A Rare Case of Partially Ossified Sacrospinous Ligament Causing Sciatic Nerve Compression.

Ossification of sacrospinous ligament induces a great risk for maintaining the stability of the pelvis. The sacrospinous ligament, along with the sacrotuberous ligament, plays a distinct role in the sacroiliac joint and pubic symphysis stability. The ossification may cause compression of neurovascular structure traversing through the greater and lesser sciatic foramen. Here we report a case of unilateral heterogenous ossification of the left sacrospinous ligament causing sciatic nerve compression and sciatic pain. A 22-year-old Bangladeshi woman, mother of one child, presented with complaints of pain in the lower back, left buttock and back of the upper thigh. Clinical examination and investigations revealed a diagnosis of the partially ossified sacrospinous ligament with sciatic nerve compression. Total excision of heterotrophic calcification and partial excision of left sacrospinous ligament through posterior approach by a left paramedian incision over the lower back was performed under general anaesthesia. On outpatient follow-up visits at 2 weeks and 6 weeks post-surgery, complete disappearance of pain was observed, and the patient was able to return to regular productive life activity. In this report, we presented a rare case of ossified sacrospinous ligament causing sciatic nerve compression with unknown etiology. The surgical approach performed, total excision of heterotrophic calcification and partial excision of left sacrospinous ligament through the posterior approach helped to preserve the pelvic stability with a good clinical outcome.

Iatrogenic Sciatic Nerve Injury in Posterior Acetabular Surgery: Surgeon More Predictive Than Position.

OBJECTIVES: To identify factors that contribute to iatrogenic sciatic nerve palsy during acetabular surgery through a Kocher-Langenbeck approach and to evaluate if variation among individual surgeons exists. DESIGN: Retrospective cohort. SETTING: Level I trauma center. PATIENT SELECTION CRITERIA: Adults undergoing fixation of acetabular fractures (AO/OTA 62) through a posterior approach by 9 orthopaedic traumatologists between November 2010 and November 2022. OUTCOME MEASURES AND COMPARISONS: The prevalence of iatrogenic sciatic nerve palsy and comparison of the prevalence and risk of palsy between prone and lateral positions before and after adjusting for individual surgeon and the presence of transverse fracture patterns in logistic regression. Comparison of the prevalence of palsy between high-volume (>1 patient/month) and low-volume surgeons. RESULTS: A total of 644 acetabular fractures repaired through a posterior approach were included (median age 39 years, 72% male). Twenty of 644 surgeries (3.1%) resulted in iatrogenic sciatic nerve palsy with no significant difference between the prone (3.1%, 95% confidence interval [CI], 1.9%-4.9%) and lateral (3.3%, 95% CI, 1.3%-8.1%) positions (P = 0.64). Logistic regression adjusting for surgeon and transverse fracture pattern demonstrated no significant effect for positions (odds ratio 1.0, 95% CI, 0.3-3.9). Transverse fracture pattern was associated with increased palsy risk (odds ratio 3.0, 95% CI, 1.1-7.9). Individual surgeon was significantly associated with iatrogenic palsy (P < 0.02). CONCLUSIONS: Surgeon and the presence of a transverse fracture line predicted iatrogenic nerve palsy after a posterior approach to the acetabulum in this single-center cohort. Surgeons should perform the Kocher-Langenbeck approach for acetabular fixation in the position they deem most appropriate, as the position was not associated with the rate of iatrogenic palsy in this series. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The "Genesis" of sciatic nerve injury.

In the Old Testament book of Genesis, Chapter 32, Jacob wrestled with an angel. After that encounter, Jacobs limped. Through careful understanding of the original meaning of the words in Verses 25, 31, and 32 of Genesis 32, we seek to learn what type of injury the angel might have inflicted on Jacob. At the time Genesis was written, the difference between tendon and nerve was not understood. While wrestling, when the angel's hand grabbed Jacob, it was most likely Jacob's hip that was affected, not his thigh. Most likely, there was a posterior dislocation of the "socket" (hip joint), and the "sinew" that was damaged was the sciatic nerve. Today, this biblical description is manifested by the sciatic nerve being removed for beef to be considered Kosher. LAY SUMMARY: In Genesis Chapter 32, Jacob wrestled with an angel, after which Jacob limped. Most likely, Jacob had a posterior hip dislocation with a sciatic nerve stretch injury. Today, this Biblical description is manifested by the sciatic nerve being removed for beef to be considered Kosher.

