Abstract
A prospective cohort study was undertaken to observe the long-term outcome of different treatments for palmar wrist ganglia. One hundred and eighty-two patients agreed to participate in the study. One hundred and fifty-five patients (88%) responded at 2 or 5 years. Seventy-nine had been treated by surgical excision, 39 by aspiration and 38 by reassurance alone. At 5 years no significant differences were observed in the recurrence rates which were 42% after excision of a palmar wrist ganglion and 47% (19 of 39) after aspiration. Twenty of the 39 untreated ganglia had disappeared spontaneously. Eighty-five per cent of the patients were satisfied irrespective of treatment. Patients having surgery had a complication rate of 20% and took more time off work (14 days). Significantly more patients in the untreated group felt the persistent ganglion was unsightly. The patient evaluation measure scores were similar. At 2 and 5 year follow-up, regardless of treatment, no difference in symptoms was found, regardless of whether the palmar wrist ganglion was excised, aspirated or left alone. One in four wrists remained weak regardless of treatment or disappearance of the ganglion.
INTRODUCTION
The palmar aspect of the wrist is the second most common site for a ganglion of the wrist or hand, after the dorsal aspect of the wrist (Angelides, 1998). Palmar wrist ganglia arise from the palmar aspect of the scapholunate joint or, in one-third of cases, from the scaphotrapezial joint (Andren and Eken, 1971). They usually lie between the radial artery and the flexor carpi radialis tendon. Their sites of origin, ease of surgical excision, recurrence rate and complications following excision are different from their dorsal counterpart.
Different treatments for wrist ganglia have been described and there are a few reports specifically on the palmar wrist ganglion. However, there is almost no information on what happens if palmar wrist ganglia are not treated. A prospective cohort study was conducted in the Trent Region of England to observe the natural history of this disorder and compare it with outcomes of common interventions.
PATIENTS AND METHODS
Patients were recruited into the Trent Region Ganglion Study from 1993 to 1995. Two hundred and thirty-three patients with palmar wrist ganglia were seen initially by hand surgeons in Trent who submitted a form documenting demographic data which identified the site and side of the ganglion and the proposed treatment.
A postal questionnaire sent out within the first year after presentation obtained written consent from 182 patients, confirmed their demographic details and gathered information about symptoms. Subsequently, questionnaires were sent at 2 (109 responded) and 5 years (122 responded). One hundred and fifty-five patients responded at either year 2 or year 5, a follow-up rate of 86%. The mean length of final follow-up was 63 (range, 55–87) months for those reviewed at 5 years. The mean age of the 155 responders was 45 years (SD 17.6; range 5–94). There were 98 women and 57 men.
Each questionnaire investigated symptoms, recurrence or persistence of the ganglion, complications and patient satisfaction. Patients who had responded at 2 years and did not report a recurrence of their ganglion, but failed to respond at 5-year follow-up were assumed not to have experienced a recurrence between years 2 and 5. Any recurrence of the wrist ganglion in this group would have increased the overall recurrence rate. The 2-and 5-year questionnaires also included a Patients Evaluation Measure (PEM) (Dias et al., 2001). This assesses hand symptoms and disability using 14 questions on different aspects of hand function such as pain, appearance, impact on work and satisfaction. The questionnaire is scored and expressed as a percentage of the maximum score, which represents a severely disabled hand.
There were three treatment groups: aspiration (38 cases), surgical excision (79 cases) and simple reassurance (38 cases). The last group provided information on the natural history of the untreated palmar wrist ganglion. No attempt was made to influence either the treatment received or who administered it and the surgeon’s preference dictated which of the three methods was used. Some surgeons reassured patients while others aspirated and dispersed the ganglion. As infiltration of steroids after aspiration does not alter the outcome (Varley et al., 1997), this was considered to represent ‘aspiration’ of the ganglion. The surgical excisions were performed by a number of senior and junior surgeons in the Hand units in Trent. All confirmed their practice to excise the ganglion and follow its stalk to the joint. No attempt was made to collect information on surgical findings because of logistic difficulties and variability in the quality of documentation.
As this was a cohort study, selection bias, which could influence the interpretation of any findings, was investigated. The 53 patients who did not consent were almost a decade younger and consisted of more men (Table 1a). There was no difference between responders (155 cases) and non-responders (25 cases) at years 2 and 5 for age, sex, initial symptoms or type of intervention. There was no difference between the patients who were reassured, those who had aspiration and those who underwent excision in terms of age, sex distribution or initial symptoms of pain, weakness or stiffness. However, those who had excision were twice as likely to consider their ganglion unsightly (Table 1b).
