{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,24]],"date-time":"2026-04-24T02:55:00Z","timestamp":1776999300987,"version":"3.51.4"},"reference-count":58,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2025,12,1]]},"abstract":"<jats:sec>\n                    <jats:title>OBJECTIVE<\/jats:title>\n                    <jats:p>Extreme subparaneurial ganglion cysts are poorly understood. In Part 1, the authors demonstrated that patterns of distribution in the subparaneurial space are consistent with the principles of the articular theory for intraneural ganglion cysts (INGCs). How a cyst transfers from the subepineurial to the subparaneurial compartment remains to be determined. In this part, the authors provide evidence supporting that cyst transfer occurs at the sciatic nerve bifurcation based on MRI and histological analysis, and introduce the geyser theory as an explanation for the redistribution of cysts.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>METHODS<\/jats:title>\n                    <jats:p>The authors analyze MR images obtained in patients with extreme subparaneurial cysts as well as newly identified cases of nearly extreme subparaneurial cysts (i.e., cysts visible in the subparaneurial compartment but not to the extreme degree as defined in Part 1) for potential crossover sites. They also analyze histological sections from 10 cadavers around the sciatic nerve bifurcation for the presence of openings in the epineurium and paraneurium.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>RESULTS<\/jats:title>\n                    <jats:p>MRI studies performed in 8 patients in Part 1 and 8 newly identified examples with nearly extreme subparaneurial INGCs showed evidence to support communication between different compartments at the sciatic nerve bifurcation (subepineurial-to-subparaneurial and subparaneurial-to-neighboring soft tissues). Openings in the epineurium of the common peroneal and tibial nerves at the sciatic nerve bifurcation were consistently found in all 10 cadaver specimens, as were openings in the paraneurium.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>CONCLUSIONS<\/jats:title>\n                    <jats:p>The authors expand on the evidence to support cyst redistribution at the sciatic nerve bifurcation for INGCs in the knee region. They put forth a logical explanation for the development of a spectrum of extreme INGCs (ranging from a faint amount of cyst around the epineurium [wedding ring sign] to extreme subparaneurial INGCs [owl eyes]) based on principles seen in a geyser. The authors believe that radiological occurrence of crossover can be explained by the presence of fenestrations in both the epineurium and paraneurium at the sciatic nerve bifurcation, allowing cyst crossover in two steps: from the subepineurial to the subparaneurial space (\"cross\") and between a shared subparaneurial space of different nerves (\"over\"). Finally, the frequent occurrence of extraneural rupture (\"cross-out\") is due to cyst transfer into the soft tissue compartment via an opening in the outermost circumneurial layer.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3171\/2025.2.jns242816","type":"journal-article","created":{"date-parts":[[2025,7,4]],"date-time":"2025-07-04T21:34:57Z","timestamp":1751664897000},"page":"1653-1666","source":"Crossref","is-referenced-by-count":4,"title":["Extreme subparaneurial ganglion cysts. Part 2: The geyser theory as a mechanistic explanation for crossover"],"prefix":"10.3171","volume":"143","author":[{"given":"Godard C. W.","family":"de Ruiter","sequence":"first","affiliation":[{"name":"Department of Neurosurgery, Haaglanden Medical Center, The Hague, The Netherlands;"},{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Miguel A.","family":"Reina","sequence":"additional","affiliation":[{"name":"CEU San Pablo University School of Medicine, Madrid, Spain;"},{"name":"Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida;"},{"name":"Department