Download to be by no means a rare occurrence, for no fewer than eight cases

INTRANEURAL
GANGLION
OF
ATHOL
Invasion
joint
of the
seems
treated
lateral
by the
author
PARKES,
popliteal
be by no means
to
a period
fifteen
eight
patients
ofjust
with
to seventy-four,
Case
1-A
milk
complaining
pain
was
was
a
described,
delivery
of sudden
throbbing
tender
onset
swelling
made.
had
and
the
the
The
patient
than
the
superior
eight
cases
tibio-fibular
were
seen
and
six years.
male
left
worse
and
of
patient
was
was discharged.
one
female
out-patient
knee.
The
: their
ages
department
There
at night.
head
from
no fewer
REPORTS
were
in the
and
behind
was
subsided
of pain
in character
osteomyelitis
seven
arising
for
over
NERVE
SCOTLAND
an average
age of fifty.
aged fifteen
came to the
boy
POPLITEAL
by a ganglion
occurrence,
CASE
Of the
LATERAL
GLASGOW,
nerve
a rare
within
THE
was
only
the
fibula
and
kept
under
observation;
from
in January
no history
positive
ranged
1952
of injury
finding
a provisional
after
and
the
on examination
diagnosis
of
early
one
the
pain
week
44
PL)
I
FIG.
Transverse
section
oflateral
April
1952 he reported
of the leg to the dorsum
back with recurrence
of the foot.
It was
In
front
the
head
of
referred
to
muscles
of
distribution
nerve
contain
and
784
the
fibula
connected
with
Examination
anterior
tibial
lateral
the
then
compartment
popliteal
of
nerve.
5.)
of the pain, which now radiated
down
the
realised
that the tender
swelling
behind
lateral
revealed
<
that
the
popliteal
there
leg
nerve
was
and
A diagnosis
and
virtual
disturbance
of
the
of
tumour
patient
paralysis
of the
of
was
all
the
sensation
in
the
lateral
popliteal
made.
exploration
a quantity
amongst
was
author.
of the
was
At
the
the
(
poplitealnervecontainingmultilocularganglion.
the
in
April
of yellowish
nerve
bundles.
1952
the
jelly-like
The
last
inch
material
material
of
the
which
extended
lateral
popliteal
was
for
THE
within
nerve
was
the
sheath
some
distance
into
JOURNAL
OF
BONE
AND
found
of the
the
JOINT
two
to
nerve
main
5URGERY
GANGLION
INTRANEURAL
branches
of
without
the
histological
of
nerve.
sacrificing
The
nerve
was
muscles,
of
In May
was
1953
large
a
popliteal
fibula.
of
affected
the
the
nerve
so-called
ganglion
Case
2-A
of
a six
dorsiflexion
weakness
of all the
There
was diminution
the
on
was
popliteal
to
nerve
forty-seven
nerve
1954 a typical
it completely
remove
were
inevitably
was
connected
This
pedicle
tibial
Within
six months
of the operation
muscles.
The patient
was followed
sign
of any
forty-one-year-old
under
treatment
His
foot
on the lateral
pain referred
muscles
diagnosis
of ganglion
October
again
it with
and
VOL.
inferior
the
inferior
cauterised
sensory
43 B,
nerve
was
tarsus.
cysts
epithelium
The
sheath
middle
subsequently
The report
are present
and
on the
within
contain
appearances
from
on the
duration.
a medical
dorsum
He
mucoid
are
those
of a
of the
neurological
of
but
and
full power
in the peronei.
a soft fleshy
swelling
was
fibula.
removal
aspect
clinic
of the left foot and with
was found
to have definite
A provisional
it was
of the
diagnosis
nerve
sheath.
An
of the nerve fibres
that
the ganglion
found
superior
patient
had regained
up for two years after
tibio-fibular
full power
operation
had
pain
come
jacket,
in the
on
agent
was referred
from
for prolapsed
intervertebral
joint.
in all the
and there
suddenly
street.
and
manipulation
left
knee
when
he
nerve
behind
the
distribution
of the
by the
anterior
tibial
diminished
of the
“
jerked
lateral
popliteal
lumbar
the
himself
but
there
distribution
nerve
was
of the
was
front
anterior
was no
made
and
aspect
with
paralysis
NO.
4,
NOVEMBER
of the
pure
of the
1961
superior
carbolic
lateral
tibio-fibular
acid.
popliteal
After
nerve.
joint.
the
No
operation
Pressure
complete
good
was
recovery
spine
and
leg to the
the
to avoid
on the swelling
paralysis
of all
power
popliteal
was
of function
in the
nerve.
A
at operation
from the
in diameter
pedicle
other
noticed
weakness
a swelling
was
confirmed
there
where
had
of
voluntary
lateral
The
hospital
Treatment
in attempting
“
the onset he had
On examination
head of the fibula.
nerve.
