Ganglion/Mucoid cysts

Status:
Effective date:
Next review date:

Essex ICB commissions surgical removal of ganglion cysts on a restricted basis.

For the purposes of this policy, ganglion cysts include mucoid (myxoid) cysts arising from joints or tendon sheaths, including those affecting the distal interphalangeal joint.

A ganglion cyst is a fluid-filled swelling that develops near a joint or tendon sheath and typically presents as a smooth, soft lump beneath the skin. Ganglia may arise at any anatomical site, including the wrist, hand, fingers, foot and ankle.

Ganglia are caused by cystic degeneration of a joint capsule or tendon sheath. Lesions at the base of the digits (“seed ganglia”) are often small but may be very tender. Mucoid cysts arise at the distal interphalangeal joint and may be associated with nail deformity or discharge.

Ganglion cysts are usually benign and can safely be left untreated. Many resolve spontaneously and others cause little functional disturbance. There are no long-term adverse consequences from leaving an asymptomatic ganglion untreated.

Ganglia arising at the wrist are rarely painful or functionally impairing, and approximately 50% resolve spontaneously within five years. In the longer term, around 60% remain resolved following aspiration and approximately 70% following surgery. When potential complications of surgery, including scar sensitivity, joint stiffness, numbness and recurrence, are taken into account, surgical excision is often an unattractive option. Appropriately counselled patients will frequently choose not to pursue surgery.

Surgical removal of a ganglion or mucoid cyst will only be funded where the lesion is 

• symptomatic, and
• causes clinically significant functional impairment, and
• has failed appropriate conservative management, 

and where one of the following applies:

• Painful seed ganglia requiring regular prescribed analgesia that persist or recur following puncture or aspiration

or

• Mucoid cysts of the distal interphalangeal joint causing significant nail deformity or recurrent spontaneous discharge, with associated risk of infection. In these cases, functional impairment refers to impairment of the affected digit or nail unit, and aspiration is not required where it is clinically inappropriate.

or

• Ganglia at any anatomical site (including the wrist, hand, fingers, foot or ankle) where:

• the ganglion causes persistent pain, neurological symptoms, or functional impairment,
• the impairment prevents or significantly restricts activities of daily living, including walking, standing, footwear tolerance, manual function or occupational activity (where relevant),
• symptoms have not responded to appropriate conservative management over a minimum period of three months, and
• the patient has been fully informed that many ganglia resolve spontaneously and is aware of the risks of surgery, including scar tenderness, stiffness, numbness and recurrence.

*Conservative treatments include: 

• Reassurance – 35 to 45% of wrist ganglia resolve with no treatment at all.  
• Aspiration – There is a significant recurrence rate after a single aspiration (using wide bore needle) but after 3 serial aspirations the recurrence rate is only 12-15% which is comparable with surgery

For audit purposes, the referral letter and hospital records should include detail on:

• Precise location of ganglion e.g. flexor tendon 
• Size in cm/inches (length and width)
• How function of the area is impaired? i.e. what is the patient unable to do as a result of the ganglion
• Degree of pain
• How long it has existed plus dates of serial aspirations

Funding for patients not meeting the above criteria will only be granted in clinically exceptional circumstances. 

Individual funding requests should only be made where the patient demonstrates clinical exceptionality.  

Further information on applying for funding in exceptional clinical circumstances can be found by visiting the ICB website.

Reference:
Ganglion excision NHSE Evidence Based Interventions