Sciatic Nerve Release: Indications and Disclosure Slide Technique

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