There
was
nerve
in the
the
down
About
six months
after
of extension
of the toes.
popliteal
to the
was
of
radiating
another
disc.
1954.
Again
an attempt
was made
to dissect
the ganglion
the ganglion
was found
to have a pedicle
half a centimetre
stump
L(8)
of
supplied
Sensation
its
stages
the
the
in a plaster
a child in the
of the ankle
peronei.
and
the
up to the
ganglion
was found
within
the
but during
this procedure
some
commission
for two years
complaint
of the
colliding
with
of dorsiflexion
in
within
foot-drop
fibres.
head
latter
in the
ablated.
immobilisation
dorsum
the
the
with
anterior
pain
recurrence.
measures.
found
caused
During
pedicle
was
Case
3-A
he had been
included
damaged.
by a small
in the
severe
extended
“
referred
the
definite
for several
inches
below
the head
it was decided
to resect the whole
tibial compartment
dorsum
of the foot
behind
the
1).
was
anterior
on the
that
now
by cubical
(Fig.
“
found
which
front
of the
Multilocular
of nerve
No
power
persistent
permanent
months’
history
of pain
of the ankle
of ten weeks’
was made.
in March
made
or lined
fascicles
muscles
of the
of sensation
lateral
of Schwannoma
At operation
unlined
aged
with
resulting
on
component
treatment.
nerve
pain
posterior
to the
was as follows:
possible
report
the softer
full
and
it was
branches
of the
and the severe
The
regained
fluid
as
The
for a fibro-lipoma.
further
when
biopsy.
resembles
recurred
gelatinous
popliteal
of lateral
1954
weakness
attempt
are
had
had
as completely
for
be taken
necessitated
nerves.
between
warehouseman
in March
present
cysts
situated
tissue
patient
re-explored,
of tibialis
of the nerves
The
are
the
containing
of the
the
it could
swelling
and down
both
of the recurrence
portions
sheath.
parts
the
sent
785
NERVE
removed
was
At places
“
nerve
was
cyst
space
Because
; they
1953
nerve
examination
material
at other
popliteal
by transplantation
histological
the
lateral
multilocular
of the
of the
treated
the
:
POPLITEAL
was
specimen
out.”
operation
by April
LATERAL
material
the
as follows
be made
of this
but
distribution
and
B and
a Schwannoma-Ant.
Schwann
cells could
Within
a month
tibial
pathological
fibres
examination
OF THE
was
nerve fibres
connecting
divided
complete
took
and
motor
place
but
786
A.
there
was
diagnosis
Case
4-A
with
a nine
no palpable
recurrence
of ganglion
was
retired
weakness
of
found
popliteal
At
aged
history
loss
nerve
extending
up from
attempt
four
Eight
years
right
region
1955
the
and
of
lateral
fibular
a typical
of the
leg
and
in the
of the
referred
right
ankle
from
a medical
foot
and
nerve
fibula
found
5-Figure
tape
at the
5-A
upper
sheet
1956.
He had
had been done
was discovered
1955
the nerve
cysts
end
of the whole
of the
and
it was
completely
field
the
There
1956
to contain
arising
thought
the
length
-
is round
of the lateral
the
medial
1955
of
patient
was
was
a palpable
of the
sheath
lateral
of the
nerve
was
found
A pedicle
:
3
the nerve
between
forty-seven
popliteal
popliteal
was
each
filled
with clear
evacuated
completely.
that
on
origin
the
there
was
1955
the
the
the
hyperalgesia
the
nerve
was
nerve
by ganglion.
Figure
3-The
nerve.
the two
referred
The
pedicle
tapes.
from
another
in the
superior
lateral
hospital
in April
most
(Fig.
but
anterior
author
of
when
sciatic
3) and
this
THE
the
its
(Fig.
was
JOURNAL
1956,
muscles
again
length
was
been
a
became
A pedicle
ligated
and
BONE
was
at its upper
2).
OF
had
following
nerve.
whole
of which
the
communicating
which
in March
tibia!
portion
from
neck
compartment,
distribution
the
bulbous
nerve
joint
the
such
as is present
in a
to dissect
out the cyst
unidentified
anterior
recovering,
cutaneous
by
popliteal
tibio-fibular
a narrow
and
re-explored
the
gelatinous
fluid
It was impossible
of the
were
enlarged
ganglion,
ofthe
probably
muscles
operation,
nerve
was
a multilocular
from
aged
“
before
swelling
In June
below
worker
By November
paralysed
paralysed.
just
metal
the joint.
strain,
May
complained
of right-sided
sciatica
since early in 1953.
