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Hanna AS, Schmidt BT, Kanarek AA, Hilger KH, Blankenbaker DG, Medhat H, Moscote-Salazar LR, Hellenbrand DJ. Anatomical Proximity Between Sciatic Nerve and Ischial Spine and its Relationship to the Development of Deep Gluteal Pain Syndrome. World Neurosurg 2024:S1878-8750(24)00880-5. [PMID: 38796142 DOI: 10.1016/j.wneu.2024.05.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Deep gluteal syndrome (DGS) is a medical diagnosis in which the pathoanatomy of the subgluteal space contributes to pain. The growing recognition that gluteal neuropathies can be associated with the presence of a bone-neural conflict with irritation or compression may allow us to shed some light on this pathology. This study aims to determine whether the location of the sciatic nerve (SN) in relation to the ischial spine (IS) contributes to the development of DGS. METHODS The SN - IS relationship was analyzed based on magnetic resonance imaging (MRI) in 15 surgical patients (SPs), who underwent piriformis release, and in 30 control patients who underwent MRI of the pelvis for reasons unrelated to sciatica. The SN exit from the greater sciatic foramen was classified as either zone A (medial to the IS); zone B (on the IS); or zone C (lateral to the IS). RESULTS The SN was significantly closer to the IS in SPs than in MRI controls (P = 0.014). When analyzing patients of similar age, SNs in SPs were significantly closer (P = 0.0061) to the IS, and located in zone B significantly more (P = 0.0216) as compared to MRI controls. Patients who underwent surgery for piriformis release showed a significant decrease in pain postoperatively (P < 0.0001). CONCLUSIONS The results from this study suggest that the relationship between the IS and SN may play a role in the development of DGS. This may also help establish which patients would benefit more from surgical intervention.
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Affiliation(s)
- Amgad S Hanna
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA.
| | - Bradley T Schmidt
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Andrew A Kanarek
- Department of Radiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Keegan H Hilger
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Donna G Blankenbaker
- Department of Radiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Heba Medhat
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Neurosurgery, Faculty Of Medicine Kasr Al-Ainy, Cairo University, Cairo, Egypt
| | | | - Daniel J Hellenbrand
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA
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Hanna AS, Staniszewski TM, Omar AH, Guevara-Moriones N, Moscote-Salazar LR, Hilger KH, Hellebrand DJ. Anatomical Relationships of the Sciatic Nerve and Pudendal Nerve to the Ischial Spine as They Exit the Greater Sciatic Foramen. World Neurosurg 2024; 183:e564-e570. [PMID: 38181879 DOI: 10.1016/j.wneu.2023.12.147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 12/28/2023] [Indexed: 01/07/2024]
Abstract
OBJECTIVE Deep gluteal syndrome is a clinical condition in which discomfort may arise due to the pathoanatomy of the subgluteal space. We conducted an anatomical exploration to categorize the relationship of the piriformis muscle, sciatic nerve (SN), and pudendal nerve (PN) to the ischial spine (IS) and sacrospinous ligament. METHODS We analyzed 22 cadavers. The piriformis muscle, SN, and PN were exposed through either a transgluteal approach or a gluteal flap. The relationship of the neural structures to the IS, sacrospinous ligament, and ischial bone as they exit the greater sciatic foramen was observed, and the exit zones were classified as zone A, medial to the IS (entirely on sacrospinous ligament); zone B, on the IS; and zone C, lateral to the IS (entirely on ischial bone). RESULTS The SN was observed either in zone B or zone C in all specimens. The PN was found to be in either zone A or zone B in 97.6% of specimens. The most common combinations were SN in zone B and PN in zone A (type I), and SN in zone C and PN in zone B (type II). CONCLUSIONS The results from this study show clear anatomical differences in the SN-PN relationship, which may play a role in pain seen in deep gluteal syndrome. Moreover, classification of the SN-IS and PN-IS relationships described in this article will help describe different pathologies affecting the deep gluteal area.
