Intraneural Peroneal Ganglion Cyst Excision in a Pediatric Patient
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Case: A 14-year-old female presented with a profound foot drop after trauma to the right leg. Clinical examination and electrodiagnostic studies demonstrated a dense palsy of the common peroneal nerve. Magnetic resonance imaging revealed an intraneural peroneal ganglion cyst at the fibular neck. Surgical treatment included decompression and transection of the articular branch to the proximal tibiofibular joint. At the 1-year follow-up, the patient demonstrated complete recovery of peroneal nerve function. Conclusions: This case demonstrates a rare finding of a pediatric intraneural peroneal ganglion cyst. The presentation and treatment is well-documented and adds depth to the literature on a sparsely reported condition.Keywords:
Ganglion cyst
Foot drop
Common peroneal nerve
Presentation (obstetrics)
Superficial peroneal nerve
Extraneural ganglion cysts of the peroneal nerve have rarely been reported in the literature. This paper reports a large extraneural ganglion cyst compressing the peroneal nerve and causing pain in the leg, and foot drop. Electromyographic study revealed a deep peroneal nerve lesion, but the superficial branch was spared. Magnetic resonance imaging showed a cystic tumor located below the superior tibiofibular joint. A complete surgical resection was undertaken. During surgery multimodal intraoperative neurophysiological monitoring was performed. An extraneural ganglion cyst should be considered in the differential diagnosis of painful foot drop. Electrophysiological and radiological studies should be carried to rule out other causes of foot drop.
Foot drop
Ganglion cyst
Superficial peroneal nerve
Common peroneal nerve
Tibial nerve
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Intraneural ganglion cysts that occur within the common peroneal nerve are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presents with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to the flexor hallucis longus to a motor branch of the anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, and no evidence of recurrence and was able to weight bare without the need of orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.Les kystes intraneuraux de ganglions qui se forment sur le péronier proximal sont une rare cause de pied tombant. La norme actuelle du traitement de ce type de kyste sur le péronier proximal comprend 1) la décompression du kyste et 2) la ligature de la ramification du nerf articulaire pour éviter une récurrence. Le transfert des nerfs est une stratégie limitée dans le temps pour récupérer la dorsiflexion de la cheville en cas de paralysie importante du péronier. Cependant, cette modalité n’a pas été utilisée pour traiter des kystes intraneuraux du ganglion touchant le nerf du péronier proximal. Les auteurs présentent le cas d’une paralysie du péronier proximal causée par un kyste intraneural de ganglion chez une femme de 74 ans. La patiente a consulté parce qu’elle ressentait une douleur dans le péronier proximal droit et avait un pied tombant depuis cinq mois. Elle a subi une décompression du kyste, une ligature de la ramification du nerf articulaire et le transfert du nerf de la ramification motrice du long fléchisseur de l’hallux à une ramification motrice du muscle du tibia antérieur. Au dernier suivi, elle présentait une récupération complète (M4+) de la dorsiflexion de la cheville, ne souffrait plus d’aucune douleur et n’avait aucune trace de récurrence. Elle pouvait supporter son poids sans orthèse. Compte tenu de la morbidité minime au site du donneur et de la récupération de la dorsiflexion de la cheville, le présent rapport fait ressortir l’importance d’envisager le transfert précoce des nerfs en cas de neuropathie importante du péronier causée par un kyste intraneural de ganglion.
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Case: A 14-year-old female presented with a profound foot drop after trauma to the right leg. Clinical examination and electrodiagnostic studies demonstrated a dense palsy of the common peroneal nerve. Magnetic resonance imaging revealed an intraneural peroneal ganglion cyst at the fibular neck. Surgical treatment included decompression and transection of the articular branch to the proximal tibiofibular joint. At the 1-year follow-up, the patient demonstrated complete recovery of peroneal nerve function. Conclusions: This case demonstrates a rare finding of a pediatric intraneural peroneal ganglion cyst. The presentation and treatment is well-documented and adds depth to the literature on a sparsely reported condition.
