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  • Tolgay Şatana

Arthroscopic Release in the Treatment of Deep Gluteal Nerve Syndrome and Priformis Syndrome

Abstract

The aim of this study was to evaluate the outcomes of Arthroscopic release of priformis to treatment of Deep Gluteal Nerve syndrome (DGNS) and priformis syndrome. DGNS painful siting with or without radiculopaty. 19 patient applied our clinic 2014-2022 and that underwent Endoscopic Prfiormis release and sciatic nerve decompression.

All patients was evaluated Radiologic of the series X-ray and MRI neuroconductive studies EMG and SSEP. Clinical outcomes of patients the preoperative and postoperative documentations were analyzed. Regarding clinical outcomes, were significantly improved. Arthroscopic priformis release provides a safe and effective treatment for deep gluteal syndrome.

Keywords: Hip Arthroscopy; Deep Gluteal Syndrome; Priformis Endoscopic Release


Introduction

Priformis syndrome is the most common type of deep gluteal syndrome. It is characterized by numbness and pain radiating from the glueal region to the leg [1-3].

Metropolitan lifestyles increasing sitting habits, extremely intense sports activities, frequent and repeated social and sportive activities, incentives for new experiences can create eccentric loads in the external rotator and obturator muscle region, which is risky of strain in the hip region. Like the priformis, unexpected stretches and strains in the genellius superior, obturator internus muscles, healing tissue and fibrosis, which develop differently depending on the degree of injury, cause nerve entrapments [4,5].

Sciatica or pudendal entrapments, characterized by nondiscogenic pelvic pain, are developing under the title of “deep gluteal nerve syndrome = DGNS”. Priformis syndrome is a one of the deep gluteal syndrome disorders that increases with sitting right after the obtutator outlet where the sciatic nerve is trapped and should be differentiated from typical sciatic pain and discogenic pain causes [6]. The biggest challenge in the diagnosis of Prifromis syndrome is that it presents findings that are confused with discogenic pain. Although MRI techniques have been developed in non-discogenic pain, the absence of pathological signal in the muscle region in the chronic stage reveals the importance of examination in the diagnosis. In physical examination, provocative tests (fair, ober, faber, etc.) [7,8].

Fair test (in a side-lying patient, it is pathognomonic as it causes local pain by trapping the sciatic nerve at the fibrotic priformis dislocation when the hip is passively brought to 90 degrees while adduction and internal rotation is forced. A reproduction of the patient’s local buttock pain is a positive test for piriformis involvement. A fair test must be repeated dynamically during the EMG test and electrophysiological findings should be recorded.

Endoscopic decompression is preferred in patients who are permanent, decrease a lot with rest, start immediately with light activity, have not benefited from conservative treatment or relapsed in a short time after treatment. A head of time, we were performing sciatic decompression by cutting the piriformis muscle using open or miniopen endoscopic techniques. As our experience in hip arthroscopy increased, we preferred separating the piriformis muscle from the musculotendinous junction due to its low mortality and patient comfort [7-17].


Materials and Methods

Early surgical results of 19 patients you have treated with hip arthroscopy in our clinic in the last seven years; We evaluated the functional results of 19 patients, 7 male and 12 female, who were treated by the same single surgeon between 2014 and 2022, mean age 46: mean follow-up time: 11 months (6-18 months)

All patients were evaluated preoperatively and postoperatively by radiological MRI and electrophysiological reassessment at 6 weeks and 6 months.

Arthroscopic priformis release was performed via posterior proximal portal and accessory proximal portal lateral decubitus position or prone position. After cleaning the bursa around the K wire, which is placed under the scope of the 30-degree arthroscope from the proximal portal to the fossa priformis, the priformis tendon is separated from insertion which is near the gluteus medius neighborhood with a total tenotomy. Subsequently, adhesions are removed by following up to the priformis obturator foramen. The sciatic nerve is exposed and neurolysis is performed distally to ensure that there is no pressure up to the quadratus level.

Results

18 patients’ single side one patient bilaterally was achieved Arthroscopic piriformis complete tenotomy. The tendon adheration of the capsule was released in all cases. No injuries to the sciatic nerve or inferior gluteal artery occurred. All patients were mobilized at the third hour postoperatively. Stretching exercises were applied to all patients for 3 weeks and heavy exercises were avoided. After six weeks, sports activities were allowed. Vitamin B1 supplementation was given for six months [18].

Discussion

Priformis syndrome is diagnosed after the missdiagnosis of discopathy or spinal disorders and treatment of pelvic sacroiliac disorders due to difficulty sitting and coccidynia, which often progress with radiculopathy. Vallerian degeneration healing pain caused by delayed entrapment neuropathy may be a problem after these patients who have received dozens of treatments have benefited from best endoscopic treatment.

Piriformis syndrome is an important differential diagnosis for Clinicians which consider medical management and conservative management in the initial treatment plan for piriformis syndrome. Patients exhausted to been recevived many options within the conservative management much promise regarding such as physical therapy, steroid injections, botulinum toxin injections, and dry needling are all potentially effective therapies with few adverse effects [19,20].

