Preoperative intra-articular fluorescein injection to detect the articular branch at surgery on a sural intraneural ganglion cyst at the ankle: illustrative case.

BACKGROUND

Intraneural ganglion cysts (IGCs) are mucinous lesions that originate from adjacent synovial joints. According to the articular theory, synovial fluid tracks from a joint into the parent nerve through an articular branch. In uncommon sites such as the sural nerve, this connection can be difficult to identify. This report illustrates the use of a preoperative intra-articular fluorescein injection as a tool to identify the articular branch during surgery.

OBSERVATIONS: A 60-year-old woman presented with lateral foot pain, numbness, and a palpable mass along the left sural distribution. MRI showed a large cyst extending along the course of the sural nerve with connection to the subtalar joint. Fluorescein was injected preoperatively into this joint to detect the articular branch intraoperatively with ultraviolet illumination. The connection was transected at the joint origin, and the cyst was decompressed, preserving the parent nerve. Postoperatively, the patient had complete pain relief and sensory recovery, and MRI at 3 and 8 months confirmed resolution of the cyst.

LESSONS: Sural IGCs conform to the articular theory and can be managed effectively by transection of the articular branch. Preoperative intra-articular fluorescein injection is a useful tool to detect the articular branch that can be difficult to find in sural IGCs. https://thejns.org/doi/10.3171/CASE251018.