An evaluation of surgical excision versus steroid injection for the management of ganglion cysts

Abstract

Ganglion cysts are benign soft tissue tumors that commonly occur in the joints, especially the wrist. Surgical excision and steroid injection are the two main treatment options; however, their efficacy remains unclear. This prospective interventional control trial included 54 patients with ganglion cysts treated between March 2023 and March 2024 at Saveetha Medical College Hospital, Chennai. Patients were divided into two groups: Group A underwent surgical excision and Group B received aspiration followed by 40 mg of intralesional triamcinolone acetonide injection. The highest incidence was observed in younger patients aged 14–19 years (13 patients), with more females (57.4%) affected. The cysts were equally distributed between the left and right hands. All patients presented with swelling, and 59.3% experienced pain/discomfort. In Group A surgical excision success rate was 92.5%, with a 7.5% recurrence rate. Group B had a lower success rate (64.3%) and higher recurrence rate (35.7%) with aspiration and injection. Surgical excision demonstrated significantly better outcomes, with higher success and lower recurrence rates than aspiration and steroid injection for the management of ganglion cysts. Therefore, this should be considered the preferred treatment option.

Introduction

Ganglion cysts are benign cystic lesion of the soft tissue that are filled with mucinous fluid and typically located near joints or tendon sheaths. They can grow in any joint but are most commonly detected in the wrist. Between 70 and 80% of ganglion cysts on the wrist are located dorsally, typically linked to the scapholunate ligament, with the pedicle arising from various dorsal wrist capsule locations^1–3. On the volar side, 13–20% occur and about 10% originate from the flexor tendon sheath, while intraosseous and intratendinous cysts are rare^4,5. Ganglion cysts often cause discomfort, pain, and functional limitations necessitating medical intervention. A new ganglion cyst develops in approximately 30 out of every 100,000 individuals annually⁶. Cystic fluid is a gelatinous substance with a high concentration of hyaluronic acid and comparatively low concentrations of albumen, globulins, and glucosamine. In terms of biochemistry, this fluid differs from the intra-articular synovial fluid and is substantially thicker. Although the origin of this fluid remains unknown, three potential sources have been suggested. There are several theories regarding the genesis of ganglion cysts, but none has been conclusive. Eller et al. proposed that cysts form when synovial fluid herniates into the tendon, whereas Carp et al. proposed that cysts form when connective tissue undergoes mucinous degeneration as a result of prolonged inflammation. Angelides et al.’s theory, which adds microtrauma as a cause in addition to Carp et al.’s findings, is among the most widely accepted modern theories^7,8. Surgical excision and steroid injection are the two primary treatment options for managing ganglion cysts, each with unique benefits and limitations⁷. Surgical excision involves complete cyst removal under local anesthesia, offering definitive resolution but posing surgical risks⁸. Conversely, steroid injections aim to reduce inflammation and alleviate symptoms, offering a less invasive alternative with minimal risks⁹. Although both surgical excision and aspiration with steroid injection have been practiced to treat ganglion cysts, the most appropriate method is less than unanimously agreed upon within the literature. The ambiguity in the optimal treatment for ganglion cysts stems from several factors. This is primarily due to the fact that ganglion cysts vary in size, location, and symptoms, making them painful or simply asymptomatic. Due to the fact that ganglion cysts have a high recurrence rate, especially with non-surgical techniques, it is still unclear if conservative measures or more invasive methods work better. There is disagreement in the guidelines with preference on the type of approach to take. Some practitioners prefer a more conservative method, while others appreciate putting the patient through surgery case by case. The cyst location, the extent to which it is debilitating, and even the patient’s preference determine the choice of treatment. It is these intricacies that make the approach to managing ganglion cysts unique and unstandardized, with no clear answer on how to go about them in the most optimal way¹⁰. However, what this study does differently from those previous studies is it provides a direct comparison between the two treatment methods and then reports on the outcome. The primary aim of this study was to compare the effectiveness of two common treatment modalities for ganglion cysts: surgical excision and aspiration followed by steroid injection. In particular, evaluation was done with respect to success rates as well as recurrence rates and postoperative complications of two treatment alternatives in a group of patients. The study also aimed to gather insights on the epidemiology, clinical presentation, and symptoms associated with ganglion cysts and to evaluate the long-term outcomes of these treatments through multiple follow-up assessments. The study also aims to provide a more rigorous quantitative comparison of the two treatment approaches. Our hypothesis is that, in terms of success rate and recurrence, surgical excision of ganglion cysts would be more beneficial than aspiration followed by steroid injection. We expect surgical excision to lead to improved long-term clinical results, fewer postoperative complications, and a decreased recurrence rate.