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Affiliation(s)
- Amgad S Hanna
- Department of Neurological Surgery, University of Wisconsin - Madison, Madison, Wisconsin, USA; Department of Biomedical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA.
| | - Thomas M Staniszewski
- Department of Neurological Surgery, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Ahmed H Omar
- Department of Neurological Surgery, University of Wisconsin - Madison, Madison, Wisconsin, USA; Department of Neurosurgery, Cairo University, Giza, Egypt
| | | | | | - Keegan H Hilger
- Department of Neurological Surgery, University of Wisconsin - Madison, Madison, Wisconsin, USA
| | - Daniel J Hellebrand
- Department of Neurological Surgery, University of Wisconsin - Madison, Madison, Wisconsin, USA; Department of Biomedical Engineering, University of Wisconsin - Madison, Madison, Wisconsin, USA
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Lo JK, Robinson LR. Piriformis syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:203-226. [PMID: 38697742 DOI: 10.1016/b978-0-323-90108-6.00002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Piriformis syndrome is a condition that is proposed to result from compression of the sciatic nerve, either in whole or in part, in the deep gluteal space by the piriformis muscle. The prevalence of piriformis syndrome depends upon the diagnostic criteria being used and the population studied but is estimated by some to be 5%-6% in all cases of low back, buttock, and leg pain and up to 17% of patients with chronic low back pain. While the sciatic nerve may pierce the piriformis muscle in about 16% of healthy individuals, this frequency is no different in those with the syndrome; thus, the relationship to this anatomic finding is unclear. The most common symptoms are buttock pain, external tenderness over the greater sciatic notch, and aggravation of the pain through sitting. Many clinical signs are reported for piriformis syndrome, but the sensitivity and specificity are unclear, in part because of the lack of a uniformly accepted case definition. In the majority of cases in the literature, it appears that the diagnosis is more ascribed to a myofascial condition rather than a focal neuropathy. Electrodiagnostic studies can be useful to exclude other causes of symptoms, but there is no well-accepted test to confirm the presence of piriformis syndrome. Ultrasound imaging may show thickening of the piriformis muscle, but further research is required to confirm that this is correlated with the clinical diagnosis. Magnetic resonance imaging and neurography may hold promise in the future, but there are not yet sufficient data to support adopting these methods as a standard diagnostic tool. The initial treatment of piriformis syndrome is typically conservative management with the general rehabilitation principles similar to other soft tissue musculoskeletal conditions. Local anesthetic, botulinum toxin, and/or corticosteroid injections have been reported by some to be beneficial for diagnostic or treatment purposes. Surgical interventions have also been used with variable success.
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Affiliation(s)
- Julian K Lo
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| | - Lawrence R Robinson
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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Hopayian K, Mirzaei M, Shamsi M, Arab-Zozani M. A systematic review of conservative and surgical treatments for deep gluteal syndrome. J Bodyw Mov Ther 2023; 36:244-250. [PMID: 37949567 DOI: 10.1016/j.jbmt.2022.12.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 12/11/2022] [Indexed: 11/12/2023]
Abstract
BACKGROUND AND OBJECTIVE Conservative and surgical treatments, are recommended as the primary treatment in the management of patients diagnosed with deep gluteal syndrome; but evidence supporting superiority of one treatment over another is lacking. The aim of this review is to systematically review the effectiveness of treatments. DATABASES AND DATA TREATMENT MEDLINE, EMBASE, Web of Science, Scopus, AMED, Cochrane Library (Central Register of Controlled Trials), and PEDro were screened (to 24 July 2019). Risk of bias of trials and surgical case series were assessed using the Cochrane risk of bias tool and Joanna Briggs Institute Critical appraisal checklists, respectively. Outcomes were reductions in pain or disability. For each outcome, the minimum clinically important difference (MCID) was calculated. A narrative synthesis was performed. RESULTS Out of 909 records, thirteen studies with 508 patients were included, eight RCTs with 336 patients and 5 case series with 172 patients. Conservative modalities were: infiltration into muscle of steroid, botulinum toxin, thiochilcoside and colchicine. There was one RCT and five case series of surgery. Only three trials reached an MCID in pain reduction for the intervention. The five surgical studies reached a before and after MCID. Only one study showed an MCID reduction in disability. The overall quality of evidence was low. CONCLUSION Given the low quality of evidence, no single conservative treatment can be recommended over another. Clinicians should follow general guidelines on the management of back pain and sciatica for first line treatment, namely physiotherapy. Surgery may have a place for chronic cases.
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Affiliation(s)
- Kevork Hopayian
- Centre for Primary Care and Population Health, University of Nicosia Medical School, Cyprus.
| | - Maryam Mirzaei
- Department of Physiotherapy, School of Rehabilitation Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - MohammadBagher Shamsi
- Department of Physiotherapy, School of Rehabilitation Sciences, Kermanshah University of Medical Sciences, Kermanshah, Iran.
| | - Morteza Arab-Zozani
- Social Determinants of Health Research Center, Birjand University of Medical Sciences, Birjand, Iran.