of Anesthesiology, Madrid-Montepr\u00edncipe University Hospital, Madrid, Spain;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"B. Matthew","family":"Howe","sequence":"additional","affiliation":[{"name":"Department of Radiology, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Xavier","family":"Sala-Blanch","sequence":"additional","affiliation":[{"name":"Department of Human Anatomy and Embryology, University of Barcelona, Spain;"},{"name":"Department of Anesthesiology, Hospital Clinic, Barcelona, Spain; and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Byung-chul","family":"Son","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, College of Medicine, Seoul St. Mary\u2019s Hospital, The Catholic University of Korea, Seoul, Republic of Korea"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kimberly K.","family":"Amrami","sequence":"additional","affiliation":[{"name":"Department of Radiology, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Robert J.","family":"Spinner","sequence":"additional","affiliation":[{"name":"Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota;"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"key":"b1","series-title":"J Neurosurg","article-title":"Extreme subparaneurial ganglion cysts. Part 1: Principles and implications","author":"de Ruiter GCW","unstructured":"de Ruiter GCW, Son BC, Hayford KM,  Extreme subparaneurial ganglion cysts. Part 1: Principles and implications. J Neurosurg. Published online July 4, 2025. doi:10.3171\/2025.2.JNS242815"},{"issue":"2","key":"b2","series-title":"J Neurosurg","first-page":"296","article-title":"Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory","volume":"107","author":"Spinner RJ","year":"2007","unstructured":"Spinner RJ, Amrami KK, Wolanskyj AP,  Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory. J Neurosurg. 2007;107(2):296\u2013307."},{"issue":"1","key":"b3","series-title":"J Neurosurg","first-page":"217","article-title":"Extreme intraneural ganglion cysts","volume":"114","author":"Spinner RJ","year":"2011","unstructured":"Spinner RJ, H\u00e9bert-Blouin MN, Rock MG, Amrami KK. Extreme intraneural ganglion cysts. J Neurosurg. 2011;114(1):217\u2013224."},{"issue":"4","key":"b4","series-title":"Clin Anat","first-page":"530","article-title":"Subparaneurial ganglion cysts of the fibular and tibial nerves: a new variant of intraneural ganglion cysts","volume":"29","author":"Prasad NK","year":"2016","unstructured":"Prasad NK, Desy NM, Howe BM, Amrami KK, Spinner RJ. Subparaneurial ganglion cysts of the fibular and tibial nerves: a new variant of intraneural ganglion cysts. Clin Anat. 2016;29(4):530\u2013537."},{"issue":"8","key":"b5","series-title":"Clin Anat","first-page":"1133","article-title":"Elaborating upon the descent phase of fibular and tibial intraneural ganglion cysts after cross-over in the sciatic nerve","volume":"27","author":"Colombo EV","year":"2014","unstructured":"Colombo EV, Howe BM, Amrami KK, Spinner RJ. Elaborating upon the descent phase of fibular and tibial intraneural ganglion cysts after cross-over in the sciatic nerve. Clin Anat. 2014;27(8):1133\u20131136."},{"issue":"4","key":"b6","series-title":"Asian J Neurosurg","first-page":"1225","article-title":"Peroneal nerve palsy due to subparaneurial ganglion cyst, a rare variant of intraneural ganglion cyst","volume":"13","author":"Kim D","year":"2018","unstructured":"Kim D, Choi JG, Son BC. Peroneal nerve palsy due to subparaneurial ganglion cyst, a rare variant of intraneural ganglion cyst. Asian J Neurosurg. 2018;13(4):1225\u20131228."},{"issue":"2","key":"b7","series-title":"Clinical series. J Neurosurg","first-page":"319","article-title":"Peroneal intraneural ganglia: the importance of the articular branch","volume":"99","author":"Spinner RJ","year":"2003","unstructured":"Spinner RJ, Atkinson JL, Scheithauer BW,  Peroneal intraneural ganglia: the importance of the articular branch. Clinical series. J Neurosurg. 2003;99(2):319\u2013329."