Common peroneal nerve palsy caused by a ganglion has rarely been reported. A ganglion may arise from a joint, tendon sheath or a peripheral nerve sheath7,8). They may also be intraosseous and intraneural but are relatively rare entities6). Although intraneural ganglion is a well recognized entity, few reports in the literature describe motor weakness and sensory change as a primary clinical manifestation.
We describe the case of a manual worker who developed foot drop and paresthesia of the anterolateral aspect of the lower leg, as a result of compression of the common peroneal nerve by a ganglion, in both intraneural and intramuscular forms.
CASE REPORT
A 42-year-old male manual worker was referred to our depart- ment with a 2 month history of weakness of the right ankle and foot. The weakness had developed progressively into a complete inability to dorsiflex the right ankle. He also complained of pain and numbness on the anterolateral aspect of the leg and foot. There was no history of trauma to the affected extremity. He had been managed with medication and physiotherapy at a local clinic, under the impression of sprain, for one month. On physical exam- ination, a foot drop was observed with mild atrophy of the mus- cles of the anterior compartment of the right leg. Muscle strength testing revealed severe weakness of ankle and big toe dorsiflexion (grade I-), resulting in complete foot drop and weakness of foot
eversion (grade IV-). A neurologic examination revealed decreased sensation in the distribution of the superficial and deep peroneal nerves and normal patella and Achilles tendon reflex. Pulsations of the dorsalis pedis and posterior tibial artery were equal to those of the contralateral side.
A plain radiogragh of the light knee showed no abnormal find- ing. MR images revealed a high signal intensity, lobulated mass extending from the level of the fibular neck proximally along the neurovascular bundle to the interosseous membrane of the leg distally. The mass also appeared to be intimately associated with the peroneal nerve and could not be differentiated from sur- rounding structures (Fig. 1). A neurophysiologic study showed denervation potentials, no motor units in right tibialis anterior, and denervation potentials in the extensor hallucis longus, per- oneus longus, peroneus brevis and extensor digitorum brevis mus- cles. These findings were compatible with right common peroneal neuropathy more severly involving a deep peroneal component.
Using the lateral approach, the common peroneal nerve was identified and traced to its bifurcation. An intraneural cyst was found to track from 5 cm proximal to the bifurcation of the com- mon peroneal nerve to 5 cm distal along the anterior tibial recur- rent branch, and an intramuscular cyst was also found to be com- pressing common peroneal nerve (Fig. 2). The anterior tibial recurrent branch was found to be associated with a lobulated mass contained within its sheath. After opening the nerve sheath, myx- oid degeneration of nerve was observed. Excisional biopsy was performed with neurolysis of the peroneal nerve, leaving signifi- cant fascicles intact. The cysts contents were colorless gelatinous and fluid. The multilobulated cysts compressing the deep peroneal nerve under the peroneus longus was completely removed with
531 J. of Korean Orthop. Assoc.
2003; 38: 531-4
531 531 531 Address reprint requests to
Oh Soo Kwon, M.D.
Department of Orthopedic Surgery, St. Mary’s Hospital Catholic University 65-1 Keumoh dong, Uijongbu 480-130, Korea
Tel: +82.31-820-3591, Fax: +82.31-847-3671 E-mail: [email protected]
A common peroneal nerve palsy caused by a ganglion has been rarely reported. A Ganglion may arise from joint, tendon sheath or sheath of peripheral nerve. They may also be intraosseous and intraneural but relatively rare entities. Although intraneural ganglion is a well recognized entity, few reports in the literature describe motor weakness and sensory change as a primary clinical manifestation.
The pathogenesis of intraneural ganglion cyst remains controversial. We describe the case of 42-year-old male manual worker with a 2 month history of weakness of the right ankle and foot drop and paresthesia of the anterolateral aspect of the lower leg, as a result of compression of the common peroneal nerve by a ganglion, in both intraneural and intramuscular forms.
Key Words: Ganglion, Peroneal nerve
Common Peroneal Nerve Palsy Caused by a Ganglion - Case Report -
Oh Soo Kwon, M.D., Won Jong Bahk, M.D., Yong In, M.D.
Department of Orthopaedic Surgery, St. Mary’s Hospital Catholic University, Uijongbu, Korea
532 Oh Soo Kwon∙Won Jong Bahk∙Yong In
the surrounding wall. Blunt dissection of the peroneus muscles was done to confirm complete release of the common peroneal nerve and of its branches, where the deep peroneal nerve runs down to the anterior compartment. The histological preparation revealed a cystic structure filled with mucoid material. The his- tological features were consistent with an intraneural ganglion
cyst (Fig. 3). Postoperatively the patient was immobilized with splint for 2 weeks, and then received intensive physiotherapy. At latest follow-up 12 months after surgery, the patient’s motor func- tion was partially restored to grade III-.
C
A B
Fig. 1. (A) Coronal T2 weighted MR image of the knee showing a multiple cystic mass around the fibular neck at high signal intensity (arrow & small arrow). (B) Sagittal T2 weighted MR image of the knee demonstrating a separate cystic mass of high signal intensity at the level of the tibiofibular joint (arrow & small arrow). (C) Axial T2 weight- ed MR image of the knee at the level of the tibiofibular joint showing a multilobulated cystic mass of high signal intensity (arrow).
