Advertisement

Deep Gluteal Syndrome

  • Hal D. Martin
  • Juan Gómez-Hoyos
Chapter

Abstract

The presence of non-discogenic, extra-pelvic sciatic nerve compression has been characterized as deep gluteal syndrome. This syndrome usually presents with symptoms of pain and dysesthesias in the buttock area, hip or posterior thigh, and/or as radicular pain.

The piriformis muscle and tendon is the most common source of extra-pelvic sciatic nerve entrapment. Nevertheless, several structures such as bone, fibrous scar bands, and other muscular structures can entrap the sciatic nerve in the deep gluteal space. The main differential diagnoses are intra-articular hip pathologies, spine issues, intra-pelvic abnormalities, ischiofemoral impingement, hamstring’s origin tendinopathy, and pudendal nerve entrapment. A comprehensive history and physical examination is key for the diagnosis of deep gluteal syndrome. Imaging-guided injections and magnetic resonance imaging are useful complementary diagnostic tools. The nonoperative treatment of deep gluteal syndrome is successful in most patients. Endoscopic sciatic nerve decompression may be indicated in cases of failure of the conservative treatment. Recent advances on new imaging protocols, innovative minimal invasive surgical techniques, and physical exam tests’ validation have been reported.

Keywords

Deep gluteal syndrome Piriformis syndrome Posterior hip pain Gluteal pain Sciatic nerve entrapment Pudendal nerve entrapment Ischiofemoral impingement Hamstring avulsion 