Materials and methods

This study involves two phases: an initial retrospective observational study, which was conducted using patient details from March 2023 to March 2024 at Saveetha Medical College Hospital in Chennai, a well-known tertiary care center, followed by a prospective interventional trial scheduled to take place from June 2024 to June 2025 with a similar sample size to further validate the accuracy of the results. This study was approved by the Institutional Ethics Committee of the Declaration of Helsinki. The prospective interventional trial was registered at CTRI (CTRI/2024/05/067579) on 17/05/2024. Patients gave their written consent to participate in the research study after being informed about it in their native tongue, and for patients aged less than 18 years, their parents or guardians gave their consent. Patients who were older than 14 years, without a history of therapy for ganglion, who had a clinical diagnosis of ganglion cysts with a size greater than 1 cm, and willingness to follow up were included in the study. Similarly, patients who were not willing to follow-up, or those who previously underwent treatment for ganglion cysts were not included in this study and those who had any concurrent medical conditions that could affect the joints or tendons were also excluded from the study. To diagnose ganglion cysts, the patient’s medical history was obtained by asking questions to assess pain (Visual Analog Score), functional disturbances, loss of dexterity, and physical examination. Radiological investigations, such as radiography and ultrasonography, were performed to confirm the diagnosis and rule out any other etiology of the lesion. Patients were also assessed for comorbidities such as diabetes and systemic hypertension, and graded using the MSTS score. All the patients were informed of the lesions and their treatment options. After the patients chose their own treatment plans, they were assigned to the appropriate group. Surgical excision was performed in group A patients, whereas aspiration and intralesional steroid injection (triamcinolone acetate) were performed in group B. Under standard aseptic conditions using iodine-based solutions, the procedure was performed in both groups. The tumors of patients in Group A surgically removed. Initially, 10 ml of 2% lignocaine, a local anesthetic, was injected locally. The surgical procedure involved making an incision, followed by tissue dissection (Fig. 1A, B). The objective of this incision would be to give enough access for the excision of the whole cyst and pedicle without inflicting damage on the surrounding tissues. For small cysts, the incision could be about 1–2 cm in size. Larger cysts or those with defined pedicles may require a little more incision size, around 2–3 cm. Then the ganglion cyst would be gently mobilized, and the pedicle, which is typically found at the base of the cyst where it connects to the joint capsule, tendon sheath, or ligament, is removed close to its origin by cutting it along with the entire cyst complex, leaving no residual tissue, and the incison is approximated by using 3–0 ethilon (Fig. 1C, D). Postoperatively, the patient was immobilized using a plaster of the Paris (POP) slab. The patients were prophylactically administered amoxicillin (500mg) in combination with clavulanic acid (125mg) orally, to prevent postoperative infections and sutures, and the POP slab was removed after 1 week. In group B, the area was first locally infiltrated with 10 ml of 2% lignocaine as in group A, and then using an 18 G syringe the cyst was first aspirated, and then a similar 18 G pre-filled syringe containing 40 mg of triamcinolone acetate was used to inject the steroid into the lesion. The patient was bound to be immobile for the entire day using a robust bandage. A follow-up session was scheduled at 1 week, 1 month, 3 months, and 6 months after the intervention, during which time they were assessed for recurrence and postoperative complications. After the last appointment, if the cyst had vanished and there were no recurrences, we considered the treatment successful. In case of any recurrence, the treatment was judged as a failure, and the success of the two treatment modalities was assessed using the Fischer exact test. The JAMOVI program was used to perform statistical analysis, and a p value < 0.05 was determined as statistically significant. The prospective design of the study decreased the recall bias and allowed for real-time data collection, which increased the reliability of the findings. Multiple follow-ups were included in the study, which made it possible to evaluate the outcomes over time. The efficacy of these drugs was demonstrated using a longitudinal approach. The long term complications and efficiency of the treatment modalities will assessed by an extended follow up period of 1 year in the prospective trail phase of the study.