Salvage of Iatrogenic Sciatic Nerve Injury Caused by Operatively Treated Acetabular Fractures: Two Cases and Literature Review.

BACKGROUND: While sciatic nerve injury has been described as a complication of acetabular fractures, iatrogenic nerve injury remains sparsely reported. This study aims to assess iatrogenic sciatic nerve injuries occurring during acetabular fracture surgery, tracking their neurological recovery and clinical outcomes, and investigating any correlation between recovery and the severity of neurologic injury to facilitate physicians in providing prediction of prognosis. CASE PRESENTATION: We present two cases of male patients, aged 56 and 22, who developed sciatic palsy due to iatrogenic nerve injury during acetabular fracture surgery. Iatrogenic sciatic nerve injury resulted from operatively treated acetabular fractures. Surgical exploration, involving internal fixation removal and nerve decompression, successfully alleviated symptoms in both cases postoperatively. At the latest follow-up, one patient achieved full recovery with excellent function, while the other exhibited residual deficits at the L5/S1 root level along with minimal pain. CONCLUSION: Sciatic nerve injury likely stemmed from reduction techniques and internal fixation procedures for the posterior column, particularly when performed with the hip flexed, thereby placing tension on the sciatic nerve. Our case reports underscore the significance of liberal utilization of electrophysiologic examinations and intraoperative monitoring for the prediction of prognosis. Surgical exploration, encompassing internal fixation removal and nerve decompression, represents an effective intervention for resolving sciatic palsy, encompassing both sensory neuropathy and motor symptoms.

Similar incidence of postoperative sciatic nerve palsy in direct anterior and posterior approach total hip arthroplasty.

BACKGROUND: Sciatic nerve palsy is a rare but devastating complication following total hip arthroplasty (THA). While the use of the direct anterior approach is increasing, limited data exist regarding sciatic nerve palsy and surgical approach. The purpose of this study was to determine the factors and outcomes associated with sciatic nerve palsy (SNP) after THA. METHODS: A retrospective analysis was performed at a single institution of 7 SNP that occurred in 4045 THA via direct anterior approach and 10 SNP in 8854 THA via posterior approach, being operated between 01 January 2017 and 12 December 2021. SNP patients were matched 1:5 to patients without SNP. Medical records were reviewed for demographics including age, gender, body mass index (BMI), comorbidities, and preoperative indication. Additional workup of SNP patients including advanced imaging and reoperation were documented. Recovery grades were assigned to all SNP patients at most recent clinical follow-up. RESULTS: 5 of the SNP were complete and 12 partial. They occurred as frequently with the direct anterior (0.17%) and posterior approach (0.11%, p = 0.5). The presence of femur cables and reoperations were associated with SNP (p = 0.04 and p = 0.002, respecitvely). Age, gender, BMI, comorbidities, and surgical indication had no effect on SNP. 4 of the 17 affected patients had almost complete recovery at latest follow-up. CONCLUSIONS: The incidence of SNP was similar in direct anterior and posterior approach. Surgeons should counsel patients regarding the risks of SNP regardless of the used approach.

Sciatic nerve palsy after direct anterior approach for total hip replacement.

SummarySciatic nerve injury after total hip replacement is rare with a reported incidence of about 0.09%-3.7%. The most commonly reported causes include traction on the nerve during reduction, compression of the nerve from subfascial haematoma, significant leg lengthening, improper retractor placement, thermal burns from cautery and extraneous cement. We present a case of complete sciatic nerve palsy in a patient operated on using direct anterior approach (DAA). To date, there are no reports describing sciatic nerve palsy secondary to haematoma immediately after primary arthroplasty through the DAA. We performed an MRI of lumbosacral spine with both hips, which revealed a haematoma. Consequently, we promptly took the patient to the operation theatre for re-exploration. Using the same approach, we dislocated the hip and removed the clots. By the end of 2 weeks, the patient was able to dorsiflex the ankle and had fully recovered from sciatic nerve palsy.

Amphiphysin-IgG autoimmune sciatic neuropathy and facial neuropathy related to primary central nervous system lymphoma: A case report.