Ganglion cyst
Foot drop
Common peroneal nerve
Presentation (obstetrics)
Superficial peroneal nerve
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Introduction: Intraneural ganglion cysts can arise from the peroneal nerve at the lateral knee secondary to synovial fluid tracking along the articular branch and transforming within the nerve into a mucinous cyst, resulting in nerve compression.
Case Report: A 17-year-old right-handed male presented with a four-month history of right foot drop. He is physically active and attributed the foot drop to a sprained ankle. EMG/NCS showed a right common peroneal neuropathy distal to the innervation of the biceps femoris short head with active denervation. MRI showed an intraneural ganglion cyst in the common peroneal nerve starting at the level of biceps femoris. On exam, he had right foot drop and sensory deficits referable to the peroneal distribution, along with a right steppage gait. He had successful decompression of the ganglion cyst, excision of the articular branch and resection of the proximal tibiofibular joint, with clinical improvement.
Conclusion: Early recognition and surgical treatment leads to better outcomes for patients when an intraneural ganglion cyst results in neurologic deficits. Physical activities and trauma, which increase stress on the knee joints, may predispose ganglion cyst formation within peroneal nerves. Fibers of the deep peroneal nerve may be preferentially affected when compared to the superficial peroneal nerve. Disconnection of the articular branch and proximal tibiofibular joint resection may decrease risk of recurrence.
Ganglion cyst
Foot drop
Common peroneal nerve
Superficial peroneal nerve
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Peroneal Intraneural Ganglion Cyst is a rare condition that only a few cases have been reported in the literature. A 55 years old middle aged Lady presented at our Outpatient Department with complaints of pain over lateral aspect of right knee and leg for the last 1 month. She also complained about the inability to extend the ankle and the toes for 1 week. No recent history of trauma was there. She has been complaining about tingling and Numbness over right foot for the last 1 month. Because of its radiological appearance and atypical clinical course, the lesion was diagnosed as Peroneal Intraneural ganglion Cyst. This 55 years old female patient, with no history of comorbidities, with above mentioned complaints, initially was managed elsewhere with conservative management. Referred to Orthopaedic surgeon for further management. After all necessary investigations, was planned for definitive management, which was Decompression of the Common peroneal nerve along with Neurolysis, Ganglion Cyst dissected and Disarticulation of proximal Tibio Fibular Joint.
Ganglion cyst
Foot drop
Neurolysis
Common peroneal nerve
Superficial peroneal nerve
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OBJECTIVE To localize the superficial peroneal nerve in surface of the leg and to provide a safety surgical approach to the fibula. METHODS Sixty-six adult legs preserved by 4% formaldehyde solution were studied involving 42 male and 24 female with the average age of 69 years old ranging from 37 to 88 years. There were 35 cases in left and 31 in right. According to the common lateral surgical approach to the fibula, the superficial peroneal nerve and its branches were dissected in 66 embalmed leg-ankle-foot specimens. The specimens were observed and measured. RESULTS The superficial peroneal nerve branched from the common peroneal nerve near the anterolateral aspect of the neck of the fibula, transversing through the muscle, deep fascia and superficial fascia. In 12 cases of specimens, superficial fibular nerve extended to the foot with no branches, in 50 cases of specimens it branched out into two before piercing the deep fascia, in the rest 4 cases of specimens, it branched out into two before piercing the muscle. CONCLUSION To avoid injuring the superficial peroneal nerve, the surgical approach to the 2/3 upper part of the fibula is at posterior crural septum, to the 1/3 lower part of the fibula is at anterior crural septum.