Fig. 1.

(A) Incision: The skin overlying the ganglion cyst is marked for the incision. (B) Dissection and Excision: After making the incision, the underlying tissues are carefully dissected to expose and reflect the ganglion cyst, which is then excised. (C) Wound Closure: The incision is approximated, and ethilon sutures are placed to close the wound following cyst removal. (D) Excised Cyst Complex: The ganglion cyst, along with its pedicle, is completely excised and removed, as shown in the image.

Results

In this investigation, 54 patients with ganglion cysts were included. Of these, 40 patients were in group A and 14 were in group B (Fig. 2). Of the 54 patients, 23 were men (42.6%) and 31 were women (57.4%), with male: female ratio of 0.74:1 (Fig. 3). In this present study, the mean age was 30.16 ± 13.01 (p = 0.012). Based on age, most patients belonged to younger age groups: 13 patients were between the ages of 14 and 19 years, and 11 patients each were within the 20–25 and 26–31 age groups. There were fewer patients in the older age group (Fig. 4). The site distribution showed that ganglion cysts were almost equally distributed between the left hand (22 patients) and right hand (21 patients), with 11 individuals having cysts in other locations, such as the right ankle (p = 0.756). This provides insight into the prevalence and distribution of ganglion cysts across different anatomical sites, aiding the understanding of the pattern of occurrence of this musculoskeletal condition in the study population (Fig. 5). The prevalence of various comorbidities was assessed, most of which were hypothyroidism followed by diabetes mellitus. The symptoms were categorized. One symptom observed in all the individuals (100%) was swelling. Furthermore, 59.3% of the patients felt pain and discomfort, 27.7% expressed concerns about their appearance (cosmetic), 18.5% expressed fear of a tumor, and 11.1% complained of loss of sensation (p = 0.712), which provided insights into the diverse range of symptoms experienced by patients with ganglion cysts, highlighting the multifaceted nature of this condition and its impact on patients’ well-being (Fig. 6). Based on the symptoms, MSTS scoring was performed, and the mean score was found to be 23.78 ± 1.87 in GROUP A and 23.5 ± 1.53 in GROUP B patients (p = 0.000). The relationship between the MSTS score and age was observed using a scatterplot (Fig. 7). Patients were also assessed for postoperative complications, and 3 of the 40 patients (GROUP A; 7.5%) and 2 of 14 patients (GROUP B; 14.3%) had complications, including postoperative infections and fever. With a 7.5% recurrence rate, surgical excision in Group A had a success rate of 92.5%, the success rate in Group B was lower at 64.3%, the recurrence rate was greater at 35.7%, and the p value was 0.047 (Table 1, Fig. 8). The correlation between age, MSTS score, and recurrence was assessed using a regression plot where recurrence was given a value of 1, and no recurrence was given a value of 0. Our analysis found a statistically significant correlation between the MSTS score, age and the rate of recurrence. This suggests that patients who are younger and had higher MSTS scores, which reflect better functional outcomes and reduced symptoms, were less likely to experience recurrence. The correlation was significant at the 0.01 level (two-tailed).

Fig. 2.

Number of patients undergoing in surgical EXCISION (Group A) and ASPIRATION AND INJECTION (Group B).

Fig. 3.

Gender distribution of the included patients.

Fig. 4.

Age distribution of the included patients (p = 0.012).

Fig. 5.

Site distribution of the included patients (p = 0.756).

Fig. 6.

Symptoms in included patients (p = 0.712).

Fig. 7.

A scatterplot showing the relationship between MSTS score and age.

Table 1.

Success and recurrence rates of both group of patients.

Treatment	Success	Percentage	Recurrence	Percentage
Surgical excison	37	92.5	3	7.5
Steroidal injection	9	64.3	5	35.7

p = 0.047 (fischer exact test).

Fig. 8.

Success and recurrence rates of both group of patients (p = 0.047).

