Ganglion Cysts

What is a ganglion?

A ganglion is a a collection of thickened fluid, usually coming from a joint, most often 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

They are most common in young adults and teenagers. They usually last up to 2 years before disappearing without any treatment. Taking the fluid out of the ganglion with a needle can reduce the size of the lump, but it often returns. The risk of the lump coming back 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. 

What causes a ganglion?

Most ganglion cysts arise from a joint. For wrist ganglions, they form in 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 being used a lot. This can cause the joint to ‘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. The lump can feel uncomfortable because of the size of the ganglion, or because of some mild irritation of nearby skin nerves.

The presence of discomfort does NOT mean that the lump is harmful – it is completely harmless 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 very typical places in the hand and wrist. The diagnosis is almost always made clinically. Investigation with scans are not usually helpful.

What is the natural history?

Most ganglions will go up and down 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 major 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 local anaesthetic 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 one 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.