},{"issue":"10","key":"b8","series-title":"J Neurosurg Case Lessons","first-page":"CASE23314","article-title":"Tibial intraneural ganglion cysts arising from the tibiofemoral joint: illustrative cases","volume":"6","author":"Lenartowicz KA","year":"2023","unstructured":"Lenartowicz KA, Wu KY, Amrami KK, de Ruiter GCW, Desy NM, Spinner RJ. Tibial intraneural ganglion cysts arising from the tibiofemoral joint: illustrative cases. J Neurosurg Case Lessons. 2023;6(10):CASE23314."},{"issue":"21","key":"b9","series-title":"J Neurosurg Case Lessons","first-page":"CASE21130","article-title":"High-resolution MRI of a peroneal intraneural ganglion cyst arising from the knee joint: illustrative case","volume":"1","author":"Smith BW","year":"2021","unstructured":"Smith BW, Jack MM, Powell GM, Frick MA, Amrami KK, Spinner RJ. High-resolution MRI of a peroneal intraneural ganglion cyst arising from the knee joint: illustrative case. J Neurosurg Case Lessons. 2021;1(21):CASE21130."},{"issue":"6","key":"b10","series-title":"Neurosurg Focus","first-page":"E17","article-title":"Peroneal and tibial intraneural ganglia: correlation between intraepineurial compartments observed on magnetic resonance images and the potential importance of these compartments","volume":"22","author":"Spinner RJ","year":"2007","unstructured":"Spinner RJ, Amrami KK, Angius D, Wang H, Carmichael SW. Peroneal and tibial intraneural ganglia: correlation between intraepineurial compartments observed on magnetic resonance images and the potential importance of these compartments. Neurosurg Focus. 2007;22(6):E17."},{"issue":"20","key":"b11","series-title":"Neurology","first-page":"e174","article-title":"Teaching NeuroImages: intraneural ganglion cyst of the tibial nerve","volume":"82","author":"Jerath NU","year":"2014","unstructured":"Jerath NU, Chen JJ, Miller BJ, Reddy CG. Teaching NeuroImages: intraneural ganglion cyst of the tibial nerve. Neurology. 2014;82(20):e174\u2013e175."},{"issue":"24","key":"b12","series-title":"Praxis (Bern 1994)","first-page":"1433","article-title":"Nervensonographie intraneuraler Ganglien als Ursache schmerzhafter N.-peronaeus-Paresen: eine Fallseries","volume":"103","author":"Schlig LH","year":"2014","unstructured":"Schlig LH, H\u00e4gele-Link S, Felbecker A,  Nervensonographie intraneuraler Ganglien als Ursache schmerzhafter N.-peronaeus-Paresen: eine Fallseries. Praxis (Bern 1994). 2014;103(24):1433\u20131438."},{"issue":"2","key":"b13","series-title":"Clin Anat","first-page":"199","article-title":"Another (internal) epineurium: beyond the anatomical barriers of nerves","volume":"33","author":"Reina MA","year":"2020","unstructured":"Reina MA, Boezaart AP, Tubbs RS,  Another (internal) epineurium: beyond the anatomical barriers of nerves. Clin Anat. 2020;33(2):199\u2013206."},{"issue":"2","key":"b14","series-title":"J Surg Orthop Adv","first-page":"136","article-title":"Extraneural rupture of intraneural ganglion cysts","volume":"20","author":"Shahid KR","year":"2011","unstructured":"Shahid KR, H\u00e9bert-Blouin MN, Amrami KK, Spinner RJ. Extraneural rupture of intraneural ganglion cysts. J Surg Orthop Adv. 2011;20(2):136\u2013141."},{"issue":"5","key":"b15","series-title":"Reg Anesth Pain Med","first-page":"447","article-title":"High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa","volume":"38","author":"Karmakar MK","year":"2013","unstructured":"Karmakar MK, Shariat AN, Pangthipampai P, Chen J. High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa. Reg Anesth Pain Med. 2013;38(5):447\u2013451."},{"key":"b16","series-title":"Open Med (Wars)","first-page":"346","article-title":"Subparaneural injection in popliteal sciatic nerve blocks evaluated by MRI","volume":"14","author":"B\u00fcttner B","year":"2019","unstructured":"B\u00fcttner B, Schwarz A, Mewes C,  Subparaneural injection in popliteal sciatic nerve blocks evaluated by MRI. Open Med (Wars). 2019;14:346-353."