Clinical Thresholds

Condition or Ganglions Treatment Commissioning Surgery for Ganglions will not routinely be offered. The following Threshold conservative measures are to be undertaken in the first instance: • Reassurance of patient (many ganglia disappear spontaneously and 40% disappear for at least 12 months after aspiration) • Aspiration under local anaesthesia using a wide bore needle (16 or 18 gauge). Repeat as necessary. • Application of a firm bandage for one week to prevent recurrence

Referral to Secondary Care Services The CCG does not routinely commission surgical removal of ganglia. If a patient’s condition is felt to be exceptional, referral should be made to the CCG’s Individual Funding Request Panel. Referral for soft tissue ultrasound can be made where there is diagnostic uncertainty. Where access to soft tissue ultrasound is not available, referral for a surgical opinion can be made to provide diagnostic support. However in these situations, where a diagnosis of a ganglion is confirmed clinically, excision will not be commissioned unless deemed an exceptional circumstance by the Individual Funding Request Panel.

NB: Few indications for surgery: Scar is often symptomatic. Up to 30% of ganglions recur. High dissatisfaction rate. Referral Exceptional cases can be referred to the CCG’s Individual Funding Guidance Request Panel for prior approval.

Re f e rr al F o r m

Effective from April 2013 Summary of Most ganglions are symptom free, but some give pain, weakness, evidence / mobility disorders or pressure neuropathy. Many disappear rationale spontaneously and many others cause little trouble.

For ganglion cysts in general, the possibilities for treatment are: • Explanation, reassurance, wait to see if the cyst disappears spontaneously • Removal of the liquid contents of the cyst with a needle (aspiration) under local anaesthetic • Surgical removal of the cyst

The Trent regional audit (which reviewed the progress of 729 ganglions up to 10 years from attendance) indicated that 33% of dorsal ganglions and 45% of volar-wrist ganglions would resolve spontaneously in six years (ref 1). The recurrence rate after excision of wrist ganglions is between 10-45%. For any individual cyst, the recommendations for treatment will depend on the location of the cyst and on the symptoms that it is causing. Many occur in young adults and often disappear spontaneously. Problems after surgery include persistent pain, loss of wrist movement and trapping of nerve branches in the scar. For these reasons, many surgeons advise against operation for these cysts. Date October 2014 Review Date October 2016 Contact for this Dr Bruce Willoughby policy GP / Governing Member B r u c e w i l l ou g hb y @nhs . net

References:

1. Primary care referral protocol for wrist ganglia Post Graduate Medical Journal F D Burke, E Y Melikyan, M J Bradley, J J Dias h t t p : / / p m j . b mj . c o m / c o n t en t / 79 / 932 / 329 . f u l l

NHS Harrogate and Rural District CCG – General Commissioning Statement - Ganglions Page 2 of 2