RESULTS
Recurrence
The ganglion was considered to have recurred if it was present at either the 1-, 2- or 5-year follow-up, though this could represent either recurrence or the formation of a new ganglion at the same site. After initial treatment, if a ganglion had recurred at 2 years follow-up but subsequently disappeared before the 5-year follow-up, it was still considered to have recurred after the initial intervention. At the 5-year follow-up, 20 of 38 of palmar wrist ganglia had disappeared without any intervention. Of those excised, 33 of 79 (42%) recurred at some time after surgery. Eighteen of 38 patients who underwent aspiration had a recurrence. There is no difference in the resolution rates of the three treatments (Table 2). Seventeen per cent of cases without a ganglion at 2 years developed one by 5 years, while half the ganglia still present at 2 years had disappeared by the fifth year.
The 69 patients in whom the palmar wrist ganglion had recurred or persisted were compared to the 86 patients in whom the ganglion did not recur or disappeared spontaneously. There were no differences between these groups for age, sex distribution or initial symptoms. Those patients who still had a ganglion at review had more pain and stiffness and were more likely to remain concerned about its appearance, but there was considerable improvement in all these symptoms from the initial level. However, the feeling of hand weakness was similar between the groups and did not alter from the initial level, regardless of recurrence. Those with a recurrence or persistence of the palmar wrist ganglion considered themselves more disabled and symptomatic, with a mean PEM score of 22% (SE 3%) compared to 9% (SE 2%) for those whose ganglion had either disappeared or had not recurred after intervention (Table 3).
Residual symptoms
There was no difference between the three groups for residual pain and weakness, with about one in five patients in each group complaining of these symptoms. About one in ten patients from each group also complained of residual stiffness (Table 2). The untreated patients were more dissatisfied with the appearance (Pearson chi-square 7.3, P=0.026) than the other two groups. At the 5-year follow-up, 22% of untreated patients felt their ganglion was unsightly, compared with 4% of those who had the ganglion aspirated and 7% of those who had their ganglion excised.
Complications
Patients with untreated ganglia had no complications. Patients undergoing excision had a complication rate of 20%. There was a complication rate of 5% for the aspiration group. The difference between the three treatment groups was significant (Pearson chi-square, P=0.003). Complications included wound infection, neuroma formation, hypertrophic scar, numbness in the distribution of palmar cutaneous branch of the median nerve and radial artery damage in one case (Table 2).
Satisfaction, hand disability and time off work
Around 85% of the patients were satisfied at the final follow-up irrespective of the type of treatment. In contrast, about 75% were satisfied with treatment at the 2-year follow-up, with the lowest satisfaction rate in those who had aspiration.
The PEM hand disability score was around 15% (where 100% is fully disabled) in all the three groups at final follow-up. There was no difference between the three groups for the individual questions of the PEM score (Table 2).
Patients having surgery took 14 (SE 2) days off work while those who had aspiration took 3.5 (SE 2) days off work. Those reassured lost no time off work (Table 2).
DISCUSSION
Any intervention for the palmar wrist ganglion, whether by aspiration or by excision, can only be justified if the intervention provides greater relief of symptoms, less recurrence, fewer complications and better patient satisfaction than if no treatment were undertaken. In interpreting the results the recruitment bias towards older individuals and female patients must be considered. While there was no difference between groups for pain, the size of the ganglion was not documented although it is difficult to see why this can have a bearing on the outcome. Findings from previous publications and from the present study on the natural history, aspiration and excision are listed in Table 4.
Does intervention decrease recurrence?
In this study, 53% of untreated palmar wrist ganglia disappeared within 5 years without any intervention. Carp and Stout (1928) reported on 12 palmar and dorsal wrist ganglia for which no intervention was undertaken and observed that seven had spontaneously disappeared after 3 years. McEvedy (1954) did a retrospective review of 19 palmar and dorsal wrist ganglia at about 10 years and also observed that nine had spontaneously disappeared.
The primary objective of intervention is to immediately remove the unsightly or symptomatic palmar wrist ganglion, either by aspiration or excision. Aspiration can be performed in the outpatient clinic and has the added benefit of re-assuring the patient about the benign nature of the lump (Westbrook et al., 2000). However, after aspiration, 47% of the palmar wrist ganglia recur. Varley et al. (1997) found a recurrence rate of 67% after aspiration of both dorsal and palmar wrist ganglia, with and without instillation of 40 mg of methylprednisolone. Stephen et al. (1999) reported on 97 wrist ganglia, of which 15 were on the front of the wrist, and found a similar recurrence rate within 1 year. Paul and Sochart (1997) demonstrated that recurrence was less likely if the ganglion was injected with hyaluronidase 20 min before aspiration and infiltration with methylprednisolone. The present study indicates that aspiration does not provide any improvement in the long-term recurrence rate over the natural spontaneous regression of this disorder.