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Ertem U, Özçakır S, İrdesel FJ, Günay SM. YouTube as a source of information on piriformis syndrome exercises. Turk J Phys Med Rehabil 2023; 69:15-22. [PMID: 37201001 PMCID: PMC10186011 DOI: 10.5606/tftrd.2022.10459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 06/29/2022] [Indexed: 05/20/2023] Open
Abstract
Objectives This study aimed to evaluate the quality and reliability of the most viewed YouTube videos on piriformis syndrome (PS) exercises and identify criteria that may be important for selecting high-quality and reliable videos. Materials and methods We searched for the keywords "piriformis syndrome exercise," "piriformis syndrome rehabilitation," "piriformis syndrome physical therapy," and "piriformis syndrome physiotherapy" on November 28, 2021. The modified DISCERN (mDISCERN), and the Global Quality Score were used to evaluate the quality and reliability of the videos. Results Of the 92 videos evaluated, most (58.7%) of the videos were shared by healthcare professionals. The median mDISCERN score was 3, and most of the videos were found to be medium or low quality. Videos with more subscribers (p=0.001), a shorter upload duration (p=0.001), videos uploaded by physicians (p=0.004), and videos uploaded by other healthcare professionals (p=0.001) were found to have high reliability. Conversely, videos uploaded by independent users were found to have low reliability (p<0.001). When the parameters of the videos were compared among the quality groups, significant differences were found in all video features (p<0.05), some upload sources (other healthcare professionals and independent users; p=0.001), and mDISCERN scores (p<0.001). Conclusion It is beneficial for physicians and other health professionals to upload more videos about health to increase the amount of reliable and high-quality information.
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Affiliation(s)
- Uğur Ertem
- Department of Physical Medicine and Rehabilitation, Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - Süheda Özçakır
- Department of Physical Medicine and Rehabilitation, Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - Fatma Jale İrdesel
- Department of Physical Medicine and Rehabilitation, Uludağ University Faculty of Medicine, Bursa, Türkiye
| | - Selim Mahmut Günay
- Department of Physical Medicine and Rehabilitation, Uludağ University Faculty of Medicine, Bursa, Türkiye
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Sharma S, Kaur H, Verma N, Adhya B. Looking beyond Piriformis Syndrome: Is It Really the Piriformis? Hip Pelvis 2023; 35:1-5. [PMID: 36937215 PMCID: PMC10020728 DOI: 10.5371/hp.2023.35.1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/29/2022] [Accepted: 11/09/2022] [Indexed: 03/21/2023] Open
Abstract
Piriformis syndrome is a common differential diagnosis related to sciatica. The following review provides a concise synopsis of the diagnosis, management, history, and alternatives to diagnosis of piriformis syndrome. A search of the literature for research articles related to piriformis syndrome and associated differential diagnosis of sciatica was conducted. A thorough review of the included articles found that the condition known as piriformis syndrome is over-diagnosed and that potential anatomic and biomechanical variations originating in the pelvic region might be related to the complaint of sciatica. The criteria for diagnosis are based on findings from both physical examination and radio imaging. Piriformis syndrome resembles a variety of clinical conditions; therefore, conduct of future studies should include development of a validated method for evaluation as well as clinical criteria for diagnosis of piriformis syndrome.
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Affiliation(s)
- Shivam Sharma
- Department of Physical and Rehabilitation Medicine, Physiotherapy Section, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Harmanpreet Kaur
- Department of Physical and Rehabilitation Medicine, Physiotherapy Section, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nishank Verma
- Department of Physical and Rehabilitation Medicine, Physiotherapy Section, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Bibek Adhya
- Department of Physical and Rehabilitation Medicine, Physiotherapy Section, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Ahadi T, Yousefi A, Sajadi S, Yousefi N, Babaei-Ghazani A. Comparing radial extracorporeal shockwave therapy and corticosteroid injection in the treatment of piriformis syndrome: A randomized clinical trial. J Bodyw Mov Ther 2023; 33:182-188. [PMID: 36775517 DOI: 10.1016/j.jbmt.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 04/17/2022] [Accepted: 09/18/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study was designed to compare the effects of shockwave therapy and corticosteroid injection in the treatment of piriformis syndrome. METHODS AND MATERIALS In this randomized clinical trial, thirty-five patients with piriformis syndrome were randomly divided into two groups of 18 in the shockwave group and 17 in the corticosteroid group. The Shockwave group underwent three sessions of shockwave therapy per week (2000 pulses per session with 5Hz frequency and pressure equal to 4 Bar) and the corticosteroid group underwent an injection of 40 mg methylprednisolone with 1 mL of 1% lidocaine under ultrasound guidance. All patients were assessed by SF-36 questionnaire and visual analogue scale (VAS). The SF-36 questionnaire was used to evaluate the quality of life before and 4 weeks after the intervention. VAS scale was used to evaluate pain before the intervention, and 1, 4, 8, and 12 weeks after the intervention. RESULTS The baseline characteristics of the two groups were not significantly different. At the end of the study, both groups had a significant improvement in pain and quality of life compared to before the intervention. However, according to the VAS, in the shockwave group improvement was seen in the first follow-up while not seen in the corticosteroid group (P-value <0.001 and P-value 1.00, respectively). According to the SF-36 questionnaire, the overall score in both groups had a significant improvement (P-value <0.05). CONCLUSIONS It seems that shockwave therapy and corticosteroid injection are both effective in the treatment of piriformis syndrome. There was no significant difference between the two groups in the quarterly follow-up. Because shockwave therapy is a relatively non-invasive treatment with fewer side effects, it can be useful to improve pain and the quality of life of patients with piriformis syndrome.
