Nonsurgical treatment of the dorsal synovial cyst in the wrist: a randomized clinical trial comparing needle aspiration versus aspiration and corticosteroid infiltration

Abstract

Synovial cyst is the most common tumor in the hand and wrist, representing around 70% of soft tissue tumors found in this segment of the body. It is a benign tumor and there is no description of malignancy in the literature. Clinically it is, in most cases, asymptomatic. Physical examination is a visible and palpable mass, with varied volume and consistency and non-adherent to the skin. Surgical resection is considered to be the definitive treatment for synovial cyst, but it can be associated with neurological injuries and painful scars. As a result, the non surgical procedures gained adherents, and became common practices in the treatment of synovial cyst of the wrist. Among the conservative treatment options, the most popular are the aspirations alone or followed by infiltration of corticosteroids. In the literature there are several articles published regarding the efficacy of these two methods, but most of them show considerable divergence of results, and poor methodology. By virtue of this gap in knowledge, we propose a prospective randomized study, to evaluate the success rate of these two methods, being able to say whether there is superiority of one method over another. The proposed study acquires relevance because the use of corticosteroids had theoretical basis in reducing inflammation. However, the inflammatory etiology of the synovial renal cysts was already departed. Added to this, there is also the fact that the infiltration of steroids can present with subcutaneous atrophy and depigmentation of the skin. Therefore, if the use of corticosteroids proves to be clinically superior it would justify its use, otherwise, the infiltration alone tends to cause fewer side effects. Our objective is to compare the effectiveness of nonsurgical treatment of dorsal wrist synovial cysts with aspiration versus needle aspiration and infiltration of corticosteroids, in the rate of cure and recurrence of the cysts. The sample will consist of patients with single synovial cyst of the dorsal wrist, with no other lesions in this segment. The diagnosis will be clinical, and it will be performed routine physical examination (palpation) and radiographs (to rule out the presence of intraosseous cysts).The inclusion criteria are: age over 15 years, with no other injuries in the wrist, no allergy to corticosteroids and no chronic use of corticosteroids. The exclusion criteria are: age below 15 years, history of previous surgery for resection of a synovial cyst, presence of intraosseous synovial cyst - or any other injury in the wrist - chronic use of corticosteroids and / or allergy to corticosteroids. Patients will be allocated randomly into two groups: Group 1 will undergo needle aspiration, and Group 2 will undergo needle aspiration followed by corticosteroid infiltration. All cases will be treated at the clinic, without the need for hospitalization or surgical environment for performing procedures. Regarding to the follow-up, no patient will be immobilized and all will return within one week, one month, two months, three months and six months after the procedure. In all returns the patients will be evaluated for pain complaints and recurrence of the synovial cyst. In case of relapse, patients will be asked about their motivation of performing the procedure again. For both groups A and B, there will be performed a maximum number of three aspirations and / or infiltration, according to the randomization performed initially, as the current literature is unanimous in stating that repeated episodes of aspiration of the cyst does not increase the rate of success of the treatment. All patients shall complete a term of informed consent, and may leave the study as well as change the treatment option, when they so decide. Such patients will be excluded from the final sample.(AU)