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Exposure of the Sciatic Nerve in the Gluteal Region Without Sectioning the Gluteus Maximus: Analysis of a Series of 18 Cases

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Exposure of the Sciatic Nerve in the Gluteal Region Without Sectioning the Gluteus Maximus: Analysis of a Series of 18 Cases

Mariano Socolovsky et al. Surg Neurol Int.

Abstract

Background: Dissecting through the gluteus maximus muscle by splitting its fibers, instead of complete sectioning of the muscle, is faster, involves less damage to tissues, and diminishes recovery time. The objective of the current paper is to present a clinical series of sciatic nerve lesions where the nerve was sufficiently exposed via the transgluteal approach.

Methods: We retrospectively selected 18 traumatic sciatic nerve lesions within the buttock, operated upon from January 2005 to December 2009, with a minimum follow-up of 2 years. In all patients, a transgluteal approach was employed to explore and reconstruct the nerve.

Results: Ten males and eight females, with a mean age of 39.7 years, were studied. The etiology of the nerve lesion was previous hip surgery (n = 7), stab wound (n = 4), gunshot wound (n = 3), injection (n = 3), and hip dislocation (n = 1). In 15 (83.3%) cases, a motor deficit was present; in 12 (66.6%) cases neuropathic pain and in 12 (66.6%) cases sensory alterations were present. In all cases, the transgluteal approach was adequate to expose the injury and treat it by neurolysis alone (10 cases), neurolysis and neurorrhaphy (4 cases), and reconstruction with grafts (4 cases; three of these paired with neurolysis). The mean pre- and postoperative grades for the tibial nerve (LSUHSC scale) were 1.6 and 3.6, respectively; meanwhile, for the peroneal division, preoperative grade was 1.2 and postoperative grade was 2.4.

Conclusions: The transgluteal approach adequately exposes sciatic nerve injuries of traumatic origin in the buttock and allows for adequate nerve reconstruction without sectioning the gluteus maximus muscle.

Keywords: Buttock; gluteus maximus; nerve repair; sciatic nerve injury; transgluteal approach.

Figures

Figure 1
Figure 1
This figure shows the available approaches for accessing the sciatic nerve within the buttock: (center) relationship of the gluteus maximus muscle to the sacrum and femur; (top) transgluteal approach, splitting muscle fibers; (left) classical approach involving sectioning of the gluteus maximus muscle; (bottom) subgluteal approach, reclining the muscle fibers superiorly
Figure 2
Figure 2
The skin incision used in the present series
Figure 3
Figure 3
Case #9 – Sciatic nerve injury after hip arthroplasty. (a) The skin incision for the transgluteal approach is in a continuous line. The cross on the left shows the ischium and the one on the right shows the trochanter. Between them, the skin projection of the sciatic nerve is seen. (b) The sciatic nerve was freed from all attachments. The arrows identify acrylic material from the hip arthroplasty, which was damaging the nerve
Figure 4
Figure 4
Case #12. (a) Fracture of the left acetabulum after a motorcycle accident; posterior displacement of a fragment was observed by plain radiography. (b) Postoperative plain X-film after open reduction and fixation. During surgery, injury to the sciatic nerve was observed. (c) 3 weeks after bone repair, the nerve was approached via a transgluteal approach and nerve repair using grafts was performed for both divisions of the nerve
Figure 5
Figure 5
Skin incision for the transgluteal approach. The dotted line depicts the suggested incision when further distal access is needed

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