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Affiliation(s)
- Tannaz Ahadi
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Arastoo Yousefi
- Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Tehran, Iran
| | - Simin Sajadi
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Naseh Yousefi
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Arash Babaei-Ghazani
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, School of Medicine, Iran University of Medical Sciences, Tehran, Iran; Department of Physical Medicine & Rehabilitation, University of Montreal Health Center, Montreal, Canada.
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8
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Tendinopathies and Allied Disorders of the Hip. Orthop Clin North Am 2022; 53:393-401. [PMID: 36208882 DOI: 10.1016/j.ocl.2022.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
There are many soft tissue structures around the hip joint that may serve as a source of pain in both the native and prosthetic hip. In this review, the role of the gluteal, piriformis, iliopsoas, and rectus femoris musculotendinous units in the etiology of pathology around the hip joint will be discussed. Management options ranging from tailored physical therapy regimens to local steroid infiltration along with more invasive open and arthroscopic surgical techniques will be reviewed for each pathological entity. While not all conditions are well understood, advancements have been made in the management of each of these often challenging cases in both the native and prosthetic hip settings. This review explores these advancing treatment methods which will supplement the practice of any hip surgeon who is presented with problematic tendinopathy around both the native and prosthetic hip joint.
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Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis. J Am Acad Orthop Surg 2021; 29:e1282-e1290. [PMID: 34874333 DOI: 10.5435/jaaos-d-21-00707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/02/2021] [Indexed: 02/01/2023] Open
Abstract
Identifying the specific source of gluteal pain can elude the most seasoned orthopaedic diagnosticians. Patients will often present with a protracted course of symptoms, and failure to successfully identify and treat the underlying etiology leads to frustration for both patient and clinician. Pain deep in the buttocks can arise from compression, inflammation, or injury of one or more of the structures in this anatomically dense area. Although sacroiliitis, hip arthritis, and trochanteric bursitis may also masquerade as gluteal pain, sciatic nerve irritation in its various presentations causes a substantial percentage of cases. Deep gluteal syndrome, hamstring syndrome, and ischiofemoral impingement can have overlapping presentations but can be differentiated by clinical examination and judiciously placed diagnostic corticosteroid injections. Although nonsurgical management, including physical therapy, relative rest, and injections represent the mainstay of treatment, open and endoscopic surgical approaches have yielded encouraging success rates in refractory cases.
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Kale A, Başol G, Cansu Gündoğdu E, Mat E, Yıldız G, Kuru B, Aboalhasan Y, Uzun ND, Usta T, tıntaş MA, Demirhan R. Laparoscopic surgical approach for the treatment of piriformis syndrome: Intrapelvic decompression technique. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/22840265211045610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Piriformis syndrome is an uncommon disease resulting from the piriformis muscle’s compression of the sciatic nerve. Pain and numbness in the buttocks and down the leg are the most common symptoms. This study analyzes the laparoscopic surgical treatment of piriformis syndrome. Methods: We report three cases of piriformis syndrome diagnosed in our hospital. The first case was a 40 years old woman with a 7-year history of intermittent low back pain and sciatica on her right side. Hyperesthesia and cutaneous allodynia were observed in the right sciatic nerve dermatome. The second case was a 30 years old woman with a 2-year history of sciatica on her left side. The third case was a 30 years old woman with a 2-year history of sciatica on her right side. All the patients underwent laparoscopic decompression surgery, which was performed to release the sciatic nerve or sacral nerve roots. Results: The patients were reexamined at the postoperative 3rd and 6th months. Their visual analog scale (VAS) scores were found to be decreased from 10/10, 9/10, and 7/10 to 0/10, 1/10, and 0/10, respectively. Conclusion: Due to the very few cases in the literature, pelvic piriformis syndrome is an exclusively clinical diagnosis. If the sciatica is refractory to conservative treatments, laparoscopic exploration and decompression surgery of the pelvic nerves and piriformis muscle could be an option.
