Ganglion Cysts

Ganglion cysts are the most common type of swelling in the wrist. They are completely harmless, and usually disappear within a few years.

What is a ganglion?
A ganglion is a a collection of thickened fluid, usually arising from a nearby joint, most commonly the wrist joint. Joints have a fine lining (synovium) which produces a lubricating fluid in order for the joint to move freely without friction. This fluid ‘leaks’ or extravasates from the joint and the soft tissues react by forming a barrier to stop it spreading – this barrier is the wall of the ganglion. There are 2 types of ganglion around the wrist:

Dorsal wrist ganglion cyst:
These typically occur in young adults and teenagers. They usually last up to 2 years before disappearing. usually disappears spontaneously. Aspiration can reduce the swelling but it often returns. The risk of recurrence after surgery is around 25%, and problems after surgery include persistent pain, loss of wrist movement and painful trapping of nerve branches within the scar. Surgery for this type of ganglion is rarely recommended, because of poor satisfaction rates.

Volar wrist ganglion cyst:
May occur in young adults, but also seen in association with wrist arthritis in older individuals. Aspiration may be useful, but care is needed as the cyst is often close to the artery at the wrist (where you can feel the pulse). The risk of recurrence after surgery is around 30%, and problems after surgery include persistent pain, loss of wrist movement and trapping of nerve branches within the scar. For these reasons, many surgeons advise against an operation for these cysts.

Seed ganglion cyst: These often occur at the base of the finger. The tendons which bend the finger are enclosed in a sheath lined with the same synovium as joints. There are straps to re-enforce the sheath and the gaps between these form the weak points where ganglia can form – often between the 1st and 2nd one at the base of the finger.

What causes a ganglion?
Most ganglion cysts arise from a point of relative weakness around a joint. For wrist ganglions, this is often the area between the attachment of the strong ligaments of the wrist. Ganglions tend to increase and decrease in size with time, often getting bigger when the wrist is loaded. An increase in the pressure generated by the wrist joint can ‘push’ fluid out into the ganglion, but there is no good way of the fluid returning to the joint.

What are the symptoms?
All ganglions produce a swelling or lump. When small, this lump may only be seen when the wrist is bent, but often the lump is fairly obvious, and occasionally the lump itself gets quite big. Pain is a common complaint in patients who come to see a specialist. This pain can be a result of the pressure within the ganglion, or can represent some mild irritation of nearby skin nerves. The presence of pain does NOT indicate damage or harm here – it is a completely HARMLESS pain, and it is very safe to use the hand normally even if the ganglion hurts.

How is the diagnosis made?
The diagnosis is usually straightforward as ganglion cysts tend to be smooth and round, fluctuate in size and occur at characteristic locations in the hand and wrist. The diagnosis is commonly made clinically. If the diagnosis is uncertain then a scan may be helpful.

What is the natural history?
The majority of ganglions will fluctuate in size over the course of weeks or months, but most will disappear within a couple of years. The ganglion is harmless and it is very rare to have a significant problem a ganglion.

The strong recommendation from doctors is to leave the ganglion alone and not to worry about it.

Are there any other options?
For ganglion cysts in general, the possibilities for treatment are:

Removal of the liquid contents of the cyst with a needle (aspiration)
Aspiration can be useful to confirm the diagnosis, but is not recommended in volar wrist ganglions because of the risk of damage to the radial artery, which often overlies the ganglion.
Aspiration of a dorsal ganglion is often done with some cold spray to numb the skin. The ganglion fluid itself is thick and jelly-like, and cannot be removed with a small needle. A large needle inserted into the cyst will allow the doctor or nurse to remove the fluid and the lump goes down. It does NOT disappear, and aspiration does not cure the problem – it simply confirms the diagnosis and temporarily settles the lump. The lump re-accumulates over the course of days to weeks Aspiration of a ganglion has some potential risks, including infection and bleeding. Occasionally severe and unpredicted complications are encountered with potential harm to patients.

Surgical removal of the cyst
Surgery is not usually recommended. This is because a ganglion is a harmless and self-limiting condition, whereas surgery ALWAYS carries a risk which can leave patients worse off following operation than they were before (see having a hand operation).
In general, satisfaction rates 1 year following this type of surgery are far lower than most surgeons would hope for. It is possible, however, to remove the ganglion surgically, but this should be discussed with the surgeon carefully before such a decision is made.

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