},{"issue":"6","key":"b17","series-title":"Anesthesiology","first-page":"1007","article-title":"Extrafasicular and intraperineural, but no endoneural, spread after deliberate intraneural injections in a cadaveric study","volume":"130","author":"Reina MA","year":"2019","unstructured":"Reina MA, Sala-Blanch X, Monz\u00f3 E, Nin OC, Bigeleisen PE, Boezaart AP. Extrafasicular and intraperineural, but no endoneural, spread after deliberate intraneural injections in a cadaveric study. 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Acta Neurochir (Wien). 2016;158(10):1891\u20131893."},{"issue":"3","key":"b22","series-title":"Neurosurg Focus","first-page":"E10","article-title":"The nearly invisible intraneural cyst: a new and emerging part of the spectrum","volume":"42","author":"Wilson TJ","year":"2017","unstructured":"Wilson TJ, H\u00e9bert-Blouin MN, Murthy NS, Garc\u00eda JJ, Amrami KK, Spinner RJ. The nearly invisible intraneural cyst: a new and emerging part of the spectrum. Neurosurg Focus. 2017;42(3):E10."},{"issue":"10","key":"b23","series-title":"Acta Neurochir (Wien)","first-page":"2689","article-title":"Does complete regression of intraneural ganglion cysts occur without surgery?","volume":"164","author":"Lenartowicz KA","year":"2022","unstructured":"Lenartowicz KA, Murthy NK, Desy NM,  Does complete regression of intraneural ganglion cysts occur without surgery?. 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Medicina (Kaunas). 2024;60(6):876."},{"key":"b1","series-title":"J Neurosurg","article-title":"Extreme subparaneurial ganglion cysts. Part 1: Principles and implications","author":"de Ruiter GCW","unstructured":"de Ruiter GCW, Son BC, Hayford KM,  Extreme subparaneurial ganglion cysts. Part 1: Principles and implications. J Neurosurg. Published online July 4, 2025. doi:10.3171\/2025.2.JNS242815"},{"issue":"2","key":"b2","series-title":"J Neurosurg","first-page":"296","article-title":"Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory","volume":"107","author":"Spinner RJ","year":"2007","unstructured":"Spinner RJ, Amrami KK, Wolanskyj AP,  Dynamic phases of peroneal and tibial intraneural ganglia formation: a new dimension added to the unifying articular theory. J Neurosurg. 2007;107(2):296\u2013307."},{"issue":"1","key":"b3","series-title":"J Neurosurg","first-page":"217","article-title":"Extreme intraneural ganglion cysts","volume":"114","author":"Spinner RJ","year":"2011","unstructured":"Spinner RJ, H\u00e9bert-Blouin MN, Rock MG, Amrami KK. Extreme intraneural ganglion cysts. J Neurosurg. 2011;114(1):217\u2013224."},{"issue":"4","key":"b4","series-title":"Clin Anat","first-page":"530","article-title":"Subparaneurial ganglion cysts of the fibular and tibial nerves: a new variant of intraneural ganglion cysts","volume":"29","author":"Prasad NK","year":"2016","unstructured":"Prasad NK, Desy NM, Howe BM, Amrami KK, Spinner RJ. Subparaneurial ganglion cysts of the fibular and tibial nerves: a new variant of intraneural ganglion cysts. Clin Anat. 2016;29(4):530\u2013537."},{"issue":"8","key":"b5","series-title":"Clin Anat","first-page":"1133","article-title":"Elaborating upon the descent phase of fibular and tibial intraneural ganglion cysts after cross-over in the sciatic nerve","volume":"27","author":"Colombo EV","year":"2014","unstructured":"Colombo EV, Howe BM, Amrami KK, Spinner RJ. Elaborating upon the descent phase of fibular and tibial intraneural ganglion cysts after cross-over in the sciatic nerve. Clin Anat. 2014;27(8):1133\u20131136."},{"issue":"4","key":"b6","series-title":"Asian J Neurosurg","first-page":"1225","article-title":"Peroneal nerve palsy due to subparaneurial ganglion cyst, a rare variant of intraneural ganglion cyst","volume":"13","author":"Kim D","year":"2018","unstructured":"Kim D, Choi JG, Son BC. Peroneal nerve palsy due to subparaneurial ganglion cyst, a rare variant of intraneural ganglion cyst. Asian J Neurosurg. 2018;13(4):1225\u20131228."