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Affiliation(s)
- Ahmet Kale
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Gülfem Başol
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Elif Cansu Gündoğdu
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Emre Mat
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Gazi Yıldız
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Betül Kuru
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Yasmin Aboalhasan
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Navdar Doğuş Uzun
- Department of Obstetrics and Gynecology, Mardin Midyat State Hospital, Mardin, Turkey
| | - Taner Usta
- Department of Obstetrics and Gynecology, Acibadem University, Altunizade Hospital, Istanbul, Turkey
| | - Mehmet Al tıntaş
- Department of General Surgery, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Recep Demirhan
- Department of Thoracic Surgery, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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Danazumi MS, Yakasai AM, Ibrahim AA, Shehu UT, Ibrahim SU. Effect of integrated neuromuscular inhibition technique compared with positional release technique in the management of piriformis syndrome. J Osteopath Med 2021; 121:693-703. [PMID: 34049428 DOI: 10.1515/jom-2020-0327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/29/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Studies have indicated that the muscle energy technique (MET) and the positional release technique (PRT) are effective in the management of piriformis syndrome (PS); however, evidence is scarce regarding the combination of these techniques in the form of an integrated neuromuscular inhibition technique (INIT) in the management of individuals with PS. Although a previous trial investigated the effect of INIT for PS, that study did not integrate Ruddy's reciprocal antagonist facilitation (RRAF) method into the INIT protocol, nor did the authors diagnose PS according to established criteria. OBJECTIVES To examine the effects of INIT with integrated RRAF compared with PRT in the management of patients diagnosed with PS. METHODS This study was designed as a single blind randomized clinical trial in which participants diagnosed with PS were randomly allocated into INIT and PRT groups. Each group attended two treatment sessions per week for 8 weeks. Patients in the INIT group received a protocol in which the patient's tender point or trigger point was palpated in the belly of the piriformis approximately halfway between the inferior lateral angle of the sacrum and the greater trochanter, at which point the therapist applied an intermittent or sustained pressure and maintained the pressure for 20-60 seconds (depending on the participant's response to pain reduction). For INIT patients, that protocol was also followed by RRAF, a method in which a patient introduces a series of tiny/miniature contractions or efforts (20 times per 10 seconds) against a therapist's resistance. Patients in the PRT group were treated by palpating the same trigger point described in the INIT group, followed by application of light pressure at the location of the trigger point, which was maintained the pressure for 2 minutes or until the pain subsided (determined by asking the participant to report a pain score using a visual analog scale at 30 second intervals). For both groups, three repetitions of the INIT or PRT treatment were performed over 10 minutes at each clinical visit. Additionally, each group also received stretching exercises immediately after the INIT or PRT treatment session. Each participant was assessed at baseline, immediately posttreatment, and at 4 months posttreatment for pain, sciatica, functional mobility, quality of life, hip abduction, and internal rotation. A repeated measures analysis of variance (ANOVA) of within-between group interactions was used to analyze the treatment effect. RESULTS Forty eight participants (age range, 25-47 years; mean age ± standard deviation, 32.81 ± 3.27 years) were randomized into the INIT and PRT groups, with 24 participants in each group. No significant between-group differences (p>0.05) were observed in the baseline demographic and clinical variables of the participants. A repeated-measures ANOVA indicated that there was a significant time effect for all outcomes, with a significant interaction between time and intervention (p<0.001). The Bonferroni post hoc analyses of time and intervention effects indicated that the INIT group improved significantly compared with the PRT group in all outcomes (p<0.05) immediately posttreatment and at the 4 months follow up period. CONCLUSIONS INIT was more effective than PRT in the management of individuals with PS. It should be noted the significant improvement achieved in both the groups may have also been contributed to by the stretching exercises that were used as adjunct therapies by both groups.