Superficial peroneal nerve
Common peroneal nerve
Deep fascia
Rest (music)
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Intraneural ganglion cysts, which occur within the common peroneal nerve, are a rare cause of foot drop. The current standard of treatment for intraneural ganglion cysts involving the common peroneal nerve involves (1) cyst decompression and (2) ligation of the articular nerve branch to prevent recurrence. Nerve transfers are a time-dependent strategy for recovering ankle dorsiflexion in cases of high peroneal nerve palsy; however, this modality has not been performed for intraneural ganglion cysts involving the common peroneal nerve. We present a case of common peroneal nerve palsy secondary to an intraneural ganglion cyst occurring in a 74-year-old female. The patient presented with a 5-month history of pain in the right common peroneal nerve distribution and foot drop. The patient underwent simultaneous cyst decompression, articular nerve branch ligation, and nerve transfer of the motor branch to flexor hallucis longus to a motor branch of anterior tibialis muscle. At final follow-up, the patient demonstrated complete (M4+) return of ankle dorsiflexion, no pain, no evidence of recurrence and was able to bear weight without the need for orthotic support. Given the minimal donor site morbidity and recovery of ankle dorsiflexion, this report underscores the importance of considering early nerve transfers in cases of high peroneal neuropathy due to an intraneural ganglion cyst.
Foot drop
Ganglion cyst
Common peroneal nerve
Superficial peroneal nerve
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Common peroneal nerve
Superficial peroneal nerve
Foot drop
Entrapment
Etiology
Presentation (obstetrics)
Entrapment Neuropathy
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One of the causes of foot drop is compression of the common peroneal nerve caused by space-occupying lesions such as a synovial cyst or a ganglion cyst. Most previous reports have involved compressive common peroneal neuropathy by intraneural ganglion cysts and synovial cysts. Compression of the peroneal nerve by extraneural ganglion cysts is rare. We report a rare case of compressive common peroneal neuropathy by an extraneural ganglion cyst.A 46-year-old man was hospitalized after he reported a right foot drop for 1 mo. Manual muscle testing revealed scores of 1/5 on dorsiflexion of the right ankle. Hypoesthesia and paresthesia on the right lateral leg and foot dorsum were noted. He was diagnosed with a popliteal cyst by using electrophysiologic study and popliteal ultrasound (US). To facilitate common peroneal nerve (CPN) decompression, 2 cc of sticky gelatinous material was aspirated from the cyst under US guidance. Electrical stimulation and passive and assisted active ROM exercises of the right ankle and strengthening exercises for weak muscles using elastic band were prescribed based on the change of muscle power. A posterior leaf spring ankle-foot orthosis was prescribed to assist the weak dorsiflexion of the ankle. Follow-up US revealed that the cystic lesion was growing and magnetic resonance imaging demonstrated compression of the CPN by the cystic mass. The cyst was resected to prevent impending compression of the CPN.Precise diagnosis and immediate treatment are important in cases of compressive common peroneal neuropathy caused by an extraneural cyst.
Foot drop
Ganglion cyst
Common peroneal nerve
Superficial peroneal nerve
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Citations (1)
Intraneural ganglion cysts of the peroneal nerve are rare, usually occurring in adult men with a typical presentation of knee or proximal leg pain preceding motor weakness and/or sensory disturbances in the peroneal nervous distribution. A history of knee trauma and a palpable mass of the lateral knee in the region of the peroneal nerve are common. We present the unusual case of an intraneural ganglion cyst of the peroneal nerve in a 4-year-old girl. Although extremely rare in the pediatric population, the condition should be considered in the differential diagnosis of children presenting with new-onset foot deformities, foot drop, or clinical examinations consistent with a peroneal nerve lesion. Surgical treatment consisting of ganglion decompression with exploration and ligation of the articular branch of the peroneal nerve may result in improved functional recovery in the pediatric population compared with the adult population. Greater access to magnetic resonance imaging may allow diagnosis of cases that were not previously identified.
Ganglion cyst
Foot drop
Superficial peroneal nerve
Common peroneal nerve
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Citations (21)