Iatrogenic superior gluteal mononeuropathy

Measurement of the gluteal compartment pressures: A cadaveric study describing safety and reproducibility of two methods

INTRODUCTION

Gluteal compartment syndrome is an uncommon entity and physicians may use intracompartmental pressure measurements for confirmation of the clinical diagnosis, or in cases where the physical exam is indeterminate. However, there is a paucity of literature describing a safe and reproducible technique to measure gluteal intracompartmental pressures during the diagnosis of gluteal compartment syndrome. The purpose of this cadaveric study is to evaluate the sole previous technique described in the literature to measure gluteal intracompartmental pressures and provide a modified technique which can be safely and reliably utilized clinically.

METHODS

A cadaveric study with three phases was performed in 16 gluteal regions in 8 cadavers. In the first phase, the previously described technique was assessed. In the second phase, a modified set of techniques was created and evaluated. In the third phase, inter-user reliability of the modified set of techniques was assessed and calculated using Cohen's ĸ coefficient. In all three phases, methylene blue was injected through pressure monitoring needles into the gluteus maximus (GMax), gluteus medius/minimus (GMM), and the tensor fascia lata (TFL) compartments. Following dissection, rate of successful penetration into each targeted compartment and distance from the neurovascular structures was recorded.

RESULTS

The previously described set of techniques was found to be variable. The modified set of techniques was effective, successfully reaching the GMax, GMM, and TFL compartments in 100%, 100%, and 81% of attempts, respectively. Inter-user reliability was excellent (ĸ = 1) for the techniques to reach both the GMax and GMM compartments, and moderate (ĸ = 0.54) for the technique to reach the TFL compartment. Within the GMax, the pressure monitoring needle was at a mean of 5.4±0.6 cm, 4.1±0.7 cm, 6.4±0.5 cm from the sciatic nerve (SN), superior gluteal nerve (SGN), and inferior gluteal nerve (IGN), respectively. Within the GMM, the pressure monitoring needle was at a mean of 9.7±1.4 cm, 7.4±1.3 cm, 11.1±1.7 cm from the SN, SGN, and IGN, respectively.

CONCLUSION

The modified set of techniques presented allows the three gluteal compartments to be safely and reproducibly reached to measure intracompartmental pressures during the diagnosis of gluteal compartment syndrome.

Superior gluteal nerve injury following landmark-guided corticosteroid injection for greater trochanteric pain: A case report

This report describes an isolated superior gluteal nerve injection injury following a corticosteroid injection for greater trochanteric pain syndrome. Ultrasound-guided injections may be beneficial to target multiple pain-producing regions of the hip while avoiding nerves and tendons.

Relationship Between the Superior Gluteal Vessels and Nerve at the Greater Sciatic Notch

Bleeding from the superior gluteal (SG) blood vessels at the greater sciatic notch is frequently encountered during acetabular fracture surgery. The purpose of this study is to define the positional anatomy of the superior gluteal vessels and nerve (SGVAN) at the greater sciatic notch. Twenty-three hemipelvi were dissected in whole human cadavers. The greater sciatic notch and SGVAN were visualized via a posterior surgical approach, identified deep in the greater sciatic notch, and traced superficially. Branches of the SGVAN and their anatomical relationship to each other were recorded. In the notch, SG arteries comprised a single vessel in 18 (78%) of 23 specimens, with all of these dividing at varying distances (1-3.5 cm) along the lateral ilium after dividing into superior and inferior branches. The SG artery branches were contiguous with periosteum of the bony notch in all specimens. More than 1 SG nerve branch was seen in the greater sciatic notch of all specimens, including an inferior branch that exited caudal or caudal-superficial to the SG vessels. The caudal-most SG nerve branch was directly adjacent to the bony notch's periosteum in 15 (65%) of 23 specimens. The SGVAN are at risk in patients undergoing acetabular fracture surgery. Individuals performing surgery along the acetabulum's posterior column would expect to encounter a major SG nerve branch (deep inferior) before encountering the SG vessels in all cases. Iatrogenic injuries to the SGVAN might be prevented by avoiding use of cautery in this area if hemorrhage is encountered.

How to avoid injuries of the superior gluteal nerve

BACKGROUND

Injuries to the superior gluteal nerve are a common complication in hip replacement surgery. They can be avoided with a good anatomical knowledge of the course of the superior gluteal nerve.

METHODS

We dissected 29 half pelvises of adult cadavers. The distance and the angle from the entry points of branches of the superior gluteal nerve into the deep surface of the gluteus medium and minimus muscles to the midpoint of the superior border of the greater trochanter were measured.

RESULTS

The dissections revealed that the nerve divided into 2 branches (86.20%) or 3 branches (13.8%). The more caudal branch was responsible for innervation of the tensor fascia latae.

CONCLUSIONS

A 2-3-cm safe area above the greater trochanter is appropriate to prevent nerve damage.

Compression and entrapment neuropathies

Peripheral nerve entrapments are frequent. They usually appear in anatomical tunnels such as the carpal tunnel. Nerve compressions may be due to external pressure such as the fibular nerve at the fibular head. Malignant or benign tumors may also damage the nerve. For each nerve from the upper and lower limbs, detailed clinical, electrophysiological, imaging, and therapeutic aspects are described. In the upper limbs, carpal tunnel syndrome and ulnar neuropathy at the elbow are the most frequent manifestations; the radial nerve is less frequently involved. Other nerves may occasionally be damaged and these are described also. In the lower limbs, the fibular nerve is most frequently involved, usually at the fibular head by external compression. Other nerves may also be involved and are therefore described. The clinical and electrophysiological examination are very important for the diagnosis, but imaging is also of great use. Treatments available for each nerve disease are discussed.

Sciatic Nerve Palsy After Total Hip Arthroplasty in a Patient Receiving Continuous Lumbar Plexus Block

We report a case of late-onset postoperative sciatic palsy after total hip arthroplasty in a 30-yr-old man with congenital hip dysplasia. The patient was receiving continuous lumbar plexus blockade and had received low-molecular-weight heparin 3 h before the onset of symptoms. Anatomic distinction between the nerve block and the sciatic palsy facilitated rapid diagnosis and treatment of a periarticular hematoma, with resulting neurologic recovery. This case illustrates that, with the expanded role of regional anesthetic techniques in acute pain management, the finding of a new postoperative deficit must be jointly investigated by both anesthesiologists and surgeons. Timely and open communication between services is critical because rapid intervention may be essential to achieving full recovery of an affected nerve.

IMPLICATIONS

A case is presented of sciatic palsy developing after total hip arthroplasty in a patient receiving a continuous lumbar plexus block. The case highlights various issues in the use of continuous peripheral nerve blocks for postoperative analgesia.

Iliac artery aneurysm causing isolated superior gluteal nerve lesion

Lesions of the superior gluteal nerve (SGN) lead to weakness of hip abduction, manifesting itself as a gait abnormality, with contralateral tilting of the pelvis with each step. Causes are numerous and may occur at different anatomical locations before the nerve enters the suprapiriform foramen, in the foramen itself, or after the nerve has exited the foramen. This case report describes an SGN lesion by a large iliac artery aneurysm in a patient presenting with a gait disorder.