Ulnar Nerve Compression From Ganglion Cyst

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Ulnar Nerve Compression From Ganglion Cyst

Authors, Editors, Case Information Author: Bradlee Sako, MD Senior Editor: Nicholas Moore, MD Clinical Vignette: An 86-year-old male with a past medical history of coronary artery disease, polymyalgia rheumatica, idiopathic gout involving the foot, CKD stage 3B, and pulmonary hypertension presented with complaints of persistent numbness and tingling in his left 4th and 5th fingers ongoing for the prior two months. He also complained of feeling a small bump at the ulnar aspect of his left forearm slightly distal to his humeroulnar joint. Type of Probe Used: Linear setting on multi-purpose point of care ultrasound device. Unlabeled short axis view of the left cubital tunnel Unlabeled short axis view of the left cubital tunnel. Labeled short axis view of the left cubital tunnel Labeled short axis view of the left cubital tunnel with ganglion cyst and ulnar nerve visible. Unlabeled long axis view of the left cubital tunnel Unlabeled long axis view of the left cubital tunnel. Labeled long axis view of the left cubital tunnel Labeled long axis view of the left cubital tunnel with ganglion cyst visible and evidence of ulnar nerve compression. Unlabeled long axis view of the ulnar nerve with Doppler Unlabeled long axis view of the ulnar nerve with Doppler Labeled long axis view of the ulnar nerve with Doppler Labeled long axis view of the ulnar nerve with Doppler with visible proximal swelling of the ulnar nerve with compression distally as it traverses ganglion cyst. #7 - Video View Video Short Axis Cine of the left cubital tunnel from proximal to distal. As the transducer tracks the ulnar nerve, a prominent, well-circumscribed, anechoic structure becomes evident, particularly from the 0:11 mark onward. This finding is highly consistent with a large ganglion cyst. The cyst creates a significant mass effect, visibly displacing and compressing the ulnar nerve within the restricted space of the tunnel. #8 - Video View Video Long Axis Cine of the left cubital tunnel from medial to lateral and back further characterizing the prominent ganglion cyst identified in the previous short-axis sweep. The large, anechoic fluid collection is clearly visualized exerting a substantial mass effect on the surrounding structures. The ulnar nerve can be seen running longitudinally, with its normal fascicular architecture visibly displaced, stretched, and bowed over the cyst. #9 - Video View Video Long Axis Cine of the left cubital tunnel from the cyst proximally and then distally, utilizing color Doppler imaging to further evaluate the prominent anechoic structure compressing the ulnar nerve. Throughout the dynamic sweep, the large fluid collection exhibits a complete absence of internal color flow within the Doppler box. This critical finding definitively rules out a vascular etiology, such as an aneurysm or prominent vein, confirming that the mass is indeed an avascular structure. This solidifies the diagnosis of a ganglion cyst acting as a space-occupying lesion and causing mechanical compression of the ulnar nerve. Interpretation Image Interpretation: Evidence of a hypoechoic structure consistent with a ganglion cyst near cubital tunnel causing visible enlargement of ulnar nerve proximally. Teaching Pearl: Electrodiagnostic testing can confirm and localize ulnar neuropathy, but ultrasound can also add the ability to identify structural causes such as a ganglion cyst compressing the nerve. In this setting, a hypoechoic or anechoic nonvascular mass adjacent to the cubital tunnel plus focal nerve enlargement defines the etiology as a space-occupying lesion. Before aspiration or injection near the cubital tunnel, Doppler should be used to exclude vascular mimics such as aneurysm or malignancy. Ultrasound-guided aspiration may be considered for selected ganglion cysts, but persistent neurologic deficit or recurrence should prompt surgical evaluation. References: 1. Shook SJ, Ginsberg M, Narayanaswami P, et al. Evidence-based guideline: neuromuscular ultrasound for the diagnosis of ulnar neuropathy at the elbow. Muscle Nerve. 2022;65(2):147-153. doi:10.1002/mus.27460 2. Yalikun A, Yushan M, Hamiti Y, Lu C, Yusufu A. Intraneural or extraneural ganglion cysts as a cause of cubital tunnel syndrome: a retrospective observational study. Front Neurol. 2022;13:921811. doi:10.3389/fneur.2022.921811 3. Norbury JW, Nazarian LN. Ultrasound-guided treatment of peripheral entrapment mononeuropathies. Muscle Nerve. 2019;60(3):222-231. doi:10.1002/mus.26517
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Authors, Editors, Case Information

Unlabeled short axis view of the left cubital tunnel

Labeled short axis view of the left cubital tunnel

Unlabeled long axis view of the left cubital tunnel

Labeled long axis view of the left cubital tunnel

Unlabeled long axis view of the ulnar nerve with Doppler

Labeled long axis view of the ulnar nerve with Doppler

#7 - Video

#8 - Video

#9 - Video

Interpretation

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