Arthroscopic priformis tenotomy would be as gold standard, when conservative management has failed, and the symptoms are significant to affect daily living activities. Endoscopic decompression of the sciatic nerve with release of the piriformis tenotomy highest success and a low complication rate. Current literature shows that the endoscopic way over the open approach is due to improved outcomes and decreased complications.


Conclusion

Releasing the sciatic decompression from the priformis thoracanteric attachment is an effective and safe method in priformis syndrome. It has been reported that the risk of neurovascular injury is high due to different variations in the open or endoscopic methods that we loosen except for the tendinosis region of the priformis.



Tolgay Satana* and Ali Ihsan Isik

Department of Orthopedic and Trauma Surgery, Istanbul Aydin University, Turkey

Submission: July 17, 2022; Published: July 25, 2022

*Corresponding author: Tolgay Satana, Department of Orthopedic and Trauma Ssdurgery, Istanbul Aydin University, Turkey


References

1. Vij N, Kiernan H, Bisht R, Singleton I, Cornett EM, et al. (2021) Surgical and Non-surgical Treatment Options for Piriformis Syndrome: A Literature Review Review. Anesth Pain Med 11(1).

2. Miller TA, White KP, Ross DC (2012) The diagnosis and management of Piriformis Syndrome: myths and facts. Can J Neurol Sci 39(5): 577- 583.

3. Hicks BL, Lam JC, Varacallo M (2020) Piriformis Syndrome. Stat Pearls Publishing.

4. Kean Chen C, Nizar AJ (2013) Prevalence of piriformis syndrome in chronic low back pain patients. A clinical diagnosis with modified FAIR test. Pain Pract 13(4): 276-281.

5. Huang ZF, Yang DS, Shi ZJ, Xiao J (2018) Pathogenesis of piriformis syndrome: a magnetic resonance imaging-based comparison study. Zhonghua Yi Xue Za Zhi 98(1): 42-45.

6. Coulomb R, Khelifi A, Bertrand M, Mares O, May O, et al. (2018) Does endoscopic piriformis tenotomy provide safe and complete tendon release? A cadaver study. Orthop Traumatol Surg Res 104(8): 1193- 1197.

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10. Jackson TJ (2016) Endoscopic Sciatic Nerve Decompression in the Prone Position-An Ischial-Based Approach. Arthrosc Tech 5(3): e637- 642.

11. Ilizaliturri VJ, Arriaga R, Villalobos FE, Suarez-Ahedo C (2018) Endoscopic release of the piriformis tendon and sciatic nerve exploration. J Hip Proserv Surg 5(3): 301-306.

12. Byrd JW (2015) Disorders of the Peritrochanteric and Deep Gluteal Space: New Frontiers for Arthroscopy. Sports Med Arthrosc Rev 23(4): 221-231.

13. Ham DH, Chung WC, Jung DU (2018) Effectiveness of Endoscopic Sciatic Nerve Decompression for the Treatment of Deep Gluteal Syndrome. Hip Pelvis 30(1): 29- 36.

14. Aguilera-Bohorquez B, Cardozo O, Brugiatti M, Cantor E, Valdivia N (2018) Endoscopic treatment of sciatic nerve entrapment in deep gluteal syndrome: Clinical results. Rev Esp Cir Ortop Traumatol 62(5): 322-327.

15. Hwang DS, Kang C, Lee JB, Cha SM, Yeon KW (2010) Arthroscopic treatment of piriformis syndrome by perineural cyst on the sciatic nerve: A Case Report. Knee Surg Sports Traumatol Arthrosc 18(5): 681- 684.

16. Todd Pierce P, Casey Pierce M, Kimona Issa, Vincent McInerney K, Anthony Festa, et al. (2017) Arthroscopic Piriformis Released. A Technique for Sciatic Nerve Decompression Arthroscopy Techniques 6(1): e163- e166.

17. Huang ZF, Lin BQ, Torsha TT, Dilshad S, Yang DS, et al. (2019) Effect of Mannitol plus Vitamins B in the management of patients with piriformis syndrome. J Back Musculoskelet Rehabil 32(2): 329- 337.

18. Gulledge BM, Marcellin-Little DJ, Levine D, Tillman L, Harrysson OL, et al. (2014) Comparison of two stretching methods and optimization of stretching protocol for the piriformis muscle. Med Eng Phys 36(2): 212- 218.

19. Terlemez R, Ercalik T (2019) Effect of piriformis injection on neuropathic pain. Agri 31(4): 178- 182.

20. Misirlioglu TO, Akgun K, Palamar D, Erden MG, Erbilir T (2015) Piriformis syndrome: comparison of the effectiveness of local anesthetic and corticosteroid injections: a double-blinded, randomized controlled study. Pain Physician 18(2): 163-171.

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