Discussion

Ganglion cysts, which account for 50–70 percent of tumors in the hand and wrist regions, are one of the most prevalent benign soft tissue tumors^2,11. There are several ways to treat ganglions, including aspiration, sclerotherapy, intralesional steroid injection, and surgical removal; however, none of these approaches have proven to be the single most effective treatment. Consequently, there is no gold standard for treatment. When our patients first presented, their average age was 30.16 ± 13.01 years (p = 0.012). Our results were consistent with those reported by Singhal et al.. The findings are similar, while in research by Paul and Sochart, the mean age was 40.25 years^12,13.

There were 54 patients in our research and a male: female ratio was found to be 1:1.35. Comparable outcomes were attained in the West with a ratio of 1:1.3¹⁴. A ratio of 1:1.4 was recorded in several studies pertaining to African and European demographic groupings^15,16. Recurrence is the most frequent side effect of ganglion cysts. To treat wrist ganglions, Paramhans et al. examined two techniques: aspiration followed by triamcinolone injection and surgical removal. They concluded that intracystic steroid injection was a safe course of therapy after discovering recurrence rates of 8.4% and 21.5%¹⁷. The claim that women have a higher incidence of ganglion cysts than males is supported by the results of every study, which consistently demonstrate that women have a higher prevalence of ganglion cysts. This link bolsters the idea that, as research now in publication suggests, ganglion cysts may be more frequent in women¹⁸. Similar to our study, preoperative discomfort was noted to be common in all patients in the study by Turgut et al. However, after the procedure, this drastically declined, with only 2.7% of the patients experiencing discomfort at the 12-month check-up. Similarly, 9.5% of patients reported feeling numb prior to the procedure; this number steadily dropped following the procedure, reaching 1.4% at the 6- and 12-month follow-ups, and our results were comparable to this¹⁹.

In our study, we have compared surgical excision, which forms Group A, and aspiration with intralesional steroid injection, forming Group B. We obtained our results, and there were more successes in Group A with a 92.5% success rate compared to Group B that indicated only a 64.3% success rate with 35.7% recurrence rates. Our findings agree with the reports of several studies conducted by comparing surgical excision to aspiration and steroid injection. Studies by Humail et al. and Jagers et al. also have documented recurrence rates and success rates to be lower in surgical excision compared with aspiration with steroid injection. Humail et al. have found that the recurrence rate was 24% after surgery, while Jagers et al. reported a recurrence rate of 24% after surgery, and it was 77% after aspiration and hyaluronidase injection^20,21. For comparison, recurrence after aspiration with steroid injection by Paramhans et al. was recorded to be 8.4%, which is drastically higher compared to 7.5% that were recurrent at follow-up in the group treated by surgical excision; it thus concurs well with a long-term view and practice whereby surgical excision still presents as the treatment modality with high effectivity¹⁷. The method of surgical excision, including the size of the incision and dissection approach, can influence the success rate and recurrence. For smaller cysts, a minimal incision of 1–2 cm is typically sufficient, while larger cysts may require a 3–4 cm incision. The key to successful excision lies in ensuring complete removal of the cyst along with its pedicle, which is the attachment point to the joint or tendon. Variations in technique, such as incomplete excision or failure to fully remove the pedicle, could lead to higher recurrence rates. Our study focused on ensuring complete excision, while aspiration only removes the fluid from the cyst, and even though these symptoms may temporarily subside as a result of aspiration, but the pedicle is still untouched. This is why, after a while, the patient experiences reformation of a cyst, hence the highest rate of recurrence which may explain the higher recurrence rates in Group B compared to Group A. Steroid injection aims to reduce inflammation, but it doesn’t address the underlying cause or structural attachment of the ganglion, leading to potential recurrence after symptom relief. This likely explains why Group B had a higher recurrence rate and lower overall success. Pathophysiology of ganglion cysts is still unclear; however, many theories are present about their formation. The most popular theory about the origin of ganglion cysts was given by Angelides et al., according to which ganglion cysts result from microtrauma to the joint or tendon sheath, causing the herniation of synovial fluid¹. This fluid contains a high amount of hyaluronic acid that contributes to the gelatinous nature of the cyst. Fluid-filled sacs can cause discomfort and may even lead to functional impairment due to pressure on surrounding tissues, like nerves or tendons.Therefore, surgical excision is a definitive measure since it removes the cyst along with its pedicle entirely, thus avoiding the recurrence when only the fluid is aspirated. On the other hand, aspiration with steroid injection does temporarily relieve symptoms but does not remove the potential for cyst recurrence because it fails to address the structural attachment of the cyst to other tissues.Such outcomes have shown several factors that might have influenced the better result in group A, including complete excision of the pedicle. Surgical excision includes completely eliminating the pedicle, a structure that links the cyst with the joint or tendon, and this is crucial since its remnants may be responsible for the recurrence of the same cyst. The ganglion cyst can be definitively treated by surgical excision, whereas aspiration only evacuates the cyst fluid, leaving the cyst wall behind. Steroid injection in Group B may reduce inflammation temporarily but does not treat the source of the problem.

