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Synovial cyst aspiration; Improving outcome

Discussion in 'General Issues and Discussion Forum' started by Mart, Jun 3, 2010.

  1. Mart

    Mart Well-Known Member


    Members do not see these Ads. Sign Up.
    Here’s some ideas I have been thinking about that I have never heard discussed before, probably means that I’m a bit bonkers but here goes anyway.

    Tx of troublesome synovial cysts surgically or by aspiration seems to have reputation for poor to moderate outcome long term because of recurrence.

    I have recently aspirated a couple of large multiloculated lesions primarily because they were regarded as a bit risky for surgery because of intimacy with neurovascular bundle in tarsal tunnel or patient didn’t want surgery.

    I did them with US guidance for obvious reasons and noticed a couple of interesting things.

    After needle insertion (20g) at cyst margin into “gel” (mostly hyaluronic acid?) there was a vacuum pressure threshold to overcome before the gel aspirated which was pretty close to max achievable with tuberculin syringe (best mechanical advantage) and then a sudden surge of aspirated gel which then stopped. On US I noticed that the cyst wall had collapsed to margins of needle. It was impossible to aspirate further in spite of compressing the cyst laterally with large force. Moving the needle further into the cyst and repeating aspiration was successful but with same limiting factor. Essentially I had to hoover up the gel to get it out.

    Using a syringe to do this whilst holding the US probe was impossible so I had to get assistance which made the process somewhat less than ideal to co-ordinate.

    So my thoughts were this;

    If the notion of getting cyst walls to adhere to prevent recurrence by period of post aspiration compression has merit then I it would be likely that the walls need to be intimately apposed in the first place. For large cysts I would estimate that aspirating blind would leave a lot of gel behind which might explain poor outcomes.

    I had previously thought that the reason that it was impossible to drain some cysts was because the gel was too viscous. Whilst this might be true, I am wondering if it is more to do with the adhesion of the gel to the cyst wall, hence that sudden surge which might be explained by needing to apply a certain force before breaking the gel molecular bonding with the cyst wall. After aspirating the gel I dumped it on a tissue and it didn’t require much effort to suck it into same needle/syringe compared to initial effort within cyst.

    To improve guided aspiration attaching the needle to a device such as a medical aspiration system would seem like a good idea, it would be relatively easy and fast to literally vacuum the contents with much greater finesse than fiddling around with a syringe.
    Anyone tried this – if so what was used and what results?

    Also has anyone tried using any kind of sclerosant to attempt to have cyst walls heal together after aspiration or tried flushing/reaspirating the cyst with sterile saline to dissolve and clean out hyaluronic gel?

    Cheers

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
    Last edited: Jun 3, 2010
  2. Mart

    Mart Well-Known Member

    Having thought about this a bit more I have been trying to figure out if a clinical suction device would generate sufficient negative pressure to be effective for cyst aspiration. Commercial units seem to generate max of -5psi. An interesting and somewhat related thread below suggests this to be far too low.

    http://www.physicsforums.com/showthread.php?t=169182

    anyone aware of an electromechanical device which could be attatched to a syringe to allow it to act a vacuuum pump?


    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  3. Paul Bowles

    Paul Bowles Well-Known Member

    Why not just inject a few cc's of lignocaine into one side of the lesions whilst aspirating from the other side? The fluid becomes less viscous and easy to remove in this manner. Food for thought...
     
  4. LuckyLisfranc

    LuckyLisfranc Well-Known Member

    A 20g needle is too small to aspirate ganglion juice. An 18g bevelled (minimum) or better a 12 or 14g biopsy needle would be more appropriate - due to the highly viscous nature of the 'gel'.

    Wrong tool for the job is the issue here.

    LL
     
  5. Mart

    Mart Well-Known Member

    Hi Paul

    I have thought about this too but never tried it. My thoughts were; is cyst substance soluble in lignocaine? I would expect it would be. The next aspiration I do I'll experiment with aspirant and find out if this is true. Also how soluble? I would estimate a fair amount of time/aggitaion needed; again I'll see what I can find out, or has anyone else tried this?

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  6. Mart

    Mart Well-Known Member

    I think you are wrong about this.

    In the cases I have done prior to the difficult tarsal tunnel one I cited I used a 16g needle with the same asumption as yourself. Because of the extreme risk for tibial nerve and vessel injury I decided to use 20g simply to reduce risk of trauma. Whilst it would likely have required more negative pressure than larger bore the aspiration still worked and I didnt notice any signifcant difference in viscosity from usual.

    My hypothesis really points to the limitation to complete evacuation of large cysts being ability in visualising and positioning needle precisely which by its nature would intuitively benefit constant vacuum (or pulsed vacuum) not easily provided by pulling a syringe plunger. Also the possibility that a permament fusion of collagen layers which form cyst wall may be better acheived with complete evacuation followed by period of compression.

