnetic resonance imaging

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Authors and Affiliations

  1. Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA

    Robert J. Spinner, Huan Wang & Kimberly K. Amrami

  2. Department of Orthopedics, Mayo Clinic, Rochester, MN, 55905, USA

    Robert J. Spinner

  3. Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA

    Benjamin M. Howe & Kimberly K. Amrami

  4. Division of Plastic Surgery, University of Missouri, Columbia, MO, 65212, USA

    Stephen H. Colbert

  5. Mayo Clinic, Gonda 8-214 South, Rochester, MN, 55905, USA

    Robert J. Spinner

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  1. Robert J. Spinner
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  2. Huan Wang
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  5. Kimberly K. Amrami
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Correspondence to Robert J. Spinner.

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Spinner, R.J., Wang, H., Howe, B.M. et al. Deep ulnar intraneural ganglia in the palm. Acta Neurochir 154, 1755–1763 (2012). https://doi.org/10.1007/s00701-012-1422-1

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