In 1954 a myelograph
which
had suggested
the presence
ofarachnoiditis,
but later that year a swelling
on the lateral
popliteal
nerve in the region
ofthe
head ofthe
fibula.
In January
had been explored
by the late Mr Eric Paterson
and was found
to contain
in its substance
The cysts were
ganglion.”
with
the
FIG.
2-Invasion
is seen joining
walls
there
The
history
The
of ganglion
inches.
2
FIG.
Case
two
and
in
weeks’
toes.
within
three
years.
tissue.
clinic
the
A diagnosis
for
oftwo
excised
a seven
popliteal
-
Case
of the
of
was
of the
a follow-up
extension
head.
ganglion
neck
during
examination
the ganglion
the ganglion
of
No
was
in
of function
level
nerve
with
the superior
tibio-fibular
joint.
This
was divided
and
the
were
evacuated
through
multiple
incisions
in the nerve
sheath.
was made
to excise
the wall of the ganglion.
months
after the operation
there was complete
return
of function
in the nerve and
afterwards
there was no sign of any recurrence.
connecting
contents
the
pain
the
in the
nerve was made.
operation
in June
ofthe
by histological
seventy-four
of
of
partial
on the
ofswelling
confirmed
dorsiflexion
to have
swelling
man
weeks’
PARKES
ANE)
was
divided.
JOINT
found
limit
found
No
SURGERY
INTRANEURAL
attempt
was
made
by incising
the
Twenty-one
and
was
free
GANGLION
to excise
the ganglion
of pain.
There
was
FIG.
6, 7 and
clinical
which
All
8-These
was
in
the
patients
swelling
on
the
is round
patients
to
the
position,
were
recovered
excellent
at
nearly
region
of the
popliteal
every
fibular
head
almost
simple
was
but
later
pedicle
in the
5
July
treated
of
nerve
in Case
nerve
in all muscles
nerve.
ganglion.
between
were
power
nerve.
popliteal
of the
decompression
of the
fifteen
lateral
was decompressed
full
of the
in
all
function
least
this
case
had
seen
and
appearance
1956
and
7 is shown
and
June
by ablation
the ganglion
none
1958.
in Figures
had
All
of the pedicle,
by incision
and
any
5.
4 and
recurrence
of
months.
SUMMARY
Pain-In
the
first
above
and
The
after
patient
of swelling
ganglion
tape
contents.
nerve
the
787
NERVE
but the ganglion
FIG.
5-The
similar
constant
of the
POPLITEAL
the nerve,
no recurrence
4-Multilocular
three
features
expression
from
LATERAL
4
7-Figure
Figure
had
wall
THE
nerve
sheath
at several
levels.
months
after this operation
Case
Cases
OF
OF
the
CLINICAL
initial
it was
FEATURES
symptom.
referred
to
Usually
the
it was
cutaneous
first
localised
distribution
to the
of the
lateral
nerve.
or complete
Paresis-Partial
supplied
by
the
anterior
paralysis
tibial
nerve
of the
was
muscles
always
of the
present.
anterior
Seldom
compartment
the
were
of the
peroneal
leg
muscles
affected.
Sensory
disturbance-There
distribution
ofthe
Palpable
swelling
extending
well
was
lateral
of the
up
into
lateral
the
was
1 the
probably
sacrificed
After
two
but
popliteal
OF
presence
some
nerve,
popliteal
SUMMARY
In Case
generally
popliteal
nerve
space
was
OPERATIVE
of a pedicle
was
blunting
in one
of sensation
throughout
or two
cases
there
the
head
of the
behind
was
the cutaneous
some
fibula
hyperalgesia.
and
sometimes
present.
PROCEDURES
AND
not
and
it was
dealt
with
(Cases
after
the
pedicle
suspected
RESULTS
not
seen.
The
nerve
unnecessarily.
operations
at which
the
pedicle
was
not
of the
swelling
1 and
5) the swelling
recurred.
In
(seven
VOL.
no
case
cases)
43B,
NO.
even
4,
was
there
when
NOVEMBER
recurrence
no
attempt
1961
was
made
to remove
the
ganglion.
had
been
extirpated
788
A. PARKES
Satisfactory
(Case
recovery
1) the
ganglion
nerve
was
of nerve
excised,
function
and
occurred
in the
other
in all except
(Case
3) an
two
attempt
cases.
was
In one
made
of these
to excise
the
completely.
DISCUSSION
Pathology-This
likely
been
condition
that some
intraneural
has
reported
ganglia.
been
described
cases ofmucoid
In attempting
before,
notably
degeneration
to understand
ofthe
by Brooks
(1952),
and
it seems
lateral
popliteal
nerve have actually
the pathology
of the condition
there
are two obvious
difficulties
: how does a ganglion
arising
from the superior
tibio-fibular
joint
come
to lie within
the sheath
of the lateral
popliteal
nerve,
and why does
the growth
of
such
a ganglion
seem
to depend
upon
its connection
with
the joint?