    There is a great medical literature review I which I will try and dig out and post which looks at inadequacy in our understanding of these lesions, the 6 main theoretic contenders for its pathophysiology and evidence to date for treatment options (including, if I remember correctly; "rubbing a dead mans hand on the area" which I have not tried)

    cheers


    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  7. drsarbes

    drsarbes Well-Known Member

    Hey Mart:
    Good thread. (and no I haven't gotten around to uploading the pics I promised)

    I've had trouble, as well, aspirating and at times blamed the viscosity. I do dilute with xylocaine at times, which helps. Frequently I end up "milking" the ganglion to get the last few drops out. I use an 18G needle with at least a 3cc syringe. In my experience the TB 1cc syringe does not supply enough vacuum.

    Since the tissue that makes up the cyst produces the fluid, I would think that some kind of sclerosing agent might work if you could keep the interior tissue from functioning or "obliterate" the space by uniting the two opposing surfaces after damaging them with a sclerosant. But if it did works, guys like me wouldn't have the fun of excising them.

    Steve
     
  8. Mart

    Mart Well-Known Member

    Hi Steve Paul and LL

    Wouldnt we all like to surgery replaced by something less invasive :pigs: ?

    for what it is worth I have attatched the paper I was thinking about. Dont be put off by title, contents generalise well to foot and ankle. It is a nicely presented review, saving a lot of work gathering papers and makes convincing work of considering what has been published.

    of note;

    no synovium within "cyst", not really a cyst therefore.

    lack of understanding of mechanism of formation and rejection of commonly held beliefs.

    no plausible reason to inject with steroid to moderate inflamation.

    risks associated with sclerosants

    behavioural effects of aspiration on decision making by patient


    worth a 10 min read

    View attachment Ganglion cysts of the wrist.pdf

    Gude, W. and V. Morelli (2008). "Ganglion cysts of the wrist: pathophysiology, clinical picture, and management." Ethics in Science and Environmental Politics: 1-7.
    This article reviews what is known about ganglion cyst formation, natural history (50% of cysts will spontaneously resolve), diagnosis, and management of this common malady. Although the exact mechanism of cyst formation is unknown, most current theories hold that extra-articular mucin "droplets" coalesce to form the main body of the tumor. Only subsequently are the "cyst wall" and pedicle (connecting the cyst to a nearby synovial joint) formed. Treatment options include watchful waiting, nonoperative aspiration/injection, and surgical removal. Although treatment is often unnecessary, many patients seeking consultation desire some form of definitive treatment. Cyst aspiration/injection is fraught with a high incidence of recurrence. Surgery generally results in lower rates of recurrence, but a higher incidence of complications. All current treatment options are suboptimal. © 2008 Humana Press.

    cheers


    Martin



    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
  9. drsarbes

    drsarbes Well-Known Member

    "Wouldnt we all like to [have] surgery replaced by something less invasive"

    Mart - are you trying to put me out of business?
     
  10. Mart

    Mart Well-Known Member


    Steve I guess if it were possible . . . . yes . . . but :pigs:not!



    Anyhow just to show you that I am trying; to my surprise I discovered that if I blocked the needle end of a 20ml syringe, pulled the plunger back to 20mls and blocked the plunger return with a Perspex rod there was no noticeable leakage after 4 hrs.

    So no need for any fancy equipment to create an evacuation system other than a fairly rigid walled tube with female Luer adapter to connect to syringe and a push button valve at the male end to control aspiration rate.

    Anyone know if such a thing exists, I have done a Google search without any luck? Perhaps it will need customizing somehow.

    Steve, I was looking at your interesting case# photos of the tarsal tunnel cyst; after you remove these I presume that you send for cytology. Do you get any report back on the histology of the cyst walls.

    If so is it consistent with Gude, W. and V. Morelli (2008) account that this is acellular?

    One thing I notice on US is that in the large cysts I have looked at there is an internal layer to the cyst wall which sonographically appears like hypertrophied synovial lining I see in DJD. It ocured to me that the evidence cited may be wrong or not generalisable to all these lesions.

    Cheers

    Martin


    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    Phone [204] 837 FOOT (3668)
    Fax [204] 774 9918
    www.winnipegfootclinic.com
     
  11. Paul Bowles

    Paul Bowles Well-Known Member

    I would hardly call milking a ganglion surgery.

    If you dont like the invasive nature of a "needle" just use textbook therapy. Hit it hard enough and its all gone!!!! :bash:
     
  12. Mart

    Mart Well-Known Member

    Hi Paul

    Nor would I . . . . . I think you may have missed the point here.

    What I have been trying to explore is possibility of improving efficacy of aspiration so that excision is less desirable. Did you get a chance to read the paper I posted? Did you find any fault in the analysis?

    When did you last successfully treat a largel tarsal tunnel cyst with by bashing with a book? :dizzy:

    cheers

    Martin

    The St. James Foot Clinic
    1749 Portage Ave.
    Winnipeg
    Manitoba
    R3J 0E6
    phone [204] 837 FOOT (3668)
    fax [204] 774 9918
    www.winnipegfootclinic.com
     
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