CC BY-NC-ND 4.0 · Indian Journal of Neurosurgery 2018; 07(03): 260-264
DOI: 10.1055/s-0038-1639385
Case Report
Neurological Surgeons' Society of India

Ulnar Neuropathy due to Intraneural Ganglion Cyst of the Ulnar Nerve at the Elbow

Byung-chul Son
1   Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
2   Catholic Neuroscience Institute, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
Jin-gyu Choi
1   Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
Hak-cheol Ko
1   Department of Neurosurgery, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
› Author Affiliations
Funding None.
Further Information

Publication History

Received: 21 July 2017

accepted after revision: 24 October 2017

Publication Date:
10 April 2018 (online)


Intraneural ganglion cysts are rare mucinous cyst originating within the epineurium of peripheral nerves. They occur most commonly in the peroneal nerve. However, they have also been described in many nerves in the vicinity of synovial joints. Intraneural ganglion cysts in the upper extremity are rare. Those at the elbow joint comprise only 9% of intraneural ganglion ever reported.

A 66-year-old and right-handed male patient presented with a sudden onset of right-hand weakness. He initially noticed paresthesia with decreased sensation in the lateral two digits and radial palm in his right hand. Physical examination showed thenar muscle atrophy and muscle weakness of the abductor pollicis brevis in the right hand. Preoperative diagnosis of intraneural ganglion cyst was made on the basis of characteristic magnetic resonance imaging (MRI) findings. On exploration, the ulnar nerve was identified proximal to the elbow joint. Its articular branch was addressed and divided from the elbow joint.

To the best of our knowledge, addressing the articular branch connecting the glenohumeral joint for the treatment of intraneural ganglion at the elbow has only been reported twice. We experienced a rare occurrence of intraneural ganglion cyst at the elbow manifesting an ulnar neuropathy. Here, we report intraoperative findings for the articular branch-connected to intraneural ganglion of the ulnar nerve at the elbow. Early diagnosis of intraneural ganglion with precise identification of the pathology and addressing the articular branch with atraumatic dissection of ganglion cyst are essential to achieve successful treatment for this rare lesion.

  • References

  • 1 Allieu PY, Cenac PE. Peripheral nerve mucoid degeneration of the upper extremity. J Hand Surg Am 1989; 14 (02) Pt 1 189-194
  • 2 Giele H, Le Viet D. Intraneural mucoid cysts of the upper limb. J Hand Surg [Br] 1997; 22 (06) 805-809
  • 3 Naam NH, Carr SB, Massoud AH. Intraneural Ganglions of the hand and wrist. J Hand Surg Am 2015; 40 (08) 1625-1630
  • 4 Spinner RJ, Atkinson JL, Tiel RL. Peroneal intraneural ganglia: the importance of the articular branch. A unifying theory. J Neurosurg 2003; 99 (02) 330-343
  • 5 Desy NM, Wang H, Elshiekh MA. et al. Intraneural ganglion cysts: a systematic review and reinterpretation of the world's literature. J Neurosurg 2016; 125 (03) 615-630
  • 6 Spinner RJ, Desy NM, Amrami KK. The cystic transverse limb of the articular branch: a pathognomonic sign for peroneal intraneural ganglia at the superior tibiofibular joint. Neurosurgery 2006; 59: 157-166
  • 7 Spinner RJ, Scheithauer BW, Amrami KK. The unifying articular (synovial) origin of intraneural ganglia: evolution-revelation-revolution. Neurosurgery 2009; 65 (04) Suppl A115-A124
  • 8 Capek S, Koutlas IG, Strasia RP, Amrami KK, Spinner RJ. An inferior alveolar intraneural cyst: a case example and an anatomical explanation to support the articular theory within cranial nerves. J Neurosurg 2015; 122 (06) 1433-1437
  • 9 Janzen DL, Peterfy CG, Forbes JR, Tirman PF, Genant HK. Cystic lesions around the knee joint: MR imaging findings. AJR Am J Roentgenol 1994; 163 (01) 155-161
  • 10 Poppi M, Nasi MT, Giuliani G, Acciarri N, Montagna P. Intraneural ganglion of the peroneal nerve: an unusual presentation. Case report. Surg Neurol 1989; 31 (05) 405-406
  • 11 Spinner RJ, Amrami KK, Wolanskyj AP. et al. Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory. J Neurosurg 2007; 107 (02) 296-307
  • 12 Spinner RJ, Carmichael SW, Wang H, Parisi TJ, Skinner JA, Amrami KK. Patterns of intraneural ganglion cyst descent. Clin Anat 2008; 21 (03) 233-245
  • 13 Spinner RJ, Luthra G, Desy NM, Anderson ML, Amrami KK. The clock face guide to peroneal intraneural ganglia: critical “times” and sites for accurate diagnosis. Skeletal Radiol 2008; 37 (12) 1091-1099
  • 14 Spinner RJ, Harish S, Amrami KK. An historical perspective on ulnar intraneural ganglion cysts and their joint origins. Hand (NY) 2014; 9 (03) 395-398
  • 15 Xu Q, Chen Z, Dellon AL, Zhang F. Microsurgical principles related to excision of intraneural ganglion at the elbow. Hand (NY) 2014; 9 (02) 214-216
  • 16 Jenkins SA. Solitary tumours of peripheral nerve trunks. J Bone Joint Surg Br 1952; 34 b 401-11
  • 17 Elangovan S, Odegard GM, Morrow DA, Wang H, Hébert-Blouin MN, Spinner RJ. Intraneural ganglia: a clinical problem deserving a mechanistic explanation and model. Neurosurg Focus 2009; 26 (02) E11
  • 18 Isaacs AM, Midha R, Desy NM, Amrami KK, Spinner RJ. The mechanism underlying combined medial and lateral plantar and tibial intraneural ganglia in the tarsal tunnel. Acta Neurochir (Wien) 2016; 158 (11) 2225-2229
  • 19 Okada M, Sakaguchi K, Oebisu N, Takamatsu K, Nakamura H. A ganglion within the ulnar nerve and communication with the distal radioulnar joint via an articular branch: case report. J Hand Surg Am 2011; 36 (12) 2024-2026
  • 20 Weyns F, Bringmans T, Vandevenne J. et al. Peripheral neuropathy caused by joint-related cysts: a review of 17 cases. Acta Neurochir (Wien) 2012; 154 (10) 1741-1753
  • 21 Prasad NK, Desy NM, Howe BM, Amrami KK, Spinner RJ. Subparaneurial ganglion cysts of the fibular and tibial nerves: a new variant of intraneural ganglion cysts. Clin Anat 2016; 29 (04) 530-537
  • 22 Muramatsu K, Hashimoto T, Tominaga Y, Tamura K, Taguchi T. Unusual peroneal nerve palsy caused by intraneural ganglion cyst: pathological mechanism and appropriate treatment. Acta Neurochir (Wien) 2013; 155 (09) 1757-1761
  • 23 Sobol GL, Lipschultz TM. Successful surgical treatment of an intraneural ganglion of the common peroneal nerve. Am J Orthop 2015; 44 (04) E123-E126
  • 24 Lowenstein J, Towers J, Tomaino MM. Intraneural ganglion of the peroneal nerve: importance of timely diagnosis. Am J Orthop 2001; 30 (11) 816-819
  • 25 Spinner RJ, Desy NM, Rock MG, Amrami KK. Peroneal intraneural ganglia. Part II. Lessons learned and pitfalls to avoid for successful diagnosis and treatment. Neurosurg Focus 2007; 22 (06) E27