Chronic expanding hematoma extending over multiple gluteal muscles associated with piriformis syndrome

Piriformis syndrome as a result of intramuscular haematoma mimicking cauda equina effectively treated with piriformis tendon release

We present a case of piriformis syndrome in a woman in her 30's following low energy trauma, presenting with unilateral lower limb weakness, altered sensation and urinary retention. CT imaging revealed a bulky piriformis muscle which was further clarified on MRI as an intramuscular haematoma within the left piriformis causing compression of the left lumbosacral plexus. Haematoma formation was exacerbated due to use of an antiplatelet medication the patient was taking for Moyamoya disease, which carries an increased risk of cerebrovascular accident. Surgical exploration of the piriformis and sciatic nerve was undertaken and confirmed a haematoma within the piriformis. A full release of the piriformis tendon was undertaken, and the sciatic nerve was inspected, no further abnormality was found. After review in clinic post-discharge, the patient reported normal sensation and normal muscle power in her feet.

Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results

INTRODUCTION

Deep gluteal syndrome (DGS) is characterized by compression, at extra-pelvic level, of the sciatic nerve within any structure of the deep gluteal space. The objective was to evaluate the clinical results in patients with DGS treated with endoscopic technique.

METHODS

Retrospective study of patients with DGS treated with an endoscopic technique between 2012 and 2016 with a minimum follow-up of 12 months. The patients were evaluated before the procedure and during the first year of follow-up with the WOMAC and VAIL scale.

RESULTS

Forty-four operations on 41 patients (36 women and 5 men) were included with an average age of 48.4±14.5. The most common cause of nerve compression was fibrovascular bands. There were two cases of anatomic variant at the exit of the nerve; compression of the sciatic nerve was associated with the use of biopolymers in the gluteal region in an isolated case. The results showed an improvement of functionality and pain measured with the WOMAC scale with a mean of 63 to 26 points after the procedure (P<.05). However, at the end of the follow-up one patient continued to manifest residual pain of the posterior cutaneous femoral nerve. Four cases required revision at 6 months following the procedure due to compression of the scarred tissue surrounding the sciatic nerve.

CONCLUSION

Endoscopic release of the sciatic nerve offers an alternative in the management of DGS by improving functionality and reducing pain levels in appropriately selected patients.

Effectiveness of Endoscopic Sciatic Nerve Decompression for the Treatment of Deep Gluteal Syndrome

Purpose

The purpose of this retrospective study was to evaluate clinical outcomes of endoscopic nerve decompression in patients with deep gluteal syndromes (DGS).

Materials and Methods

Between October 2013 and March 2015, 24 patients who underwent surgical treatment of DGS were retrospectively included in this study. The mean age was 47 years (range, 35 to 76 years), and there were 11 males and 13 females. The mean duration of pain was 12 months (range, 5 to 35 months) and the mean follow-up period was 32 months (range, 26 to 45 months). Clinical evaluations included the visual analog scale (VAS) pain score, modified Harris hip score (mHHS), and the symptom-rating scale.

Results

Significant improvement in symptoms following endoscopic decompression were achieved as measured using the VAS score (decrease in the mean from 7.1±0.9 to 2.5±1.5; P<0.001) and mHHS (increase from 59.4±6.5 to 85.0±8.3; P<0.001).

Conclusion

Endoscopic sciatic nerve decompression was satisfactory for treating recalcitrant DGS, making it an effective treatment option to improve symptoms of DGS.

Surgical Management of Deep Gluteal Syndrome Causing Sciatic Nerve Entrapment: A Systematic Review

PURPOSE

To assess the causes, surgical indications, patient-reported clinical outcomes, and complications in patients with deep gluteal syndrome causing sciatic nerve entrapment.

METHODS

Three databases (PubMed, Ovid [MEDLINE], and Embase) were searched by 2 reviewers independently from database inception until September 7, 2016. The inclusion criteria were studies reporting on both arthroscopic and open surgery and those with Level I to IV evidence. Systematic reviews, conference abstracts, book chapters, and technical reports with no outcome data were excluded. The methodologic quality of the studies was assessed with the MINORS (Methodological Index for Non-randomized Studies) tool.

RESULTS

The search identified 1,539 studies, of which 28 (481 patients; mean age, 48 years) were included for assessment. Of the studies, 24 were graded as Level IV, 3 as Level III, and 1 as Level II. The most commonly identified causes were iatrogenic (30%), piriformis syndrome (26%), trauma (15%), and non-piriformis (hamstring, obturator internus) muscle pathology (14%). The decision to pursue surgical management was made based on clinical findings and diagnostic investigations alone in 50% of studies, whereas surgical release was attempted only after failed conservative management in the other 50%. Outcomes were positive, with an improvement in pain at final follow-up (mean, 23 months) reported in all 28 studies. The incidence of complications from these procedures was low: Fewer than 1% and 8% of open surgical procedures and 0% and fewer than 1% of endoscopic procedures resulted in major (deep wound infection) and minor complications, respectively.

CONCLUSIONS

Although most of the studies identified were case series and reports, the results consistently showed improvement in pain and a low incidence of complications, particularly for endoscopic procedures. These findings lend credence to surgical management as a viable option for buttock pain caused by deep gluteal syndrome and warrant further investigation.

LEVEL OF EVIDENCE

Level IV, systematic review of Level II through IV studies.