We reported a 61-year-old man presented with 10-month progressing left sciatic neuropathy and 10-day right facial neuropathy. Serum amphiphysin-IgG was positive. 18F-FDG PET/CT of the whole body showed no signs of malignancy. Treatment with plasma exchange and oral prednisone relieved the symptoms. Nine months later, right hemiparesis and seizure of right limbs developed. 18F-FDG and 18F-PBR06 (18 kDa translocator protein, TSPO) radioligand PET/MRI of the whole body revealed intense uptake in the intracranial lesions. Intracranial lymphoma was diagnosed by stereotactic needle brain biopsy. Mononeuropathies could be paraneoplastic syndromes. TSPO shows high uptake in intracranial lymphoma on 18F-PBR06 PET images.

Characterizing peroneal nerve injury clinicoradiological patterns with MRI in patients with sciatic neuropathy and foot drop after total hip replacement.

OBJECTIVE: Sciatic nerve injury following total hip arthroplasty (THA) predominantly affects the peroneal division of the sciatic nerve, often causing a foot drop. This can result from a focal etiology (hardware malposition, prominent screw, or postoperative hematoma) or nonfocal/traction injury. The objective of this study was to compare the clinicoradiological features and define the extent of nerve injury resulting from these two distinct mechanisms. METHODS: Patients who developed a postoperative foot drop within 1 year after primary or revision THA with a confirmed proximal sciatic neuropathy based on MRI or electrodiagnostic studies were retrospectively reviewed. Patients were divided into two cohorts: group 1 (focal injury), including patients with an identifiable focal structural etiology, and group 2 (nonfocal injury), including patients with a presumed traction injury. Patient demographics, clinical examinations, subsequent surgeries, electrodiagnostic study results, and MRI abnormalities were noted. The Student t-test was used to compare time to onset of foot drop and time to secondary surgery. RESULTS: Twenty-one patients, treated by one surgeon, met inclusion criteria (8 men and 13 women; 14 primary THAs and 7 revision THAs). Group 1 had a significantly longer time from THA to the onset of foot drop, with a mean of 2 months, compared with an immediate postoperative onset in group 2 (p = 0.02). Group 1 had a consistent pattern of localized focal nerve abnormality on imaging. In contrast, the majority of patients in group 2 (n = 11) had a long, continuous segment of abnormal size and signal intensity of the nerve, while the other 3 patients had a segment of less abnormal nerve in the midthigh on imaging. All patients with a long continuous lesion had Medical Research Council grade 0 dorsiflexion prior to secondary nerve surgeries compared with 1 of 3 patients with a more normal midsegment. CONCLUSIONS: There are distinct clinicoradiological findings in patients with sciatic injuries resulting from a focal structural etiology versus a traction injury. While there are discrete localized changes in patients with a focal etiology, those with traction injuries demonstrate a diffuse zone of abnormality within the sciatic nerve. A proposed mechanism involves anatomical tether points of the nerve acting as points of origin and propagation for traction injuries, resulting in an immediate postoperative foot drop. In contrast, patients with a focal etiology have localized imaging findings but a highly variable time to the onset of foot drop.

Posterior Hip Dislocation in Association With Anterior Column Acetabular Fracture, Femoral Head Fracture, and Sciatic Nerve Injury: A Case Report.

CASE: Posterior hip dislocations are classically associated with posterior acetabular wall fractures. We report the case of a 29-year-old man presented after a motorcycle accident with an unusual combination of injuries that included posterior hip dislocation, anterior column acetabulum fracture, femoral head fracture, and sciatic nerve injury. At the final follow-up, excellent outcomes were obtained with complete recovery of the sciatic nerve injury. CONCLUSION: A favorable outcome may be achieved in young patients who sustain this unusual compilation of ipsilateral anterior acetabulum fracture, posterior hip dislocation, femoral head fracture, and sciatic nerve injury with meticulous preoperative surgical planning and tailored patient management.

Early perioperative magnetic resonance findings in patients with foot drop following total hip Arthroplasty: A descriptive case-series.

