Minimally Invasive Image-Guided Transgluteal Approach for Resection of a Sciatic Nerve Tumor: A Technical Note

There are a variety of surgical approaches to lesions around the sciatic notch. Historically, peripheral nerve surgeons prefer an infragluteal approach involving a large incision with reflection of the gluteus maximus to better visualize the operative field. This approach was imperative when lesion localization was imprecise. Comparatively, orthopedic surgeons prefer a muscle-splitting, transgluteal approach to operate on the static structures of the posterior hip. The transgluteal approach is significantly less morbid, allowing for same-day discharge and less extensive rehab given preservation of the gluteal muscle. In this article we describe the use of dynamic ultrasound imaging to localize and aid in the resection of three unique tumors around the sciatic notch using a minimally invasive, tissue-sparing, transgluteal technique. We offer a comprehensive description of the benefits, anatomic considerations, and nuances of using a transgluteal approach for the resection of lesions at the sciatic notch.

Retroperitoneal Migration And Transgluteal Extrusion of a Distal Lumboperitoneal Shunt Catheter: An Unusual Complication of Cerebrospinal Fluid Shunt

Cerebrospinal fluid shunts provide many and different complications. Only 1-3% of them are rare, related to migration, and perforation of hollow organs. Even more unusual are the complications associated with the distal catheter leaving the peritoneal cavity and the tip migrating through some of the anatomical foramens to the muscle layers on the back. We present a rare complication, migration of the distal lumboperitoneal shunt catheter through the retroperitoneum and the gluteal muscles to the hypoderma. The peritoneal catheter entered the retroperitoneal area, passed through the greater sciatic foramen below the piriformis, and through the gluteal muscles, before it reached the hypodermal area. Despite the continuous improvement of the material of flexible silicone catheters, injuries of hollow organs with subsequent migration to unusual areas still occur. Our case is the only one that has been reported, in which the catheter made its way through the retroperitoneum and the gluteal muscles.

Patient-Reported Outcomes Following Total Hip Arthroplasty: A Multicenter Comparison Based on Surgical Approaches

BACKGROUND

Comparisons of patient-reported outcomes (PROs) based on surgical approach for total hip arthroplasty (THA) in the United States are limited to series from single surgeons or institutions. Using prospective data from a large, multicenter study, we compare preoperative to postoperative changes in PROs between posterior, transgluteal, and anterior surgical approaches to THA.

METHODS

Patient-reported function, global health, and pain were systematically collected preoperatively and at 1, 3, and 6 months postoperatively from patients undergoing primary THA at 26 sites participating in the Comparative Effectiveness of Pulmonary Embolism Prevention After Hip and Knee Replacement (ClinicalTrials.gov: NCT02810704). Outcomes consisted of the brief Hip disability and Osteoarthritis Outcome Score, the Patient-Reported Outcomes Measurement Information System Physical Health score, and the Numeric Pain Rating Scale. Operative approaches were grouped by surgical plane relative to the abductor musculature as being either anterior, transgluteal, or posterior.

RESULTS

Between 12/12/2016 and 08/31/2019, outcomes from 3018 eligible participants were examined. At 1 month, the transgluteal cohort had a 2.2-point lower improvement in Hip disability and Osteoarthritis Outcomes Score (95% confidence interval, 0.40-4.06; P = .017) and a 1.3-point lower improvement in Patient-Reported Outcomes Measurement Information System Physical Health score (95% confidence interval, 0.48-2.04; P = .002) compared to posterior approaches. There was no significant difference in improvement between anterior and posterior approaches. At 3 and 6 months, no clinically significant differences in PRO improvement were observed between groups.

CONCLUSION

PROs 6 months following THA dramatically improved regardless of the plane of surgical approach, suggesting that choice of surgical approach can be left to the discretion of surgeons and patients without fear of differential early outcomes.

Ultrasound-Guided Subgluteal Sciatic Nerve Perineural Injection: Report on Safety and Efficacy at a Single Institution

OBJECTIVES

To determine the safety and efficacy of ultrasound (US)-guided subgluteal sciatic nerve injections.

METHODS

A retrospective chart review of US-guided subgluteal sciatic nerve injections at our institution was performed.

RESULTS

Of 221 US-guided subgluteal sciatic nerve injections, 100% achieved technical success, with no postprocedure complications. Sixty-eight percent of patients with follow-up reported symptom relief. Most patients with no relief had suboptimal preprocedure screening.

CONCLUSIONS

With appropriate screening, our technique of US-guided subgluteal sciatic nerve injection is safe and effective.

Less invasive causal treatment of ejaculatory duct obstruction by balloon dilation: a case report, literature review and suggestion of a CT- or MRI-guided intervention

Uni- or bilateral ejaculatory duct obstruction (EDO) is a rare but correctable cause of infertility, chronic pelvic pain and postejaculatory pain.

EDO is a congenital or acquired condition, it is the underlying cause of infertility in approximately 5% of infertile men. If acquired, the etiology often remains unresolved, but prostatitis or urethritis with post-inflammatory adhesion of the duct walls seems to be a common underlying pathomechanism.

Although a certain constellation of physicochemical semen parameters may lead to correct diagnosis, EDO often resembles a diagnosis by exclusion. Imaging of acquired EDO remains a challenge and the established surgical therapy, transurethral resection of the ejaculatory ducts (TURED), leads to a low rate of natural conception and a high rate of complications such as reflux of urine and epididymitis.

We present a case of a male with suspected EDO who underwent a combined approach to both, semi-invasive diagnosis and therapy by transrectal puncture of the seminal vesicles and antegrade balloon-dilation of the ejaculatory ducts. Possibilities and pitfalls of this procedure are described and the literature is reviewed.

Furthermore, we suggest a CT- or MRI-guided, percutaneous intervention for treatment of ejaculatory duct obstruction by balloon dilation and demonstrate initial steps of this procedure with a body donor. We call this new procedure PTED (percutaneous transgluteal ejaculatory ductoplasty).

Comparison of ultrasound-guided anterior versus transgluteal sciatic nerve blockade for knee surgery

BACKGROUND

Ultrasound-guided sciatic nerve block, in combination with femoral nerve and lateral femoral cutaneous nerve blocks, is frequently used to induce anesthesia for lower limb surgery. The anterior approach to the sciatic nerve is performed in the supine position and repositioning of the patient between injections is avoidable. We compared the relative utility and efficiency of anterior versus transgluteal sciatic nerve blocks in conjunction with femoral nerve and lateral femoral cutaneous nerve blockade.

MATERIALS AND METHODS

Twenty-four patients were enrolled in this prospective double-blind randomized study and were randomly divided into two equal groups: Anterior (Group A) and transgluteal (Group T). We evaluated the following parameters: ultrasound view quality, procedural duration, onset time to block, quality of anesthesia during surgery and postoperative analgesia, required administration of supplemental sedation or narcotics during surgery, amount of pethidine administered within 24 hours post surgery, and overall patient satisfaction.

RESULTS

There were no significant differences between patient groups with regard to the demographic data, onset time to block, quality of ultrasound view, use of narcotics to augment the anesthesia during surgery, and patient satisfaction. Although procedural completion time for the sciatic injection alone was shorter in Group T, the total completion time of all blocks together was significantly less in Group A.

CONCLUSION

Ultrasound-guided anterior blockade of the sciatic nerve has advantages over the transgluteal approach - it provides efficient anesthesia and results in excellent patient satisfaction.