SRP 052 Ganglion/Mucoid Cysts

Policy number: SRP 052
Policy name: Ganglion/Mucoid Cysts
Status: Individual Prior Approval
Effective date: 1 April 2024
Next review date: 1 April 2026

Mid and South Essex ICB commissions surgical removal of ganglion/mucoid cysts on a restricted basis.

A ganglion cyst is a fluid-filled swelling that develops near a joint or a tendon, they look and feel like a smooth, soft lump under the skin. Ganglions can occur alongside any joint in the body; however, the most common location is on the wrist, hand, fingers and foot. This policy applies to ganglion in all locations.

Ganglia are caused by cystic degeneration of a joint capsule or tendon sheath. Lesions at the base of the digits are often small but very tender (seed ganglion). Mucoid cysts arise at the distal interphalangeal joint and may disturb nail growth. Ganglion cysts are usually harmless and can safely be left alone. Many disappear spontaneously and many others cause little trouble. There are no long-term consequences from leaving the ganglion untreated.

Ganglia arising at the level of the wrist are rarely painful or functionally impairing and about 50% will resolve spontaneously within 5 years. In the longer term, approximately 60% of ganglia remain resolved following aspiration and about 70% following surgery. When other complications of surgery such as scar sensitivity, joint stiffness or distal numbness are taken into account operating is usually an unattractive option. Appropriately counselled patients will often not request surgical referral.

Patients with asymptomatic ganglia should not be referred to secondary care. They should be reassured by primary care clinicians and asked to seek assistance if the ganglion becomes symptomatic.

There is no indication for the routine excision of simple or asymptomatic ganglia; these should not be referred.

Surgical removal of ganglion will only be funded when they meet the criteria specified below:

Painful seed ganglia requiring regular analgesia which persist or recur after puncture/aspiration.

Mucoid cysts that are causing significant nail deformity or have recurrent spontaneous discharge (risk of septic arthritis in distal inter-phalangeal joint)

Surgery for ganglion of the wrist where:
- there are symptoms associated with the ganglia such as pain, loss of sensation in certain parts of the hand, neurological loss or weakness of the wrist with the ganglion, and where the ganglion has resulted in functional impairment which prevents the individual from fulfilling activities of daily living, but has not responded to all appropriate conservative treatments* over a minimum period of 3 months AND
- the patients is aware that most ganglia resolve spontaneously over time AND
- the patient is aware of the complications of excision such as scar tenderness, stiffness or numbness, and likelihood of recurrence.

*Conservative treatments include:

Reassurance-35-45% 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 3 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.

Find out more information on applying for funding in exceptional clinical circumstances