Piriformis muscle syndrome: A cross-sectional imaging study in 116 patients and evaluation of therapeutic outcome

OBJECTIVES

To increase the clinical awareness of piriformis muscle syndrome (PMs) by reporting cross-sectional imaging findings, the clinical impact of imaging studies and treatment outcome.

METHODS

Within a 10-year-period, 116 patients referred for radiological evaluation of clinically suspected PMs, with excluded lumbar pathology related to symptomatology, were prospectively studied with MRI and/or computed tomography (CT). Piriformis muscle (PM), sciatic nerve (SN), piriformis region and sacroiliac joints were evaluated. PMs was categorised into primary/secondary, according to a reported classification system. Treatment decisions were recorded. Outcome was categorised using a 3-point-scale.

RESULTS

Seventy-four patients (63.8%) exhibited pathologies related to PMs. Primary causes were detected in 12 and secondary in 62 patients. PM enlargement was found in 45.9% of patients, abnormal PM signal intensity/density in 40.5% and sciatic neuritis in 25.7%. Space-occupying lesions represented the most common related pathology. Treatment proved effective in 5/8 patients with primary and 34/51 patients with secondary PMs. In 34 patients, imaging revealed an unknown underlying medical condition and altered treatment planning.

CONCLUSIONS

Secondary PMs aetiologies appear to prevail. In suspected PMs, PM enlargement represented the most common imaging finding and space-occupying lesions the leading cause. Imaging had the potential to alter treatment decisions.

KEY POINTS

• In clinically suspected PMs cross-sectional imaging may reveal variable pathology. • Secondary PMs aetiologies appeared to be more common than primary. • PM enlargement represented the most common imaging finding in clinically suspected PMs. • Space-occupying lesions in the piriformis region represented the leading cause of PMs. • In clinically suspected PMs cross-sectional imaging may alter treatment planning.

Clinical results of endoscopic sciatic nerve decompression for deep gluteal syndrome: mean 2-year follow-up

BACKGROUND

The purpose of this study is to assess the effectiveness of endoscopic sciatic nerve decompression and evaluated the differences of clinical results between atraumatic and traumatic groups.

METHODS

Sixty consecutive patients. We retrospectively reviewed sixty consecutive patients without major trauma (45 hips) or with major trauma (15 hips) groups to compare the outcomes of endoscopic treatment.). The mean follow-up period was 24 ± 2.6 months (range, 24-38.4 months).

RESULTS

The mean duration of symptoms was 14.1 months (range, 12 to 32 months). Compromising structures were piriformis muscle, fibrovascular bundles, and adhesion with scar tissues. The mean VAS score for pain decreased from 7.4 ± 1.5 to 2.6 ± 1.5 (P = .001). The mean mHHS increased from 81.7 ± 9.6 to 91.8 ± 7.6 (P = .003). Clinically, positive paresthesia and seated piriformis test were statistically significant to diagnosis sciatic entrapment syndrome. Paresthesia and sitting pain were significantly improved at the final follow-up (P = .002). More favorable outcome was observed a group without major trauma. No complication was observed.

CONCLUSIONS

Endoscopic sciatic nerve decompression is a safe and effective procedure for the management of DGS. Patients with major trauma could have poor clinical outcome. Seated piriformis test, FADIR, and tenderness of sciatic notch are maybe useful guide for pre and postoperative evaluation of DGS.

Management of chronic expanding haematoma using triamcinolone after latissimus dorsi flap harvesting

Chronic expanding haematoma (CEH) is a rare type of haematoma that enlarges slowly and continuously without coagulation. It can occur following surgery because of shear stress-induced bleeding in the scar tissue between the subcutaneous fat and fascia. We present three cases of large chronic CEH that were successfully treated with triamcinolone injections. Three female patients developed large chronic CEH at 9 months, 5 years, and 6 years, respectively, after latissimus dorsi flap harvesting for breast reconstruction. Although the condition did not improve after multiple sessions of haematoma aspiration in the first two patients, it resolved following a single 40-mg triamcinolone injection along with appropriate compression dressing for several weeks. In the third patient, triamcinolone was injected immediately after the initial aspiration of the haematoma, and the condition improved considerably. There were no side effects in any of the patients. To the best of our knowledge, this is the first report of successful treatment of large CEH using triamcinolone. Therefore, we suggest that triamcinolone injections be considered for the treatment of CEH.

Chronic expanding hematoma in the stumps of persons following transfemoral amputation: A report of two cases

BACKGROUND

Two persons presented with severe stump pain following transfemoral amputation.

CASE DESCRIPTION AND METHODS

A 21-year-old female and a 31-year-old male with transfemoral amputation were ambulatory with prostheses and suffered from severe stump pain caused by the presence of masses around the tip of the bone stump. From the clinical courses, imaging studies, and the intraoperative findings, the masses were diagnosed as a relatively rare condition known as chronic expanding hematoma.

FINDINGS AND OUTCOME

The two patients were treated successfully with surgical resection. The hematomas were soft cystic masses with a thick capsule containing old blood clots and serous fluid. There were no pathological signs of malignancy. After surgical treatment, the patients achieved walking without stump pain.

CONCLUSION

Although chronic expanding hematoma is a rare condition, it should be considered as a possible cause of stump pain.

CLINICAL RELEVANCE

Stump pain is caused by many conditions. Although chronic expanding hematoma is a rare condition, it should be considered as a possible cause of stump pain.