Sciatic Nerve Release: Indications and Technique 1st European Hip Arthroscopy Course Brussels, Belgium December 6 – 7, 2013 Hal David Martin DO Hip Preservation Center Baylor University Medical Center Dallas, TX Sub Gluteal Space Disclosure Slide Consultant Smith and Nephew and Pivot Medical Presentation does not reflect policies of Baylor University Medical Center SN & Piriformis a) Undivided below b) Divided through and below c) Divided above and below d) Undivided between heads of muscle e) Divided between and above f) Undivided above Etiologies of SN Entrapment: Kinematics of Sciatic Nerve –Fibrovascular bands –Vascular compression –Piriformis muscle –Hamstring muscles –Bone structures –Other Diagnosis • Comprehensive History and PE including all hip layers The Pattern and Technique in the Clinical Evaluation of Adult Hip: The Common Physical Examination Tests of Hip Specialists MAHORN GROUP ARHTRO 26: 161-172 Clinical presentation Presentation of Sciatic Nerve Entrapment – posterior hip pain – history of trauma – sit pain (inability to sit for more than 30 minutes) – radicular pain – paresthesias of the affected leg. Benson & Schutzer 1999 n=35 Active Piriformis Test 18 Seated Piriformis Stretch Test (patients) 12 Tinel’s Sign (Sciatic Nerve) (patients) 11 Hypoesthesia (S1, L5, L4) (patients) 9 Diminished Deep Tendon Reflexes (patients) 5 Hyperactive Deep Tendon Reflexes (patients) 4 Lesègue's Test (patients) 4 Hal D. Martin, D.O., Shea A. Shears, B.S.N., R.N., J. Calvin Johnson, M.D. The Endoscopic Treatment of Sciatic Nerve Entrapment/ Deep Gluteal Syndrome. Arthroscopy, 2011. Diagnostic accuracy of clinical tests for SN entrapment # Martin HD, Kivlan BR, Palmer IJ, Martin RL, KSSTA 2013 The Seated Piriformis Stretch Test Physical Examination Active Piriformis Test Test Stretch Active Combined Sensitivity Specificity 0.52 0.90 0.78 0.80 0.91 0.80 Differential Diagnosis Sources of Deep Gluteal Pain • Spine • Intra-pelvic • Deep gluteal space – Sciatic nerve entrapment – Ischiofemoral Impingement – Hamstring avulsions – Pudendal nerve entrapment • Hip joint Sacral plexus - Internal iliac artery branches Possover, M Fertil Steril. 2011 Feb Sciatic Nerve Varicosities Treatment • Physical Therapy • Injections • Surgical – Open – Endoscopic Open Sciatic Nerve Decompression Author Miller A, et al. Number of Procedures 1 Vandertop & Bosma 1 Results Immediate pain relief, 2.5 years post-op no pain yet decreased sensation over the posterolateral aspect of thigh 4 years post-op, doing well Chen, WS 1 Hughes SS, et al. 5 Sayson, et al. Benson & Schutzer 1 15 pain resolved in one week. Motor weakness of the ankle extensors and toes for 3 months. 4 years post-op asymptomatic At 1 year: 1)No pain, slight residual tenderness in buttock, 2) asymptomatic, 3) No pain, slight residual tenderness in buttock, 4) No pain, 5) Excellent 6 months post-op: No pain 2 years post-op: 11 Excellent, 4 Good Meknas K, et al. 12 No pain decrease at 6 months. 8 years post-op: significant decrease in pain Filler AG et al. 64 2 years post-op: Excellent: 59%, Good: 23% , No Benefit: 17%, Worse: 2% Lewis AM, et al. 4 2 months post-op: 3 excellent, 1 still experiencing pain Issack P, et al. 10 1 year post-op: Partial to complete relief of radicular pain, of diminished sensation, and of paresthesias. Young IJ, et al. 44 Hamstring 53 months post-op: 33 satisfied, 5 somewhat satisfied, 6 not satisfied. Beauchesne & Schutzer Jones HG, et al. 1 Immediate pain relief, residual numbness and limp resolved in 4 weeks. 1 Immediate pain relief, 6 weeks post-op: complete resolution of symptoms Endoscopic Piriformis/Sciatic nerve release • Polesello et. al, Rev. Braz. Ortop2011 – Endoscopic SN release in 3 patients • Cabrita et. al., 2012, ISHA 2012 – Endoscopic SN release in 15 patients: all had sciatica relief Endoscopic Piriformis Release • Dezawa et al., Arthroscopy, 2003 – Piriformis release in 6 patients: good results in all Luiz Pérez Carro experience • 26 patients (14 female -12 male). • Age: 38 (31-58). • Follow up: 11 months. • Duration of Symptoms (yrs.) 3 (1-7) • Sit Pain (patients) 26 • Narcotic Use (patients) 24 • Paresthesias / Radicular Pain (patients) 21 Endoscopic Sciatic Nerve Release Luiz Pérez Carro results • Martin et al., Arthroscopy 2011 • 35 patients • Of 26 patients, 19 reported good to excellent outcomes. Did not have sit pain and were able to sit in a chair for more than 30 minutes. • 7 patients better but required continued narcotic use after surgery . Preoperat MHHS 56 (35 35-72) 3535 – 12 months average follow-up – Pre-VAS pain score: 6.9 – Post-VAS pain score: 2.4 – Pre-mHHS: 54.4 – Post-mHHS: 78 Postoperat • 83% percent of patients had no postoperative sciatic sit pain (inability to sit for 30 minutes). 