PURPOSE: This study aims to characterize iatrogenic sciatic nerve injury patterns in the early, perioperative period following posterior-approach total hip arthroplasty (THA) with magnetic resonance imaging (MRI). METHODS: This was an IRB-approved retrospective analysis of patients acquired from a longitudinal, single site radiology database of patients who underwent MRI for "foot drop" within 4 weeks following posterior-approach THA surgery, over a 20-year period. RESULTS: MRI exams from 51 patients (mean age 62 years; 32 females) who met inclusion criteria were evaluated. Mean time to MRI was 2.4 days. Of 51 patients, 43 underwent primary THA, 6 revision THA and 2 explantation with antibiotic spacer placement. Ten exams revealed a normal appearance of the sciatic nerve. Nineteen showed compression of the sciatic nerve by edema or a fluid collection, without intrinsic nerve abnormality. Fifteen demonstrated perineural tethering or scar/granulation tissue encasement of the nerve, and in half of these cases the sciatic nerve was enlarged and/or hyperintense on fluid-sensitive sequences. Six patients had sciatic nerve compression secondary to quadratus femoris retraction. Six patients had complete resolution of the foot drop at a mean follow-up of 37.3 months following surgery, and in these cases the sciatic nerve appeared normal on the initial postoperative MRI. Remaining patients all had persistent weakness and paresthesias in the sciatic nerve distribution at a mean follow-up duration of 34.3 months. CONCLUSION: This retrospective case series demonstrates various sciatic nerve injury patterns in the early perioperative period on MRI and proposes a targeted MRI protocol to evaluate the sciatic nerve post THA surgery.

Risk of Postoperative Sciatic Nerve Palsy After Posterior Acetabular Fracture Fixation: Does Patient Position Matter?

OBJECTIVES: To determine whether the prone or lateral position is associated with postoperative sciatic nerve palsy in posterior acetabular fracture fixation. DESIGN: Retrospective cohort study. SETTING: Three Level I trauma centers. PATIENTS: Patients with acetabular fractures treated with a posterior approach (n = 1045). INTERVENTION: Posterior acetabular fixation in the prone or lateral positions. OUTCOME MEASUREMENTS: The primary outcome was the prevalence of postoperative sciatic nerve palsy by position. Secondary outcomes were risk factors for nerve palsy, using multiple regression analysis and propensity scoring. RESULTS: The rate of postoperative sciatic nerve palsy was 9.5% (43/455) in the prone position and 1.5% (9/590) in the lateral position ( P < 0.001). Intraoperative blood loss and surgical duration were significantly higher for patients who developed a postoperative sciatic nerve palsy. Subgroup analysis showed that position did not influence palsy prevalence in posterior wall fractures. For other fracture patterns, propensity score analysis demonstrated a significantly increased odds ratio of palsy in the prone position [aOR 7.14 (2.22-23.00); P = 0.001]. CONCLUSIONS: With the exception of posterior wall fracture patterns, the results of this study suggest that factors associated with increased risk for postoperative sciatic nerve palsy after a posterior approach are fractures treated in the prone position, increased blood loss, and prolonged operative duration. These risks should be considered alongside the other goals (eg, reduction quality) of acetabular fracture surgery when choosing surgical positioning. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A Sciatic Neuralgia Case of an Entrapment Neuropathy Mimicking Piriformis Syndrome Due to Soft Tissue Hemangioma.

BACKGROUND: Lumbosacral pain is commonly seen in daily clinical practice. In fact, entrapment of the part of the sciatic nerve after the sacral foramen causes some of these pains, which should not be overlooked. The sciatic nerve may be compressed during its course after the sacral foramen for a variety of reasons. We aimed in this article to review extra-spinal compressive sciatic neuropathy reasons and abnormal magnetic resonance imaging (MRI) by presenting a sciatic neuralgia case of an entrapment neuropathy mimicking piriformis syndrome due to soft tissue hemangioma. CASE PRESENTATION: A 30-year-old male patient was admitted with complaints of lumbosacral pain spreading to the leg that had been worsening over the previous 10 days. With the preliminary diagnosis of labral damage and piriformis syndrome, the patient was referred to the radiology clinic for a hip MRI. In the hip MR images, a mass lesion suggestive of heterogeneously enhanced soft tissue hemangioma after the injection of paramagnetic contrast material was observed in the proximal left thigh. The soft tissue hemangioma extends towards the obturator foramen and compresses the sciatic nerve proximal to the femur after the sciatic foramen. CONCLUSION: The diagnosis of lower extremity entrapment neuropathy is frequently misdiagnosed. In these cases, MRI becomes more important for accurate diagnosis. The radiologists' knowledge of the sciatic nerve in MRI, regional anatomy during the course of the sciatic nerve, and abnormal nerve imaging findings will aid in the diagnosis.

Open Sciatic Nerve Decompression for Compartment Syndrome after Prolonged Lithotomy Position: A Case Report.