},{"issue":"2","key":"b7","series-title":"Clinical series. J Neurosurg","first-page":"319","article-title":"Peroneal intraneural ganglia: the importance of the articular branch","volume":"99","author":"Spinner RJ","year":"2003","unstructured":"Spinner RJ, Atkinson JL, Scheithauer BW,  Peroneal intraneural ganglia: the importance of the articular branch. Clinical series. J Neurosurg. 2003;99(2):319\u2013329."},{"issue":"10","key":"b8","series-title":"J Neurosurg Case Lessons","first-page":"CASE23314","article-title":"Tibial intraneural ganglion cysts arising from the tibiofemoral joint: illustrative cases","volume":"6","author":"Lenartowicz KA","year":"2023","unstructured":"Lenartowicz KA, Wu KY, Amrami KK, de Ruiter GCW, Desy NM, Spinner RJ. Tibial intraneural ganglion cysts arising from the tibiofemoral joint: illustrative cases. J Neurosurg Case Lessons. 2023;6(10):CASE23314."},{"issue":"21","key":"b9","series-title":"J Neurosurg Case Lessons","first-page":"CASE21130","article-title":"High-resolution MRI of a peroneal intraneural ganglion cyst arising from the knee joint: illustrative case","volume":"1","author":"Smith BW","year":"2021","unstructured":"Smith BW, Jack MM, Powell GM, Frick MA, Amrami KK, Spinner RJ. High-resolution MRI of a peroneal intraneural ganglion cyst arising from the knee joint: illustrative case. J Neurosurg Case Lessons. 2021;1(21):CASE21130."},{"issue":"6","key":"b10","series-title":"Neurosurg Focus","first-page":"E17","article-title":"Peroneal and tibial intraneural ganglia: correlation between intraepineurial compartments observed on magnetic resonance images and the potential importance of these compartments","volume":"22","author":"Spinner RJ","year":"2007","unstructured":"Spinner RJ, Amrami KK, Angius D, Wang H, Carmichael SW. Peroneal and tibial intraneural ganglia: correlation between intraepineurial compartments observed on magnetic resonance images and the potential importance of these compartments. Neurosurg Focus. 2007;22(6):E17."},{"issue":"20","key":"b11","series-title":"Neurology","first-page":"e174","article-title":"Teaching NeuroImages: intraneural ganglion cyst of the tibial nerve","volume":"82","author":"Jerath NU","year":"2014","unstructured":"Jerath NU, Chen JJ, Miller BJ, Reddy CG. Teaching NeuroImages: intraneural ganglion cyst of the tibial nerve. Neurology. 2014;82(20):e174\u2013e175."},{"issue":"24","key":"b12","series-title":"Praxis (Bern 1994)","first-page":"1433","article-title":"Nervensonographie intraneuraler Ganglien als Ursache schmerzhafter N.-peronaeus-Paresen: eine Fallseries","volume":"103","author":"Schlig LH","year":"2014","unstructured":"Schlig LH, H\u00e4gele-Link S, Felbecker A,  Nervensonographie intraneuraler Ganglien als Ursache schmerzhafter N.-peronaeus-Paresen: eine Fallseries. Praxis (Bern 1994). 2014;103(24):1433\u20131438."},{"issue":"2","key":"b13","series-title":"Clin Anat","first-page":"199","article-title":"Another (internal) epineurium: beyond the anatomical barriers of nerves","volume":"33","author":"Reina MA","year":"2020","unstructured":"Reina MA, Boezaart AP, Tubbs RS,  Another (internal) epineurium: beyond the anatomical barriers of nerves. Clin Anat. 2020;33(2):199\u2013206."},{"issue":"2","key":"b14","series-title":"J Surg Orthop Adv","first-page":"136","article-title":"Extraneural rupture of intraneural ganglion cysts","volume":"20","author":"Shahid KR","year":"2011","unstructured":"Shahid KR, H\u00e9bert-Blouin MN, Amrami KK, Spinner RJ. Extraneural rupture of intraneural ganglion cysts. J Surg Orthop Adv. 2011;20(2):136\u2013141."},{"issue":"5","key":"b15","series-title":"Reg Anesth Pain Med","first-page":"447","article-title":"High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa","volume":"38","author":"Karmakar MK","year":"2013","unstructured":"Karmakar MK, Shariat AN, Pangthipampai P, Chen J. High-definition ultrasound imaging defines the paraneural sheath and the fascial compartments surrounding the sciatic nerve at the popliteal fossa. 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