While this study is of great value in terms of insight into the management of ganglion cysts, several limitations must be considered. This study was conducted at a single tertiary care center, limiting the generalizability of results to other populations or settings. Patient demographics, clinical practices, and resources vary greatly between different hospitals and regions, potentially influencing outcomes. Although the study included 54 patients, the sample size can be considered relatively small, especially in Group B with 14 patients which may affect the robustness of the study. A larger cohort would give stronger data and better conclusions. Selection bias could occur when patients are not randomly assigned to groups but rather select their preferred treatment, which may then affect outcomes. A prospective randomized controlled trial would be better in minimizing bias and offering stronger evidence that has been registered with CTRI and scheduled to take place from June 2024 to June 2025 where we will include a more comprehensive assessment of patient-reported outcomes (PROs) such as pain scales, functional assessments, and quality of life measures, to better understand the impact of ganglion cysts and their treatments on patients’ daily lives. This will provide a more comprehensive evaluation of the effectiveness of surgical excision versus steroid injection in improving patient well-being and the follow up period will be further extended upto 1 year. Future research should focus on refining treatment protocols, exploring potential risk factors for recurrence, and investigating long-term outcomes of different treatment modalities. There is a growing interest in minimally invasive approaches for the management of ganglion cysts, such as endoscopic removal and aspiration with adjunctive therapies. These techniques may offer advantages over traditional methods, such as reduced recurrence rates, shorter recovery times, and lower complication rates²². Future studies should explore these minimally invasive techniques in greater detail, including their efficacy, safety profile, and potential benefits in comparison to traditional surgical excision and steroid injection which may provide valuable insights into optimizing the management of ganglion cysts.

Conclusion

This study was aimed at comparing the efficacy of two commonly used treatment modalities for ganglion cysts, namely surgical excision and aspiration with steroid injection, in terms of success rates, recurrence rates, and postoperative complications. The results show superiority of the surgical excision as higher success rates with lower recurrence rates at 92.5% and 7.5%, respectively, against aspiration combined with steroid injection, which was successful in 64.3% of the patients with a recurrence rate of 35.7%. It indicates that surgical excision has more definitive eradication because it involves the total removal of the cyst along with its pedicle, thus eliminating the source of recurrence. It has also provided valuable epidemiology and clinical presentation knowledge for ganglion cysts. Swelling was the common symptom that the condition presented itself to, especially in young patients, followed closely by pain and cosmetic concerns. Larger, multi-center prospective randomized controlled trials are, however, needed to be performed for validating the findings and inquiring more into risk factors that contribute to the recurrence of this ganglion cyst and what roles adjunctive therapies will have in the management. Further, investigation of minimally invasive approaches may also elucidate the strategy of optimal treatment of this relatively common musculoskeletal pathology.

Author contributions

Conceptualization, K.G. and K.K.; methodology, K.G.; software, K.G.; validation, K.G. and, K.K.; formal analysis, K.K.; investigation, K.G.; resources, K.G.; data curation, K.G.; writing—original draft preparation, K.G.; writing—review and editing, K.G. and, K.K.; visualization, K.K.; supervision. All the authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Data availability

The data presented in this study are available upon request from the corresponding author.

Declarations

Competing interests

The authors declare no competing interests.

Informed consent statement

Informed consent was obtained from all the subjects involved in the study.

Institutional review board statement

All subjects provided informed consent for inclusion before participating in the study. The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by the Ethics Committee of Saveetha Medical College.