Clinical Thresholds

ClinicalThresholds

Conditionor
Treatment / Ganglions
Commissioning
Threshold / SurgeryforGanglionswill notroutinelybe offered.Thefollowing
conservative measuresareto beundertaken inthefirstinstance:
•Reassurance ofpatient(manyganglia disappearspontaneously and 40% disappearforatleast 12monthsafteraspiration)
•Aspiration underlocal anaesthesiausingawide bore needle(16 or18gauge).Repeatasnecessary.
•Application ofafirmbandageforoneweek to prevent recurrence
ReferraltoSecondaryCare Services
The CCGdoesnotroutinelycommission surgicalremoval ofganglia.If a patient’scondition isfelttobe exceptional,referral should bemadeto the CCG’sIndividual FundingRequestPanel.
Referralforsofttissueultrasound canbemadewherethere is diagnosticuncertainty.Whereaccesstosofttissue ultrasound isnot
available,referralforasurgical opinion can be made toprovide diagnosticsupport. Howeverin thesesituations,where a diagnosisofa
ganglionisconfirmed clinically,excisionwill notbe commissioned unlessdeemedan exceptional circumstancebythe Individual Funding RequestPanel.
NB:Fewindicationsforsurgery:Scarisoften symptomatic. Up to30% of ganglionsrecur.Highdissatisfaction rate.
Referral
Guidance / Exceptional casescan be referredtothe CCG’sIndividual Funding
RequestPanelfor priorapproval.
ReferralForm
Effective from / April 2013
Summaryof
evidence / rationale / Most ganglionsaresymptomfree, butsomegivepain,weakness, mobilitydisordersorpressure neuropathy.Manydisappear
spontaneouslyandmanyotherscause little trouble.
Forganglion cysts ingeneral,the possibilitiesfortreatment are:
•Explanation,reassurance,waittosee ifthe cystdisappears spontaneously
•Removal ofthe liquidcontentsofthecyst with aneedle (aspiration) underlocal anaesthetic
•Surgicalremoval ofthecyst
TheTrentregional audit(which reviewed the progressof729ganglions up to10 yearsfrom attendance)indicatedthat33%ofdorsalganglions and 45%ofvolar-wrist ganglionswould resolve spontaneously in six years(ref1).Therecurrence rate afterexcisionofwristganglionsis between 10-45%.
Forany individual cyst,the recommendationsfortreatmentwill depend on the location ofthecystandonthe symptoms thatitiscausing.Many occurinyoungadultsand often disappearspontaneously.Problems aftersurgery include persistent pain,lossofwristmovement and trappingofnerve branchesin thescar. Forthesereasons,many surgeonsadvise againstoperationforthese cysts.
Date / October2014
ReviewDate / October 2016
Contactforthis
policy / DrBruceWilloughby
GP/Governing Member

References:

1. Primarycarereferral protocolforwristgangliaPostGraduate Medical Journal F D Burke,E Y Melikyan,MJBradley,JJDias

NHS HarrogateandRural District CCG– General CommissioningStatement- Ganglions

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