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Managment-Operative Management

Surgical decision making is first dependent on whether a cyst is causing suprascapular nerve compression. If a ganglion cyst is present, then the cyst is a result of intra-articular pathology; in athletes, this frequently is because of a labral tear. The natural history of ganglion cysts about the shoulder is not known; however, it commonly is thought that these cysts persist and may enlarge over time. Even so, reports of spontaneous cyst resolution have appeared.

Approximately 90% of ganglion cysts about the shoulder that cause suprascapular nerve compression are associated with labral tears. In these cases, the current recommendation is arthroscopic debridement or repair of the labrum. Some surgeons recommend direct decompression of the cyst while also addressing the labral pathology.

Multiple approaches to cyst decompression have been reported to have good success; these approaches include arthroscopy, open cyst excision, and percutaneous aspiration under CT or ultrasound guidance. Ganglion cyst decompression about the shoulder without also addressing the intra-articular pathology has been associated with a failure rate of up to 50%, whereas the inability to aspirate the cyst has been reported to occur in 18% of cases (93,153).It is worth noting, however, that excellent results have been reported with open decompression/excision of the cyst without exploration of the glenohumeral joint.

Controversy exists with regard to the timing of surgery if suprascapular nerve dysfunction is present but no periarticular cyst is identified. Some authors (including the senior author) use the criteria of no improvement in comfort and strength despite 6 months of nonoperative management and/or no improvement of EMG findings as an indication for surgical decompression of the suprascapular nerve.

Other authors advocate immediate surgical intervention once the diagnosis has been made to prevent progressive and, potentially, irreversible muscle atrophy and, because it is felt that the pathology, if not the symptoms, likely have been present for at least 6 months by the time the diagnosis has been established.

Still other clinicians and surgeons recommend surgical decompression of the nerve at the first evidence of any muscle wasting to enhance the possibility of maximal muscle recovery. On the other hand, some surgeons recommend surgery only after one full year of nonoperative management (provided no cyst present).

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