Is surgery more effective than aspiration with or without steroid injection in the management of ganglion cysts?
Date First Published:
February 4, 2010
Last Updated:
February 18, 2010
Report by:
Ramawad Soobrah, Surgical Teaching Fellow (Northwick Park & St Marks Hospitals)
Search checked by:
Philomena McLaughlin , Northwick Park & St Marks Hospitals
Three-Part Question:
In [adult patients with ganglion cysts] is [operative treatment better than aspiration with (or without) steroid injection] in [preventing the recurrence of those cysts]?
Clinical Scenario:
A 33 year old office clerk presents with a painful wrist swelling which he noticed a few months ago. The lump is interfering with his daily activities at work. Clinically it is a soft cystic mobile lump on the anterior aspect of the wrist. You wonder whether to aspirate the cyst in the department or refer him for surgical excision.
Search Strategy:
Medline using the National Library of Medicine interface:
{ (“ganglion cyst” OR “ganglion cysts” OR ganglia OR “synovial cyst” OR “synovial cysts”) AND (aspiration OR “needle aspiration” OR “puncture”) AND (steroid OR “steroid injection” OR triamcinolone OR corticosteroid OR methylprednisolone) AND (surgery OR excision OR “surgical excision” or “arthroscopic excision”) AND (recurrence*) } LIMITS: English language and Humans
{ (“ganglion cyst” OR “ganglion cysts” OR ganglia OR “synovial cyst” OR “synovial cysts”) AND (aspiration OR “needle aspiration” OR “puncture”) AND (surgery OR excision OR “surgical excision” or “arthroscopic excision”) AND (recurrence*) } LIMITS: English language and Humans
A MeSH search was also performed in Pubmed and Cochrane Library. LIMITS: English language and Humans
CINAHL Plus: (1960 – 2009), LIMITS: English Language
References cited by retrieved research papers were also reviewed.
{ (“ganglion cyst” OR “ganglion cysts” OR ganglia OR “synovial cyst” OR “synovial cysts”) AND (aspiration OR “needle aspiration” OR “puncture”) AND (steroid OR “steroid injection” OR triamcinolone OR corticosteroid OR methylprednisolone) AND (surgery OR excision OR “surgical excision” or “arthroscopic excision”) AND (recurrence*) } LIMITS: English language and Humans
{ (“ganglion cyst” OR “ganglion cysts” OR ganglia OR “synovial cyst” OR “synovial cysts”) AND (aspiration OR “needle aspiration” OR “puncture”) AND (surgery OR excision OR “surgical excision” or “arthroscopic excision”) AND (recurrence*) } LIMITS: English language and Humans
A MeSH search was also performed in Pubmed and Cochrane Library. LIMITS: English language and Humans
CINAHL Plus: (1960 – 2009), LIMITS: English Language
References cited by retrieved research papers were also reviewed.
Outcome:
Medline search: t7 papers identified (39 when excluding steroid search set)
MeSH search: tt37 papers indentified (36 in Medline and 1 in Cochrane)
CINAHL search: t2 papers identified
Six relevant papers that compared aspiration (+/- steroid injection) against surgical excision were reviewed (4 on wrist ganglia and 2 on foot & ankle ganglia).
MeSH search: tt37 papers indentified (36 in Medline and 1 in Cochrane)
CINAHL search: t2 papers identified
Six relevant papers that compared aspiration (+/- steroid injection) against surgical excision were reviewed (4 on wrist ganglia and 2 on foot & ankle ganglia).
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Anterior wrist ganglion. Wright, T.W., Cooney, W.P. & Ilstrup, D.M. 1994 USA | ANTERIOR wrist ganglia only Aspiration + steroid injection (n=24) Surgical excision (n=60) Average follow-up = 5 years (2 – 11 years) |
Observational study, retrospective |
recurrence | Aspiration group: 83% (20/24) recurrence, [12 out of 20 had surgery and 2 recurrences noted] | - Anterior wrist ganglia constitute only about 20% of all wrist ganglia - Recurrence data based on patient’s own assessment in questionnaire. - no mention of demographic differences between two groups - study period 1979 – 1988; was same steroid used? |
| recurrence | Surgery group: 20% (12/60) recurrence, [4 out of 12 had further surgery and 2 recurrences noted] | ||||
| Management of flexor tendon sheath ganglions: A cost analysis. Bittner, J., Kang, R. & Stern, P. 2002 USA | ANTERIOR wrist ganglia only Observation alone (n=20) Surgical excision (n=14) Aspiration only (n=141) Average follow-up = 32 months ( 17 – 42 months) |
Cost analysis* & observational study, Retrospective [* cost analysis not discussed because of different healthcare setting] |
Success rates of aspiration vs surgery | Observation group: 13 (65%) spontaneous resolution | 15 patients lost to follow-up evaluation after 1st aspiration, but were still included in analysis. Study only included anterior wrist ganglia. Small sample size for surgery group no mention of demographic differences between three groups |
| Success rates of aspiration vs surgery | surgery group: 7% (1/20) recurrence | ||||
| Success rates of aspiration vs surgery | aspiration group: 31.2 % (44/141) recurrence, {44 failed aspiration – 20 had repeat aspiration – 9 recurred; 24 had surgery – none recurred} | ||||
| The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. Dias, J.J., Dhukarma, V. & Kumar, P. 2007 UK | DORSAL wrist ganglia only Observation alone (n=55) Surgical excision (n=103) Aspiration group [i.e. aspiration alone or aspiration + steroid injection] (n=78) Average follow-up = 70 months |