The
only
possible
answer
to the first
question
seems
to
Lateral
be that
the ganglion
initially
tracks
along
the sheath
of the
small
lateral
N arve
6
FIG.
Diagram
showing
articular
branchsupplyingsuperior
recurrent
popliteal
follows
consists
histology
:
of one
within
and
The
examined
author
has
and
direction
(Fig. 6).
with
the pedicle
The fact that the
this
it certainly
articular
to correspond
of the
recurrent
ganglion
articular
of the
was
found
of the ulnar
a carpal
joint
in
several
as
seen
branch
at
and
operation
arises
from
anterior
anterior
in the
compartment.
pedicles
artery
vein and nerve
bundle
It is of interest
that the author
and
the
in position
that part of the trunk
which
is about
to become
the
tibial
nerve
probably
accounts
for the muscles
of the
compartment
being
more
severely
affected
than
those
removed
at operation
(Case
This is a thin-walled
cyst containing
clear sticky
fluid.
of dense
acellular
collagen
with a simple
synovial
lining.
the
off joint
from
branch
seems
“
within
tibio-fibular
is given
the sheath
of the main
nerve
where
extend
mainly
in a proximal
direction.
cadavera
small
sheath
it with
to branch
the superior
which
thus
comes
to lie
it is free to enlarge
lateral
The
articular
nerve
adventitia
is present
has operated
of
an
(Fig. 7).
on two
“
artery.
One
cases
was
7) was
in which
burrowing
vessels
in the lower
forearm
(Fig.
8) and had
; the other was within
the sheath
of the radial
reported
Microscopically
At one part
on
the
of the
a dissecting
as
wall
wall a
ganglion
proximally
within
the
a pedicle
which
connected
artery
on the dorsal
aspect
the carpus.
Its pedicle
was emerging
from
between
the bases
of the first and second
metacarpals
and could
easily
have been arising
from one of these carpo-metacarpal
joints.
The other
interesting
question
could,
it seems,
only
be answered
satisfactorily
if one
of
accepted
the possibility
of the gelatinous
content
of the ganglion
originating
in the joint
and
passing
via the pedicle
into the sac rather
than
being
secreted
by the wall of the sac itself.
If this be so, then ganglia
occurring
elsewhere
may perhaps
not require
complete
excision
of
the sac provided
that a pedicle
can be located
and removed.
Differential
diagnosis-The
possibilities
of error
provisional
osteomyelitis
ofthe
diagnoses
with which
the
head of the fibula, prolapsed
peripheral
the lateral
and Schwannoma.
nerve,
only the
diverse
the
neuritis
popliteal
diagnosis
will
Treatment-It
of
the pedicle
decompression
within
the
nerve
become
clear
seems from
connecting
of the
sheath
Provided
last-mentioned
in diagnosis
are
exemplified
above
patients
intervertebral
were referred.
disc, poliomyelitis,
a palpable
should
swelling
is sought
cause
any difficulty.
by
the
widely
These
included
arachnoiditis,
and found
on
In that case
at exploration.
this series that
the ganglion
multilocular
is unnecessary
the correct
with
the
cyst.
and
treatment
superior
Any attempt
to
liable
to damage
THE
is early exploration,
tibio-fibular
joint
remove
nerve
JOURNAL
the wall
fibres.
OF
BONE
extirpation
and
simple
of the
AND
JOINT
sac
from
SURGERY
INTRANEURAL
GANGLION
OF
THE
LATERAL
7
of ganglion
POPLITEAL
NERVE
FIG.
Case
7-Section
of wall
FIG.
Transverse
VOL.
43 B,
L-l(8)
NO.
4,
NOVEMBER
section
1961
of
ganglion
within
pedicle.
(
t
32.)
8
adventitia
of
ulnar
vessels.
( x 51.)
789
790
A. PARKES
SUMMARY
1
.
Eight
cases
of intraneural
a period
of six years
2. In seven
of these
probably
3. The
4. The
I wish
ganglion
are described.
a pedicle
was
of the
found
lateral
arising
popliteal
from
the
present
in the remaining
case.
essential
step at operation
is to find and extirpate
implications
of these findings
are discussed.
to express
my thanks
to Dr
Mary
Catto
for
the
nerve
superior
the
histological
seen
at operation
tibio-fibular
within
joint-it
was
pedicle.
examinations
and
for
her
help
with
the
photomicrographs.
REFERENCE
BROOKS,
D. M. (1952):
Nerve
Compression
by Simple
Ganglia.
Journal
THE
ofBone
JOURNAL
andJoint
OF
BONE
Surgery,
AND
JOINT
34-B,
391.
SURGERY