Keywords
Peroneal nerve - Ganglion cyst - Tibiofibular joint
Introduction
Leg pain, loss of ankle dorsiflexion and sensory loss,neurogenic claudication most
commonly produced by degenerative disc disease of the lumbar spine. On the other hand,
isolated peroneal nerve compression can mimic lumbar disc disease. Differentiation
of symptoms of vascular claudication from symptoms of neurogenic claudication is important.
Ganglion cyst is the most frequent tumours of the upper extremity. Despite their high
incidence, ganglion cyst rarely result in peripheral nerve compression [[1]]. Compression neuropathies of the lower extremity are much less common and comprise
only a minority of cases have been described [[2],[3],[4],[5],[6],[7],[8],[9]]. The peak incidence has been seen at the fourth decade of life and it is rare in
children [[2],[8]]. Neurologic symptoms and pain are typical manifestations. We describe a case with
a ganglion cyst as a rare cause of peroneal neuropathy and mimicking intermittent
claudication treated surgically.
Case presentation
A 51-year-old female patient presented to her physician with a six-month history of
intermittent claudication. She developed aching, cramping, pain and weakness of her
right calf. She has radiating pain and hypoesthesia, while motor weakness was less
prominent. She was referred to a vascular surgeon. After examination of the case there
was nothing that concerns vascular surgery. Tenderness in the area of the right fibular
head with gradual development of swelling in the same area was determined. Therefore,case
was referred to orthopedic surgeon. A comprehensive physical examination revealed
soft tissue swelling in the region around the fibular head and neck. There was slightly
weakness in foot eversion and dorsiflexion, especially of the first toe. Inversion
was normal. Electromyogram studies of the common peroneal nerve demonstrated significant
neuropathic abnormalities. Subsequent magnetic resonance imaging demonstrated a lobulated,
multilocular,cystic-appearing mass around the proximal fibular area. It was measured
approximately 3 cm × 2 cm × 2 cm ([Figure 1]). The lesion was located anterior to the lateral aspect of the fibular neck, with
the common peroneal nerve compressed against the posterior aspect of the cyst. It
extended along the nerve toward its bifurcation. Using a lateral approach, the common
peroneal nerve was recognized and traced to its bifurcation ([Figure 2]). The mass was followed down to its stalk and removed completely. The peroneal nerve
was recognized as intact. All nerve branches were preserved under loupe magnification.
The surgical material was diagnosed as ganglion cyst by histopathological examination.
After one month of the surgery, the patient had no complaints of pain and the claudication
also recovered completely.
Figure 1 Characteristic magnetic resonance imaging findings of ganglion cyst with
high signal intensity on the T2 sequence images.
Figure 2 Intraoperative photograph of the lesion as seen associated with the peroneal
nerve.
Discussion
Peripheral nerve lesions owing to ganglionic cysts are infrequent findings. The pathogenesis
of these cysts has been the subject of controversy. However, evidence has demonstrated
that they are of articular origin [[10],[11]]. Ganglionic cysts compressing the peroneal nerve may be extraneural or intraneural
[[12]]. Most of the ganglionic cysts defined in the literature causing peroneal nerve
compression were intraneural type. Compression of the peroneal nerve was owing to
an extraneural cyst as in our case is a condition rarely encountered and history of
knee trauma is a common findingd [[13],[14]]. There was knee trauma history in our case. The most frequent symptoms of this
condition are weakness in the tibialis anterior, peroneus longus and brevis muscles,
and pain radiating to the lateral malleolus [[15],[16],[17]]. Swelling of the proximal tibio-fibular joint are less common. Our case presented
with radiating pain and hypoesthesia, while motor weakness was less prominent. The
other complaints were swelling and localized pain in the region around the fibular
head and neck. The differential diagnosis should include root compression, a nerve
compression near the tendinous arch of the peroneal longus muscle, a nerve-sheath
tumor, the osteocartilaginous exostosis at the proximal lower leg [[18],[19],[20]] and intermittent claudication as in our case. Plain radiographs have little importance
in the diagnosis of ganglion cyst, but may be beneficial in eliminating a bony anomaly
or fracture of the proximal part of fibula. Furthermore it may be useful in excluding
degenerative disc disease of the lumbar spine. Magnetic resonance imaging is more
useful in terms of the diagnosis. It may be difficult to differentiate a ganglion
cyst from nerve sheath tumors and also solid masses on magnetic resonance imaging.
Ultrasonography may be effective in showing the cystic nature of the mass and in differentiating
it from solid tumors [[21]]. Compression of the fibular nerve by an extraneural ganglion is an infrequent and
often misleading condition. If the patient has intermittent claudication especially
with paresthesia, weakness in foot eversion and dorsiflexion, ganglion cyst should
be considered in the differential diagnosis. A combination of magnetic resonance imaging
and ultrasonography is helpful for correct diagnosis of the disorder, and it should
be treated by microsurgical technique when possible.
Conclusion
When a patient presenting with intermittent claudication, compression neuropathy of
the peroneal nerve secondary to a ganglion cyst should be kept in mind in aspect of
the differential diagnosis. After a complete history and physical examination, electromyogram
and magnetic resonance imaging should be performed in terms of the differential diagnosis
of a ganglion cyst. Careful preoperative evaluation, and early surgical excision by
microsurgical technique in the management of the ganglion cyst should be recommended.
Consent
Written informed consent was obtained from the patient for publication of this case
report and accompanying images.
Competing interests
We declare that we have no competing interests.
Authors’ contributions
AK is the chief author who deals the patient clinically, BCG draws SKM attention for
this case, RO and VU help AK in every aspect and YD take care of this patient preoperatively.
All authors have read and approved the final manuscript.
Authors’ information
Corresponding Author: Raif Ozden M.D. Assistant Professor. Mustafa Kemal University
Faculty of Medicine, Department of Orthopaedics and Traumatology, Antakya, Hatay,
Turkey.
Vedat Uruc M.D. Assistant Professor. Kemal University Faculty of Medicine, Department
of Orthopaedics and Traumatology, Antakya, Hatay, Turkey.
Aydıner Kalacı M.D. Associate Professor. Mustafa Kemal University Faculty of Medicine,
Department of Orthopaedics and Traumatology, Antakya, Hatay, Turkey.
Yunus Dogramacı M.D. Associate Professor. Mustafa Kemal University Faculty of Medicine,
Department of Orthopaedics and Traumatology, Antakya, Hatay, Turkey.
Cite this article as: Ozden et al.: Compression of common peroneal nerve caused by an extraneural ganglion cyst mimicking
intermittent claudication. Journal of Brachial Plexus and Peripheral Nerve Injury 2013 8:5.