Observational study, prospective |
Recurrence, Post procedure: pain, weakness, satisfaction, weakness, complications | Observation group: 42% (23/55) spontaneous resolution, Pain – 29%, Satisfaction | Recurrence data based on patient’s own assessment in questionnaire Aspiration group consisted of aspiration only and aspiration + steroid injection – data not presented separately Junior and senior surgeons performed operations |
| Recurrence, Post procedure: pain, weakness, satisfaction, weakness, complications | surgery group: 39% (42/103) recurrence; Pain – 27%, weakness - 34%, stiffness - 15%, satisfaction - 83%, complications - 8% | ||||
| aspiration group: 58% (45/78) recurrence; Pain – 29%, weakness - 24%, stiffness - 13%, satisfaction - 81%, complications - 3% | |||||
| Randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment of dorsal carpal ganglion. Limpaphayom, N. & Wilairatana, V. 2004 Thailand | DORSAL wrist ganglia only Aspiration + steroid injection (n=13) Surgical excision (n=11) Follow-up 2 weeks & 6 months |
RCT | recurrence | aspiration group: 61.5% (8/13) recurrence | Small sample Follow-up period too short |
| recurrence | surgery group: 18.2% (2/11) recurrence (p value = 0.047) | ||||
| Ganglia of the foot and ankle. Kliman, M.E. & Freiberg, A. 1982 Canada | Foot and ankle ganglia Surgical excision (n=21) Aspiration + steroid inj (n=12) Average follow-up = 3.5 years (8 mo – 8 years) |
Observational study | recurrence | surgery group: 43% (9/21) recurrence | Small sample size ?too long follow-up: studies with an extended period of follow-up may incorrectly include cysts that naturally resolved (Gude, 2008. |
| recurrence | aspiration group: 25% (4/12) recurrence | ||||
| Ganglions of the foot and ankle. A retrospective analysis of 63 procedures. Pontious, J., Good, J. & Maxian, S.H. 1999 USA | Foot and ankle ganglia Surgical excision (n=23) [ + 13 patients had surgery after failed conservative treatment ] Conservative treatment [i.e. Aspiration alone or aspiration + steroid injection or injection only] (n=40) Average follow-up = 18 months (3 mo – 60 mo) |
Observational study, retrospective |
recurrence | surgery group: 11% (4/36) recurrence (p value<0.05), complications = 17% (6/36) | A variety of amounts and types of steroids were used. Statistical data not presented separately for surgery group. |
| recurrence | conservative treatment group: 62.5% (25/40) recurrence, No complications |
Author Commentary:
The use of steroid at the time of aspiration has not proved to be beneficial and in fact, its success seems to be no better than aspiration alone (Varley, 1997). Many reasons such as pain, fear of malignancy and cosmetic concern lead patients to seek medical advice. Surgery offers higher success rates in most series, but is associated with increased morbidity – wound infection, delayed healing, keloid formation, joint stiffness and damage to cutaneous nerves. Higher rates of recurrence have been attributed to inadequate dissection and incomplete operative excision (Gude, 2008). Meticulous dissection and wide excision could explain the relatively low recurrence rates reported in some studies. A number of factors needs to be taken into consideration, such as, patients’ symptoms, occupation (time off work post-operatively), cosmetic reasons, patient perceptions [25% fear cancer (Westbrook, 2000)]. Prior to selecting treatment, the advantages and disadvantages of each modality should be explained to patients and their expectations explored. Ultimately, the decision to operate has to be carefully weighed and should involve patients who are fully informed.
Bottom Line:
Based on current evidence, surgery is the most successful form of treatment when considering only the cure rate.
Other references:
Gude, W. & Morelli, V. (2008). Ganglion cysts of the wrists: pathophysiology, clinical picture and management. Curr Rev Musculoskelet Med, 1, 205-211.
Varley, G.W., Neidoff, M., Davis, T.R.C, Clay, N.R. (1997). Conservative management of wrist ganglia: aspiration versus steroid infiltration. Journal of Hand Surgery, 22(5), 636–7.
Westbrook, A.P., Stephen, A.B., Oni, J. & Davis, T.R.C. (2000). Ganglia: the patient’s perception. Journal of Hand Surgery, 25B, 566-67.
Other references:
Gude, W. & Morelli, V. (2008). Ganglion cysts of the wrists: pathophysiology, clinical picture and management. Curr Rev Musculoskelet Med, 1, 205-211.
Varley, G.W., Neidoff, M., Davis, T.R.C, Clay, N.R. (1997). Conservative management of wrist ganglia: aspiration versus steroid infiltration. Journal of Hand Surgery, 22(5), 636–7.
Westbrook, A.P., Stephen, A.B., Oni, J. & Davis, T.R.C. (2000). Ganglia: the patient’s perception. Journal of Hand Surgery, 25B, 566-67.
References:
- Wright, T.W., Cooney, W.P. & Ilstrup, D.M.. Anterior wrist ganglion.
- Bittner, J., Kang, R. & Stern, P. . Management of flexor tendon sheath ganglions: A cost analysis.
- Dias, J.J., Dhukarma, V. & Kumar, P. . The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention.
- Limpaphayom, N. & Wilairatana, V. . Randomized controlled trial between surgery and aspiration combined with methylprednisolone acetate injection plus wrist immobilization in the treatment of dorsal carpal ganglion.
- Kliman, M.E. & Freiberg, A.. Ganglia of the foot and ankle.
- Pontious, J., Good, J. & Maxian, S.H. . Ganglions of the foot and ankle. A retrospective analysis of 63 procedures.