Background
Anterior wrist ganglion, which mainly originates from the radiocarpal joint, accounts
for 15%-20% of wrist ganglions [[1],[2]]. Anterior wrist ganglion show high recurrence rates [[3]], and we experienced a recurrent ganglion related to incomplete surgical resection.
Although some previous reports suggest that carpal tunnel syndrome is occasionally
caused by ganglion cysts [[4]], few reports demonstrate median nerve neuropathy in the forearm due to a ganglion
cyst. Furthermore, no reports have suggested that recurrence of anterior wrist ganglion
that originated from the Scaphotrapezial joint caused median nerve neuropathy in the
forearm. Here, we report a rare case of anterior wrist ganglion recurrence, which
originated from the Scaphotrapezial joint, which caused median nerve neuropathy in
the forearm.
Case presentation
A 47-year-old right-handed housewife noted a soft swelling on the volar aspect of
her left distal forearm 3 years ago. She was diagnosed with a ganglion, and local
resection surgery was performed twice at another hospital. Similar methods were used
to perform both operations, which involved intralesional resections of the cyst with
1-cm skin incisions of the volar aspect of the forearm without following the stalk
of the cyst. However, 1 year after the last surgery, the swelling reappeared and was
associated with numbness and pain in the radial volar aspect of the hand, thumb, index
finger, and middle finger. She came to our hospital and a physical examination revealed
decreased sensitivity of the left median nerve area associated with a positive Tinel’s
sign on the volar aspect of the distal forearm. The patient had no evidence of polyneuropathy,
vasculitis, tuberculosis, hypertrophic tenosynovitis, sarcoidosis, gout, or other
systemic disorders. She did not give history of previous trauma except for the surgeries
at the other hospital, and her wrist joint showed no signs of carpometacarpal arthrosis
or instability. The nerve conduction velocity (44.2 m/s) and terminal latency (5.94
ms) of the left median nerve were prolonged and delayed respectively, compared with
those of the contralateral nerve (58.0 m/s, 4.12 ms). A radiograph of her left forearm
showed no space-occupying lesions around the median nerve and carpal tunnel, and significant
osteoarthritic changes of the carpal bones were not observed. Magnetic resonance imaging
revealed that the multi-cystic lesion originated from the Scaphotrapezial joint and
had expanded beyond the wrist ([Figure 1]).
Figure 1
Magnetic resonance imaging results. (A, B) T2-weighted fat-suppressed magnetic resonance
image showing origination of the multicystic lesion (arrow) from the Scaphotrapezial
joint (A; arrow head) and expansion to the distal forearm beyond the wrist (B).
We decided to perform surgery. Exploration of the left median nerve showed that it
was compressed by a large ovoid cystic lesion at the distal forearm near the proximal
end of the carpal tunnel ([Figure 2]). We resected the cystic lesion, following the stalk of the cyst to the Scaphotrapezial
joint with elongation of the incision, and released the carpal tunnel simultaneously.
Nerve compression was observed only around the cyst in the distal forearm and not
in the carpal tunnel. Her symptoms had disappeared 1 week after surgery, and pathological
examination of the resected cystic lesion showed an appearance consistent with a ganglion.
On the basis of these findings, we diagnosed median nerve neuropathy in the forearm
due to recurrence of anterior wrist ganglion originated from the Scaphotrapezial joint.
Complications or recurrent symptoms were absent 13 months after surgery.
Figure 2
Intraoperative view of the distal forearm showing (A) the median nerve (arrow head)
compressed by the large ovoid cyst (arrow) and (B) the large ovoid cyst expanded to
the volar of the forearm passing between the flexor carpi radialis (*) and flexor
digitorum superficialis (*)
Discussion
Carpal tunnel syndrome is a common compressive neuropathy of the upper extremities
and occasionally caused by ganglion cysts [[5]]. Kerrigan et al. reviewed ganglion cysts and carpal tunnel syndrome [[4]] and found some recent reports of carpal tunnel syndrome caused by space-occupying
lesions associated with ganglions [[6],[7],[8]]. Although some of these reports have featured typical neuropathies caused by ganglions
[[9]], none clearly demonstrated a relationship between recurrence of anterior wrist
ganglion and median nerve neuropathy in the forearm. Here, we describe a case of recurrent
anterior ganglion that originated from the Scaphotrapezial joint and caused compression
of the median nerve in the distal forearm.
Anterior wrist ganglion is a common soft-tissue tumor in the wrist and may originate
from the radioscaphoid or scapholunate joint [[2],[3]]. Ganglions that originate from the Scaphotrapezial joint are less frequent (33%;
35/104) than those that originate from the Radioscaphoid joints (65%; 68/104), and
there is no report of such ganglions that have expanded to the forearm and compressed
the median nerve. This case showed that a ganglion originating from the Scaphotrapezial
joint can expand to the forearm. Cases with anterior wrist ganglion have high recurrence
rates. The recurrence rate for cases treated with aspiration is 83% (20/24) and for
those treated by surgical resection is 20% (12/60) [[2]]. In the present case of anterior wrist ganglion recurrence in a 47-year-old woman,
the origin of the cyst was not explored during the earlier local resections. Because
of the high recurrence rate, it has been suggested that greater attention should be
given to determining the origin of the anterior wrist ganglion by careful dissection
of the stalk [[2]]. In addition, it has been reported that recurrent ganglion cysts have the potential
to cause severe neuropathy [[10]]. Thus, on the basis of these previous reports, we believe that the previous surgeries
may have been incomplete, which may have induced expansion of the ganglion and caused
median nerve neuropathy by compression. We performed carpal tunnel release simultaneously
to observe the median nerve in the carpal tunnel. It remains to be seen whether carpal
tunnel release may contribute to recovery in this case because there were no indications
of median nerve compression in the carpal tunnel.
On the basis of the findings in this case and those in the previous reports, we suggest
that primary total resection of the anterior wrist ganglion with a wide incision to
identify structures at risk, such as the radial artery, and allow sufficient exposure
to identify the stalk of the ganglion following it down to its capsular attachment.
In addition, preoperative detection of the origin of the wrist ganglion by MRI or
ultrasound is useful to avoid incomplete surgery. The necessity of carpal tunnel release
when the median nerve is compressed in the forearm is controversial, but we believe
that carpal tunnel release contributes in special cases where the ganglion expands
beyond the wrist and may compress the median nerve in the forearm.
Conclusions
Cases with anterior wrist ganglion have high recurrence rates and require extra attention
during their treatment. This case suggests that anterior wrist ganglion should be
completely excised during primary surgery. Incomplete resection may induce widening
of the cyst and cause several disorders including median nerve compression.
Consent
Written informed consent was obtained from the patient for publication of this case
report and any accompanying images. A copy of the written consent is available for
review by the editor-in-chief of this journal.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
KO performed the surgery, performed all pertinent literature reviews on the subject,
and drafted the manuscript. JM assisted KO in the surgery. TK, HM, TM, and HY helped
to draft the manuscript. All authors read and approved the final manuscript.
Cite this article as: Okada et al.: Median nerve neuropathy in the forearm due to recurrence of anterior wrist ganglion
that originates from the scaphotrapezial joint: Case Report. Journal of Brachial Plexus and Peripheral Nerve Injury 2012 7:1.