References

  1. 1.
    McCrory P, Bell S. Nerve entrapment syndromes as a cause of pain in the hip, groin and buttock. Sports Med. 1999;27:261–74.CrossRefPubMedGoogle Scholar
  2. 2.
    Martin HD, Shears SA, Johnson JC, Smathers AM, Palmer IJ. The endoscopic treatment of sciatic nerve entrapment/deep gluteal syndrome. Arthroscopy. 2011;27:172–81.CrossRefPubMedGoogle Scholar
  3. 3.
    Vandertop WP, Bosma NJ. The piriformis syndrome. A case report. J Bone Joint Surg Am. 1991;73:1095–7.CrossRefPubMedGoogle Scholar
  4. 4.
    Puranen J, Orava S. The hamstring syndrome. A new diagnosis of gluteal sciatic pain. Am J Sports Med. 1988;16:517–21.CrossRefPubMedGoogle Scholar
  5. 5.
    Young IJ, van Riet RP, Bell SN. Surgical release for proximal hamstring syndrome. Am J Sports Med. 2008;36:2372–8.CrossRefPubMedGoogle Scholar
  6. 6.
    Cox JM, Bakkum BW. Possible generators of retrotrochanteric gluteal and thigh pain: the gemelli-obturator internus complex. J Manip Physiol Ther. 2005;28:534–8.CrossRefGoogle Scholar
  7. 7.
    Meknas K, Kartus J, Letto JI, Christensen A, Johansen O. Surgical release of the internal obturator tendon for the treatment of retro-trochanteric pain syndrome: a prospective randomized study, with long-term follow-up. Knee Surg Sports Traumatol Arthrosc. 2009;17:1249–56.CrossRefPubMedGoogle Scholar
  8. 8.
    Miller A, Stedman GH, Beisaw NE, Gross PT. Sciatica caused by an avulsion fracture of the ischial tuberosity. A case report. J Bone Joint Surg Am. 1987;69:143–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Labropoulos N, Tassiopoulos AK, Gasparis AP, Phillips B, Pappas PJ. Veins along the course of the sciatic nerve. J Vasc Surg. 2009;49:690–6.CrossRefPubMedGoogle Scholar
  10. 10.
    Papadopoulos SM, McGillicuddy JE, Albers JW. Unusual cause of ‘piriformis muscle syndrome’. Arch Neurol. 1990;47:1144–6.CrossRefPubMedGoogle Scholar
  11. 11.
    Beauchesne RP, Schutzer SF. Myositis ossificans of the piriformis muscle: an unusual cause of piriformis syndrome. A case report. J Bone Joint Surg Am. 1997;79:906–10.CrossRefPubMedGoogle Scholar
  12. 12.
    Chen WS. Sciatica due to piriformis pyomyositis. Report of a case. J Bone Joint Surg Am. 1992;74:1546–8.CrossRefPubMedGoogle Scholar
  13. 13.
    Possover M. Laparoscopic management of endopelvic etiologies of pudendal pain in 134 consecutive patients. J Urol. 2009;181:1732–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Loukas M, Louis RG Jr, Hallner B, Gupta AA, White D. Anatomical and surgical considerations of the sacrotuberous ligament and its relevance in pudendal nerve entrapment syndrome. Surg Radiol Anat. 2006;28:163–9.CrossRefPubMedGoogle Scholar
  15. 15.
    Meknas K, Christensen A, Johansen O. The internal obturator muscle may cause sciatic pain. Pain. 2003;104:375–80.CrossRefPubMedGoogle Scholar
  16. 16.
    Solomon LB, Lee YC, Callary SA, Beck M, Howie DW. Anatomy of piriformis, obturator internus and obturator externus: implications for the posterior surgical approach to the hip. J Bone Joint Surg Br. 2010;92:1317–24.CrossRefPubMedGoogle Scholar
  17. 17.
    Standring S. Grays anatomy the anatomical basis of clinical practice. London: Elsevier; 2008.Google Scholar
  18. 18.
    Miller SL, Gill J, Webb GR. The proximal origin of the hamstrings and surrounding anatomy encountered during repair. A cadaveric study. J Bone Joint Surg Am. 2007;89:44–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Filler AG. Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery. Neurosurg Focus. 2009;26:E9.CrossRefPubMedGoogle Scholar
  20. 20.
    Moore K, Dalley A. Essential clinical anatomy. Philadelphia: Lippincott Williams and Wilkins; 1999.Google Scholar
  21. 21.
    Windhofer C, Brenner E, Moriggl B, Papp C. Relationship between the descending branch of the inferior gluteal artery and the posterior femoral cutaneous nerve applicable to flap surgery. Surg Radiol Anat. 2002;24:253–7.CrossRefPubMedGoogle Scholar
  22. 22.
    Kalhor M, Beck M, Huff TW, Ganz R. Capsular and pericapsular contributions to acetabular and femoral head perfusion. J Bone Joint Surg Am. 2009;91:409–18.CrossRefPubMedGoogle Scholar
  23. 23.
    Gautier E, Ganz K, Krugel N, Gill T, Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. J Bone Joint Surg Br. 2000;82:679–83.CrossRefPubMedGoogle Scholar
  24. 24.
    Sunderland S, Hughes ES. Metrical and non-metrical features of the muscular branches of the sciatic nerve and its medial and lateral popliteal divisions. J Comp Neurol. 1946;85:205–22.CrossRefPubMedGoogle Scholar
  25. 25.
    Sunderland S, Ray LJ. The intraneural topography of the sciatic nerve and its popliteal divisions in man. Brain. 1948;71:242–73.CrossRefPubMedGoogle Scholar
  26. 26.
    Seidel PM, Seidel GK, Gans BM, Dijkers M. Precise localization of the motor nerve branches to the hamstring muscles: an aid to the conduct of neurolytic procedures. Arch Phys Med Rehabil. 1996;77:1157–60.CrossRefPubMedGoogle Scholar
