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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.

Search Outcome

Medline search: 7 papers identified (39 when excluding steroid search set)
MeSH search: 37 papers indentified (36 in Medline and 1 in Cochrane)
CINAHL search: 2 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Wright TW 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]
Bittner J 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}
Dias JJ 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		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%
			Recurrence, Post procedure: pain, weakness, satisfaction, weakness, complications	aspiration group: 58% (45/78) recurrence; Pain – 29%, weakness - 24%, stiffness - 13%, satisfaction - 81%, complications - 3%
Limpaphayom N 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)
Kliman ME 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
Pontious J 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

Comment(s)

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.

Clinical 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.

References

1. Wright, T.W., Cooney, W.P. & Ilstrup, D.M. Anterior wrist ganglion. The Journal of Hand Surgery 2004;19(6), 954-8.
2. Bittner, J., Kang, R. & Stern, P. Management of flexor tendon sheath ganglions: A cost analysis. The Journal of Hand Surgery 2002; 27(4), 586–590.
3. Dias, J.J., Dhukarma, V. & Kumar, P. The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. The Journal of Hand Surgery European Volume 2007;32(5),502–508.
4. 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. Journal of the Medical Association of Thailand 2004:87(12),1513-7.
5. Kliman, M.E. & Freiberg, A. Ganglia of the foot and ankle. Foot & Ankle 1982;3(1), 45-6.
6. Pontious, J., Good, J. & Maxian, S.H. Ganglions of the foot and ankle. A retrospective analysis of 63 procedures. Journal of the American Podiatric Medical Association 1999;89(4),163-8.