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Affiliation(s)
- Musa S Danazumi
- Department of Physiotherapy, Federal Medical Center, Nguru, Yobe State, Nigeria.,Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Abdulsalam M Yakasai
- Medical Rehabilitation Therapists (Reg.) Board of Nigeria, North-West Zonal Office, Kano, Nigeria.,Department of Physiotherapy, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Aminu A Ibrahim
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria.,Department of Physiotherapy, Muhammad Abdullahi Wase Teaching Hospital, Hospitals Management Board, Kano, Kano State, Nigeria
| | - Usman T Shehu
- Department of Public Health, School of Health Sciences, University of Salford Manchester, Manchester, UK
| | - Shehu U Ibrahim
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
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Vij N, Kiernan H, Bisht R, Singleton I, Cornett EM, Kaye AD, Imani F, Varrassi G, Pourbahri M, Viswanath O, Urits I. Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review. Anesth Pain Med 2021; 11:e112825. [PMID: 34221947 PMCID: PMC8241586 DOI: 10.5812/aapm.112825] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Accepted: 01/30/2021] [Indexed: 01/03/2023] Open
Abstract
Context Piriformis syndrome is a solely clinical diagnosis that often eludes the practitioner and goes underdiagnosed. PS is a pain syndrome and for those it affects, causes persistent pain and limits daily activity and work capacity. It is a form of deep gluteal syndrome that needs to be considered on the differential of low back pain as it comprises between 0.3% - 6% of all low back pain cases and is frequently underdiagnosed. Piriformis syndrome may be primary due anatomic anomalies or secondary, though the majority of cases are secondary to some insult. The objective of this manuscript is to provide a description of the epidemiology and presentation of piriformis as well as both non-operative and operative treatment options. We review all of the recent clinical evidence regarding the aforementioned therapies. Evidence Acquisition Literature searches were performed using the below MeSH Terms using Mendeley version 1.19.4. Search fields were varied until further searches revealed no new articles. All articles were screened by title and abstract. Decision was made to include an article based on its relevance and the list of final articles was approved three of the authors. This included reading the entirety of the article. Any question regarding the inclusion of an article was discussed by all authors until an agreement was reached. Results Medical management and physical therapy show some promise; however, when conservative treatment fails minimally invasive methods such as steroid injections, botulinum toxin injections, dry needling are all efficacious and there is substantial clinical evidence regarding these therapies. In those patients in which minimally invasive techniques do not result in an adequate relief of pain and return of function, endoscopic release can be considered. Endoscopic release is far superior to open release of the piriformis syndrome given the higher success and lower rate of complications. Conclusions Piriformis syndrome is an important differential diagnosis in the work up of lower back pain and should not be ruled out with proper examination and testing. Clinicians should consider medical management and conservative management in the initial treatment plan for piriformis syndrome. There are many options within the conservative management and the literature shows much promise regarding these. Physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects. Surgical options remain as gold standard, but only when conservative management has failed and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with or without release of the piriformis muscle has a reported high likelihood of success and a low complication rate. Current literature supports the preference of the endoscopic approach over the open approach due to improved outcomes and decreased complications. Further research is to well define the metrics for the diagnosis of piriformis syndrome and may include a need to develop diagnostic criteria.
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Affiliation(s)
- Neeraj Vij
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
- Corresponding Author: University of Arizona College of Medicine-Phoenix, Phoenix, USA.
| | - Hayley Kiernan
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Roy Bisht
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Ian Singleton
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
| | - Elyse M. Cornett
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
| | - Alan David Kaye
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
| | - Farnad Imani
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
| | | | - Maryam Pourbahri
- Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran
- Corresponding Author: Pain Research Center, Department of Anesthesiology and Pain Medicine, Iran University of Medical Sciences, Tehran, Iran.
| | - Omar Viswanath
- University of Arizona College of Medicine-Phoenix, Phoenix, USA
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
- Department of Anesthesiology, Creighton University School of Medicine, Omaha, USA
- Valley Anesthesiology and Pain Consultants-Envision Physician Services, Phoenix, USA
| | - Ivan Urits
- Department of Anesthesiology, Louisiana State University Health Shreveport, Shreveport, USA
- Southcoast Health Physicians Group Pain Medicine, Wareham, USA
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Pearce JMS. The deep gluteal (piriformis) syndrome. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2021. [DOI: 10.47795/ejiz4910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Piriformisa syndrome is a subgroup of the deep gluteal syndrome, an important differential diagnosis of sciatica. Piriformis is a short external rotator muscle of the hip joint passing close to the sciatic nerve as it passes through the great sciatic foramen. Compression causes numbness, ache or tingling in the buttocks, posterolateral aspect of the leg and foot. The causes of sciatic nerve entrapment in the deep gluteal syndrome are best shown by endoscopic exploration. The frequency of anatomical variants in normal subjects however, should caution that such anomalies are not necessarily the cause of symptoms.