Background: Position-related compressive nerve injury is a frequently reported complication of the lithotomy position. In contrast, compartment syndrome-induced neuropathy after lithotomy with prolonged surgery is rare and prone to misdiagnosis. This case describes the successful open decompression of sciatic neuropathy due to compartment syndrome after a prolonged lithotomy position. Case presentation: A 56-year-old male patient complained of an abnormal sensation in the lower leg and difficulty in dorsiflexion and plantarflexion of the left foot and toes after laparoscopic anterior hepatic sectionectomy for 16 h in a lithotomy position. Physical examination revealed severe pain and paresthesia below the distal left thigh. In manual muscle test grading, dorsiflexion and plantarflexion of the left ankle and toes were classified as grade 1. Computed tomography and magnetic resonance imaging showed ischemic changes in the mid-thigh posterior muscles, and the sciatic nerve was severely swollen at the distal thigh, which was compressed by the proximal edge of the well-leg holder. After debridement of the necrotic tissue and decompression of the sciatic nerve, the pain subsided immediately, and the ankle and toe dorsiflexion motor function improved to grade 4. Conclusions: Most case reports of compressive neuropathy associated with the lithotomy position have been related to conservative treatment. However, if a lesion compressing the nerve is confirmed in an imaging study and the correlation with the patient's symptoms is evident, early surgical intervention can be an effective treatment method to minimize neurological deficits.

Amyloid Deposition: An Unusual Case of Deep Gluteal Syndrome and Sciatic Nerve Compression: A Case Report.

CASE: Soft-tissue amyloidomas are exceedingly rare, with only a few cases reported in the literature. There are no reports of sciatic nerve compression secondary to a soft-tissue amyloidoma. We report a unique case of a 71-year-old man with an incidentally found amyloidoma who was initially believed to have deep gluteal syndrome. He had a favorable outcome after surgical decompression. CONCLUSION: For patients who do not have classic examination and electromyography/nerve conduction findings of piriformis syndrome, providers should explore other etiologies of peripheral nerve compression including soft-tissue amyloidoma.

Sciatic nerve injury after acetabular fractures: a meta-analysis of incidence and outcomes.

PURPOSE: To investigate the incidence and the outcome of post-traumatic and iatrogenic sciatic nerve palsy (SNP) associated with fractures of the acetabulum. The results of sciatic nerve grafting for treatment were also investigated. METHODS: PUBMED, SCOPUS and COCHRANE databases were searched for longitudinal observational studies reporting sciatic nerve palsy related to acetabular fractures in adult patients over the last 20 years. Data regarding patients demographics, type of acetabular fracture, rate of post traumatic and iatrogenic sciatic nerve palsies as well as recovery rate are reported. Studies were assessed for their quality. Random effects meta-analyses were carried out to pool overall proportions of SNP incidence and complete recovery. Variations in SNP incidence by main study characteristics were assessed by subgroup analysis and meta-regression. A narrative review of sciatic nerve grafting was also conducted. RESULTS: Twenty studies reporting 44 post-operative and 18 iatrogenic SNPs in 651 patients were reviewed. The pooled incidence of posttraumatic SNP was 5.1% (95% CI 2.7-8.2%). The pooled incidence of iatrogenic SNP was 1.4% (95% CI 0.3-2.9%). Complete recovery of post-traumatic and iatrogenic SNP occurred in 64.7% (95% CI 41.7-85.4%) and 74.1% (95% CI 31.5-100%), respectively. CONCLUSION: A favorable outcome of both post-traumatic and iatrogenic SNP related to acetabular fractures has been found. Due to the poor results of sciatic nerve grafting, a "wait and see" approach may be the best option, in cases of a contused but anatomically intact sciatic nerve.

"Floating Hip" and "Floating Knee" Associated with Hip Dislocation, Sciatic Nerve Palsy, and Patella Fracture: A Case Report.

CASE: We report a very rare case of simultaneous ipsilateral floating hip and floating knee (SIFHFK) injury with the neck of the femur and patella fracture and hip dislocation associated with sciatic nerve injury in a 45-year-old man after a road traffic accident. We adopted a staged approach for surgical fixation of the fractures after stabilization. At the latest 2 years follow-up, the patient was asymptomatic with satisfactory clinical outcome. CONCLUSION: SIFHFK injuries present a challenging and emergent clinical scenario and require extensive clinical experience, careful planning, and multidisciplinary teamwork because of the paucity of specific treatment protocols for the treatment of this complex injury.