The recurrence rate after excision of 42% in the present study is higher than that reported by others who have specifically looked at palmar wrist ganglia (Paul and Sochart, 1997; Stephen et al., 1999; Varley et al., 1997). These studies, however, were retrospective. The duration of follow-up was also shorter than in this study. In all the three treatment groups, there was a trend towards disappearance of the ganglion between the 2- and 5-year follow-ups.
The recurrence rate probably reflects the activity of the underlying process, which forms the mucoid cyst, which is probably unaltered by either aspiration or excision of the ganglion itself.
Does intervention improve symptoms?
The second reason to treat palmar wrist ganglia is to improve symptoms of pain, weakness and stiffness. These are attributed to the ganglion by patients and, very often, by the treating clinician. Very few papers document symptoms and in this study there was no difference between the treatment groups for pain, stiffness and weakness. The number of patients complaining of pain and stiffness decreased regardless of treatment. About a fifth of the patients had residual pain, while about one in ten complained of stiffness in the wrist or hand. One in four patients continued to feel that their wrist was weak regardless of intervention or recurrence. The persistence of symptoms, particularly weakness, suggests that the ganglion itself may not cause these and it is possible that underlying disorder causing the ganglion may also cause symptoms.
Compared with the two intervention groups, more patients who were reassured remained concerned about the unsightliness of their ganglion, but curiously they were no less satisfied. Thus, the act of intervention improved the patient’s perception about the appearance, regardless of recurrence, and this is the only identifiable benefit of intervention. However, cosmesis may be an important issue, it would be prudent to warn patients about recurrence before intervention.
This study did not identify any factors which predisposed a patient to having a recurrence. It did, however, observe that patients with a recurrence were more symptomatic and considered themselves more symptomatic and disabled. This was regardless of intervention. These symptoms could be attributed to the ganglion but could equally be attributed to the severity of the underlying aetiological condition. Varley et al. (1997) found no benefit of repeated aspirations for recurrent ganglia with 23 of 24 such ganglia recurring after a second aspiration and all five recurring after a third aspiration. This could be interpreted as suggesting that the underlying disorder is more active in cases that have a recurrence.
Other possible benefits of intervention
There was no difference in hand symptoms and disability as assessed by the PEM score between the three groups, even when the individual questions on the PEM questionnaire were assessed individually. The satisfaction rate improved between 2 and 5 years irrespective of the treatment with about 75% of the patients being satisfied at the 2-year follow-up and about 85% at the 5-year follow-up.
Drawbacks of intervention
Neither aspiration nor excision confers much identifiable benefit over the natural history of the palmar wrist ganglion in the long term, but these interventions have 5% and 20% complication rates, respectively. There is a moderate risk of nerve injury and a lower risk to the radial artery (Greendyke et al., 1992; Jacobs and Goavers, 1990). Most commonly complications were related to scar tenderness and sensory problems. A complication rate of as high as 28% has been reported (Jacobs and Goavers, 1990), which included damage to the palmar cutaneous branch of the median nerve. These risks must be clearly explained to patients prior to intervention. Six patients in this study felt at 5 years that their hand had worsened since treatment, all had had surgery and they represented 8% of the surgical patients. None of the patients who had their ganglia treated by aspiration or had it left untreated felt that their hand had been worsened by their ganglion management.
Treatment for ganglia demands healthcare resource. Over 46 years ago, McEvedy (1954) observed that operative treatment of the wrist ganglion led to ‘‘… The occupation of valuable hospital beds’’ and resulted in ‘‘…taking up time of competent surgeons who might be more usefully engaged…’’. The economic consequences of surgical intervention are obvious. A net saving of US$100,000 for every 100 patients has been calculated for aspiration, including subsequent surgery should three aspirations fail when compared with primary excision of wrist ganglia (Zubowicz and Ishii, 1986). At our hospital, day surgery costs £494 for wrist ganglion excision compared to £56 for an outpatient consultation with an injection and £25 for an outpatient consultation without any intervention (excluding salary and any X-ray costs). In addition, the cost to the patient from time lost at work is higher after excision.
In conclusion, this study indicates that the only long-term benefit of aspiration or excision of palmar wrist ganglia is the patients’ perception of the ganglions’ unsightliness. Patients with a persisting ganglion are more symptomatic although over time fewer patients had symptoms.
Footnotes
Acknowledgements
Mr Tony Hui assisted in setting up the project and the database. We are grateful to the Hand Surgeons in Trent who contributed cases and provided useful feedback at regular meetings over 7 years. This study was partly funded by the Audit Office of the Trent Health Authority.