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Intrapelvic Nerve Entrapment Syndrome Caused by a Variation of the Intrapelvic Piriformis Muscle and Abnormal Varicose Vessels: A Case Report. Int Neurourol J 2021; 25:177-180. [PMID: 33504131 PMCID: PMC8255827 DOI: 10.5213/inj.2040232.116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 08/16/2020] [Indexed: 11/08/2022] Open
Abstract
Entrapment neuropathy of the sciatic nerve and pudendal nerve are painful syndromes that are often overlooked by physicians. Laparoscopic surgical interventions for nerve entrapment syndromes of the posterior pelvis focus on removing the compression lesion with the purpose of eliminating the suspected cause of sciatica, as well as pudendal neuralgia. Herein, the authors report the rare event of sciatic and pudendal nerve entrapment, which was caused by aberrant vessels and a variant piriformis muscle bundle, as a seldom-diagnosed cause of sciatica and pelvic pain, for both neurosurgeons and neuropelveologists. The authors present the laparoscopic decompression technique for the pudendal and sciatic nerves by giving our technical “tips and tricks” enriched by a surgical video.
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Manoharan D, Sudhakaran D, Goyal A, Srivastava DN, Ansari MT. Clinico-radiological review of peripheral entrapment neuropathies - Part 2 Lower limb. Eur J Radiol 2020; 135:109482. [PMID: 33360825 DOI: 10.1016/j.ejrad.2020.109482] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 06/15/2020] [Accepted: 12/14/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE This review discusses the relevant anatomy, etiopathogenesis, current notions in clinical and imaging features as well as management outline of lower limb entrapment neuropathies. METHODS The review is based on critical analysis of the current literature as well as our experience in dealing with entrapment neuropathies of the lower limb. RESULTS The complex anatomical network of nerves supplying the lower extremities are prone to entrapment by a heterogenous group of etiologies. This leads to diverse clinical manifestations making them difficult to diagnose with traditional methods such as clinical examination and electrodiagnostic studies. Moreover, some of these may mimic other common conditions such as disc pain or fibromyalgia leading to delay in diagnosis and increasing morbidity. Addition of imaging improves the diagnostic accuracy and also help in correct treatment of these entities. Magnetic resonance imaging is very useful for deeply situated nerves in pelvis and thigh while ultrasound is well validated for superficial entrapment neuropathies. CONCLUSION The rapidly changing concepts in these conditions accompanied by the advances in imaging has made it essential for a clinical radiologist to be well-informed with the current best practices.
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Affiliation(s)
- Dinesh Manoharan
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Dipin Sudhakaran
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Goyal
- Department of Radiology, All India Institute of Medical Sciences, New Delhi, India.
| | | | - Mohd Tahir Ansari
- Department of Orthopedics, All India Institute of Medical Sciences, New Delhi, India
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Fahmi A, Rahmadhan MA, Aprianto DR, Subianto H, Turchan A. Complete resolution of recurrent piriformis syndrome after piriformis resection with 3 years' follow up: A case report. Int J Surg Case Rep 2020; 77:576-579. [PMID: 33395849 PMCID: PMC7708764 DOI: 10.1016/j.ijscr.2020.11.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022] Open
Abstract
Some of piriformis syndrome intractable with conservative treatment. Surgery was indicated for intractable piriformis syndrome. Piriformis resection can be a feasible option for intractable piriformis syndrome. Piriformis resection decrease visual analog scale in intractable piriformis syndrome.
Introduction Piriformis syndrome (PS) is an uncommon neuromuscular condition characterized by buttock pain radiating to the leg. Although the goal of PS treatment is symptom relief, it is difficult in some patients using conservative treatment alone. Presentation of case A 72-year-old male underwent piriformis resection after failed sequential steroid injection of the piriformis. The patient ultimately underwent surgery for resection of the piriformis muscle and experienced satisfactory pain relief (pain reduction > 75% according to visual analog scale for at least 12 months) following surgery and in the 3-year follow-up period. Discussion Conservative treatment is first-choice treatment for managing PS. Surgery was indicated when the patient did not achieve satisfactory pain relief with conservative treatment. Surgical resection of the piriformis muscle has been shown to be effective and feasible. Conclusion Piriformis resection is effective and can be a feasible option for the treatment of PS following failure of appropriate conservative treatment(s).