79(78 (788-95) Endoscopy of the Deep Gluteal Space • Supine position • 70° standard and long arthroscopes Ten Steps Technique for Safe Sciatic Nerve Decompression 1) 2) 3) 4) 5) 6) 7) Trochanteric bursectomy Identify SN and quadratus femoris muscle Evaluate the SN Identify vascular branches to SN Endoscopic neurolysis of the sciatic nerve Distal inspection Turn the scope proximal and identify the obturator internus muscle and tendon 8) Crossing branch of the inferior gluteal artery 9) Identify and resect the pirifomis muscle and tendon 10) Probe the sciatic nerve for tension and look for hidden muscle or tendon branches traversing the nerve 1) Trochanteric bursectomy 2) Identify SN and quadratus femoris muscle 3) Evaluate the SN - abnormal 5) Endoscopic neurolysis of the sciatic nerve 6) Distal inspection 3) Evaluate the SN - normal 4) Identify vascular branches to sciatic nerve 7) Turn the scope proximal 8) Crossing branch of the inferior gluteal artery Monopolar Radiofrequency Usage in Deep Gluteal Space Endoscopy: Sciatic Nerve Safety and Fluid Temperature Arthroscopy, 2013 Martin HD, Palmer IJ, Hatem M. Ligation Monopolar Radiofrequency: Sciatic Nerve Safety and Fluid Temperature Activation Time (sec) 0 Temperature in relation to the sciatic nerve On the surface In the perineurium 19.9°C (range, 19 to 21 °C) 18.4°C (range, 17 to 20°C) 2 20.5°C (range, 19 to 22 °C) 18.5°C (range, 17 to 20°C) 5 20.7°C (range, 19 to 24 °C) 18.6°C (range, 17 to 21°C) 10 20.8°C (range, 20 to 22 °C) 19.1°C (range, 17 to 22°C) 9) Endoscopic Piriformis Tendonotomy • Shave Distal boarder of Piriformis muscle • Use arthroscopic scissors for tendon release • Resect 2 cm of the tendon 9) Endoscopic Piriformis Tendonotomy 10) Probe the nerve – hidden crossing tendon Rehabilitation • Critical Factor for Success! • Stretch Injury can cause neuralgia and neuropraxia • Six – 12% increase stretch nerve dysfunction • Knee brace some cases with very slow increases in stretch (Ilizarov principle) Piriformis Syndrome can Resolve Post FAI Treatment ( Now Able to Stretch) Experimental stretch neuropathy: Changes in nerve conduction under tension. Wall et al. JBJS[Br];1992. Characteristics of five low-improvement cases. Caseno. Gender DOS (mo) 1 F 16 Surgical history Laparoscopy, breast MHHS MHHS BOR VAS Pre Post Pre 53.9 61.6 Poor 6 VAS Post 8 FV 1 7 F 51 Hysterectomy, spinal fusion, appendectomy 53.9 44.0 Poor 7 5.5 18 19 F 6 64.9 N/A 6 5 22 23 M 10 Hip arthroscopy, 54.0 gall bladder None 35.2 46.2 Fair 10 5 -1 28 M 10 Jaw, knee, tonsillectomy 57.2 Poor 10 4 9 35.0 Summary • Be aware of four extra-articular posterior hip pathologies • Good physical examination, special testing including injection • Endoscopic decompression of the sciatic nerve useful in improving function and diminishing hip pain in sciatic nerve entrapment /deep gluteal syndrome. Thank You Open Sciatic Nerve Decompression • Filler, 2005 – 62 operations with mean follow-up of 2 years • • • • excellent 59% good 22% no benefit 17% worse 2% Filler, Aaron G., et al. "Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment." Journal of Neurosurgery: Spine 2.2 (2005): 99-115. • Young, 2008 – 46 operations with mean follow-up of 4.4 years • 77% had returned to their previous sporting activities, • 14% were not satisfied with surgical results • 11% were somewhat satisfied; • 75% were very satisfied. Young, Ian J., Roger P. van Riet, and Simon N. Bell. "Surgical release for proximal hamstring syndrome." The American journal of sports medicine36.12 (2008): 2372-2378. • Isaac, 2007 – 10 Sciatic Nerve Release Following Fracture or Reconstructive Surgery of the Acetabulum – All patients had partial to complete relief of radicular pain – No patient had evidence of worsening on neurologic examination after the release. Issack, Paul S., et al. "Sciatic nerve release following fracture or reconstructive surgery of the acetabulum." The Journal of Bone & Joint Surgery 89.7 (2007): 1432-1437. Intra-Op NCS • Benson, 1999 – 15 operations with mean follow-up of 3.1 year • Initial • During Decompression • 11 excellent results • 4 good • MEP Final Benson, Eric R., and STEVEN F. SCHUTZER. "Posttraumatic Piriformis Syndrome: Diagnosis and Results of Operative Treatment*." The Journal of Bone & Joint Surgery 81.7 (1999): 941-9. Thank You