Fig. 2.The common peroneal nerve was compressed by an intra- neural ganglion at the level of the bifurcation of the common per- oneal nerve.
Fig. 3.Histopathological findings showing that the cystic wall was composed of loose connective tissue, which included collagen bundles and fibrous tissue.
Common Peroneal Nerve Palsy Caused by a Ganglion 533
DISCUSSION
Intraneural ganglion cysts are benign soft tissue masses involv- ing the peripheral nerve. The cyst is more commonly accompa- nied by nerve irritation. The common peroneal nerve near the head of the fibula is the most common localization; other sites reported include the radial, ulnar, median, sciatic, and the tibial nerve4,6). The pathogenesis of intraneural ganglion cyst remains controversial10). Some authors have suggested mucoid or myxoid degeneration of connective tissue within the nerve resulting from trauma2,5). Others have proposed a synovial origin, and have re- ported that cysts are connected with the neighboring joint in 40%
of the cases, which is located mainly proximal to the tibiofibular joint1,3). In histologic study, cell lining the common peroneal nerve cyst consisted of myofibroblast, endothelial cell, and cells of mes- enchymal origin-similar to those of ganglion cysts found in the wrist joint, suggesting that intraneural ganglion cysts can orig- inate from the proximal joint9).
In this case, the intraneural ganglion cyst was found to track distally within for the nerve sheath along the common peroneal nerve to the recurrent anterior tibial branch for about 7 cm. In addition, a multilobulated ganglion cyst was found under the peroneus longus muscle distal to the bifurcation of the peroneal nerve. These findings suggest that the intraneural and intermus- cular ganglions could have originated independently, and that the common peroneal nerve might have been compressed by an intra- neural ganglion and by an intramuscular ganglion in peroneus longus muscle, which mainly compresses the deep peroneal nerve.
Various treatment methods have been described, such as the injection of sclerosing agent, radiotherapy and excision. Surgical excision is recommended as the treatment of choice in the pres- ence of nerve palsy5). A compressed nerve by a ganglion should be released to reduce tension on the involved nerve. If nerve is partly or completely severed the area of compression should be resected and repaired either primarily or with a nerve graft. In the present case, removal of the cyst and neurolysis was sufficient,
and in such cases we would recommend complete excision of the cyst with its wall and a thorough examination of the involved nerve.
REFERENCE
1. Antonini G, Bastianello S, Nucci F, et al: Ganglion of deep peroneal nerve: Electrophysiology and CT scan in the diagnosis. Electromyogr Clin Neurophysiol 31: 9-13, 1991.
2. Barrie HJ, Barrington TW, Colwill JC, et al: Ganglion migrans of the proximal tibiofibular joint causing lesions in the subcutaneous tissue, mus- cle, bone, or peroneal nerve: Report of three cases and review of the litera- ture. Clin Orthop 149: 211-215, 1980.
3. Coleman SH, Beredjeklian PK and Weiland AJ: Intraneural ganglion cyst of the peroneal nerve accompanies by complete foot drop. A case report.
Am J Sports Med. 29(2): 238-241, 2001.
4. De Schrijver F, Simon JP, De Smet L and Farby G: Ganglia of the superior tibiofibular joint: Report of three cases and review of the literature.
Acta Orthop BeIg 64: 233-241, 1998.
5. Donahue F, Turkel DH, Mnaymneh W, et al: Intraosseous ganglion cyst associated with neuropathy. Skeletal Radiol 25: 675-678, 1996.
6. Evans JD, Neumann L and Frostick SP: Compression neuropathy of the common peroneal nerve caused by a ganglion. Microsurgery 15: 193- 195, 1994.
7. Fansa H, Plogmeire K, Gonschirek A and Feistner H: Common per- oneal nerve palsy caused by a ganglion. Case report. Scand J Plast Reconstr Surg Hand Surg 32(4): 425-427, 1998.
8. Petit-Lacour MC, Pico F, Rappoport N, Gagey O and Said G: Fluc- tuating peroneal nerve palsy caused by an intraneural cyst. J Neurol 249(4):
490-491, 2002.
9. Scherman BM, Bilbao JM, Hudson AR, et al: Intraneural ganglion:
A case report with electron microscopic observation. Neurosurgery 8: 487- 490, 1981.
10. Yamazaki H, Saitoh S, Seki H, Murakami N, Misawa T and Takao- ka K:Peroneal palsy caused by intraneural ganglion. Skeletal Radiol. 28(1):
52-56, 1999.
534 Oh Soo Kwon∙Won Jong Bahk∙Yong In
결절종에 의한 총비골신경 마비는 종종 보고되고 있으며 그 생성 원인에 있어서 여러 가설이 있다. 저자들은 신경내와 근육내에 독립적으로 발생한 결절종이 총비골신경을 압박하여족하수 및 감각신경 마비를 초래한 증례를 경험하여 보고하고자 한다.
색인 단어 : 결절종, 비골신경
결정종에 의한 총 비골신경 마비 - 증례보고 -
권오수∙박원종∙인용
가톨릭대학교 의과대학 의정부 성모병원 정형외과교실