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Affiliation(s)
- Achmad Fahmi
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
| | - Mustaqim Apriyansa Rahmadhan
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Dirga Rachmad Aprianto
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Department of Surgery, Faculty of Medicine, Universitas Islam Sutan Agung, Semarang, Indonesia
| | - Heri Subianto
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Agus Turchan
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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Hogan E, Vora D, Sherman JH. A minimally invasive surgical approach for the treatment of piriformis syndrome: a case series. Chin Neurosurg J 2020; 6:8. [PMID: 32922937 PMCID: PMC7398220 DOI: 10.1186/s41016-020-00189-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Accepted: 03/18/2020] [Indexed: 11/10/2022] Open
Abstract
Background Piriformis syndrome accounts for approximately 6% of patients who present with sciatic pain. There are many treatment options ranging from physical therapy, to trigger point injections, to surgical intervention. We discuss a surgical method that represents a minimally invasive technique for the treatment of piriformis syndrome. Methods We describe a novel operative approach and technique for release of the piriformis muscle in the treatment of piriformis syndrome. Described are the preoperative planning, incision and approach, and technique for identifying and releasing the piriformis muscle. Results Three patients were treated for piriformis syndrome using the described technique. Each patient displayed successful relief of their symptoms immediately following the surgical procedure and at delayed follow-up. Conclusion Early experience with our method of piriformis release suggests that it is well suited for the treatment of piriformis syndrome. The novel integration of pre-operative trigger point localization coupled with intraoperative neuromonitoring allows effective pain relief with minimal morbidity.
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Affiliation(s)
- Elizabeth Hogan
- Department of Neurosurgery, the George Washington University, 2150 Pennsylvania Avenue, NWSuite 7-420, Washington, DC 20037 USA
| | - Darshan Vora
- Medicine and Health Sciences, the George Washington University, Washington, DC USA
| | - Jonathan H Sherman
- Department of Neurosurgery, the George Washington University, 2150 Pennsylvania Avenue, NWSuite 7-420, Washington, DC 20037 USA
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Iwanaga J, Eid S, Simonds E, Schumacher M, Loukas M, Tubbs RS. The majority of piriformis muscles are innervated by the superior gluteal nerve. Clin Anat 2018; 32:282-286. [PMID: 30408241 DOI: 10.1002/ca.23311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/01/2018] [Indexed: 12/25/2022]
Abstract
The piriformis muscle is clinically implicated in pain disorders, posterior approaches for total hip arthroplasty, and iatrogenic injury to the muscle and the surrounding nerves. The piriformis muscle has been said to receive innervation from L5 to S3 ventral rami with most sources using S1 and S2 ventral rami as the most common innervation this muscle. However, descriptions of the nerve in the literature are vague. Therefore, the aim of this study was to clarify the anatomy of the nerve supply to the piriformis muscle. Twenty sides from ten fresh-frozen cadavers were studied. Specifically, via anterior dissection of the sacral plexus, branches to the piriformis were identified. Once identified, the nerves to the piriformis muscle were traced proximally to clarify their origin. Nerves supplying the piriformis muscle existed on all sides. On 80% of sides, the piriformis was innervated by two to three nerves. The origin of these nerves was from the superior gluteal nerve on 14 sides (70%), inferior gluteal nerve on one side (5%), L5 ventral ramus on one side (5%), S1 ventral ramus on 17 sides (85%), and S2 ventral ramus on 14 sides (70%), respectively. The most common nerve branches to the piriformis are from the superior gluteal nerve, and the ventral rami of S1 and S2. Based on our study, a single "nerve to piriformis" does not exist in the majority of specimens thus this term should be abandoned. Clin. Anat. 32:282-286, 2019. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - Seif Eid
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | | | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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Aguilera-Bohorquez B, Cardozo O, Brugiatti M, Cantor E, Valdivia N. Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results. ACTA ACUST UNITED AC 2018. [DOI: 10.1016/j.recote.2018.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Aguilera-Bohorquez B, Cardozo O, Brugiatti M, Cantor E, Valdivia N. Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018; 62:322-327. [PMID: 29807785 DOI: 10.1016/j.recot.2018.03.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/04/2018] [Accepted: 03/13/2018] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- B Aguilera-Bohorquez
- Cirugía de Preservación y Artroscopia de Cadera, Pontificia Universidad Javeriana Cali, Centro Médico Imbanaco, Cali, Colombia.
| | - O Cardozo
- Cirugía de Preservación y Artroscopia de Cadera, Pontificia Universidad Javeriana Cali, Centro Médico Imbanaco, Cali, Colombia
| | - M Brugiatti
- Cirugía de Preservación y Artroscopia de Cadera, Pontificia Universidad Javeriana Cali, Centro Médico Imbanaco, Cali, Colombia
| | - E Cantor
- Instituto de Investigaciones, Centro Médico Imbanaco, Cali, Colombia
| | - N Valdivia
- Cirugía de Preservación y Artroscopia de Cadera, Pontificia Universidad Javeriana Cali, Centro Médico Imbanaco, Cali, Colombia
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