  27. 27.
    Moayeri N, Groen GJ. Differences in quantitative architecture of sciatic nerve may explain differences in potential vulnerability to nerve injury, onset time, and minimum effective anesthetic volume. Anesthesiology. 2009;111:1128–34.CrossRefPubMedGoogle Scholar
  28. 28.
    Sladjana UZ, Ivan JD, Bratislav SD. Microanatomical structure of the human sciatic nerve. Surg Radiol Anat. 2008;30:619–26.CrossRefPubMedGoogle Scholar
  29. 29.
    Georgakis E, Soames R. Arterial supply to the sciatic nerve in the gluteal region. Clin Anat. 2008;21:62–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Karmanska W, Mikusek J, Karmanski A. Nutrient arteries of the human sciatic nerve. Folia Morphol (Warsz). 1993;52:209–15.Google Scholar
  31. 31.
    Ugrenovic SZ, Jovanovic ID, Vasovic LP, Stefanovic BD. Extraneural arterial blood vessels of human fetal sciatic nerve. Cells Tissues Organs. 2007;186:147–53.CrossRefPubMedGoogle Scholar
  32. 32.
    Del Pinal F, Taylor GI. The venous drainage of nerves; anatomical study and clinical implications. Br J Plast Surg. 1990;43:511–20.CrossRefPubMedGoogle Scholar
  33. 33.
    Testut L, Latarjet A. Traite d’anatomie humaine. Paris: G. Doin & Cie; 1949.Google Scholar
  34. 34.
    Possover M, Schneider T, Henle KP. Laparoscopic therapy for endometriosis and vascular entrapment of sacral plexus. Fertil Steril. 2011;95:756–8.CrossRefPubMedGoogle Scholar
  35. 35.
    Beaton L, Anson B. The sciatic nerve and the piriformis muscle: their interrelation and possible cause of coccygodynia. J Bone Joint Surg Am. 1938;20:686–8.Google Scholar
  36. 36.
    Smoll NR. Variations of the piriformis and sciatic nerve with clinical consequence: a review. Clin Anat. 2010;23:8–17.CrossRefPubMedGoogle Scholar
  37. 37.
    Coppieters MW, Alshami AM, Babri AS, Souvlis T, Kippers V, Hodges PW. Strain and excursion of the sciatic, tibial, and plantar nerves during a modified straight leg raising test. J Orthop Res. 2006;24:1883–9.CrossRefPubMedGoogle Scholar
  38. 38.
    Fleming P, Lenehan B, O’Rourke S, McHugh P, Kaar K, McCabe JP. Strain on the human sciatic nerve in vivo during movement of the hip and knee. J Bone Joint Surg Br. 2003;85:363–5.CrossRefPubMedGoogle Scholar
  39. 39.
    Wall EJ, Massie JB, Kwan MK, Rydevik BL, Myers RR, Garfin SR. Experimental stretch neuropathy. Changes in nerve conduction under tension. J Bone Joint Surg Br. 1992;74:126–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Guvencer M, Akyer P, Iyem C, Tetik S, Naderi S. Anatomic considerations and the relationship between the piriformis muscle and the sciatic nerve. Surg Radiol Anat. 2008;30:467–74.CrossRefPubMedGoogle Scholar
  41. 41.
    Yeoman W. The relation of arthritis of the sacro-iliac joint to sciatica, with an analysis of 100 cases. Lancet. 1928;2:1119–22.CrossRefGoogle Scholar
  42. 42.
    Robinson DR. Pyriformis syndrome in relation to sciatic pain. Am J Surg. 1947;73:355–8.CrossRefPubMedGoogle Scholar
  43. 43.
    Adams JA. The pyriformis syndrome – report of four cases and review of the literature. S Afr J Surg. 1980;18:13–8.PubMedGoogle Scholar
  44. 44.
    Benson ER, Schutzer SF. Posttraumatic piriformis syndrome: diagnosis and results of operative treatment. J Bone Joint Surg Am. 1999;81:941–9.CrossRefPubMedGoogle Scholar
  45. 45.
    Dezawa A, Kusano S, Miki H. Arthroscopic release of the piriformis muscle under local anesthesia for piriformis syndrome. Arthroscopy. 2003;19:554–7.CrossRefPubMedGoogle Scholar
  46. 46.
    Filler AG, Haynes J, Jordan SE, Prager J, Villablanca JP, Farahani K, McBride DQ, Tsuruda JS, Morisoli B, Batzdorf U, Johnson JP. Sciatica of nondisc origin and piriformis syndrome: diagnosis by magnetic resonance neurography and interventional magnetic resonance imaging with outcome study of resulting treatment. J Neurosurg Spine. 2005;2:99–115.CrossRefPubMedGoogle Scholar
  47. 47.
    Hughes SS, Goldstein MN, Hicks DG, Pellegrini VD Jr. Extrapelvic compression of the sciatic nerve. An unusual cause of pain about the hip: report of five cases. J Bone Joint Surg Am. 1992;74:1553–9.CrossRefPubMedGoogle Scholar
  48. 48.
    Mayrand N, Fortin J, Descarreaux M, Normand MC. Diagnosis and management of posttraumatic piriformis syndrome: a case study. J Manip Physiol Ther. 2006;29:486–91.CrossRefGoogle Scholar
  49. 49.
    Sayson SC, Ducey JP, Maybrey JB, Wesley RL, Vermilion D. Sciatic entrapment neuropathy associated with an anomalous piriformis muscle. Pain. 1994;59:149–52.CrossRefPubMedGoogle Scholar
  50. 50.
    Bano A, Karantanas A, Pasku D, Datseris G, Tzanakakis G, Katonis P. Persistent sciatica induced by quadratus femoris muscle tear and treated by surgical decompression: a case report. J Med Case Rep. 2010;4:236.CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Brown JA, Braun MA, Namey TC. Pyriformis syndrome in a 10-year-old boy as a complication of operation with the patient in the sitting position. Neurosurgery. 1988;23:117–9.CrossRefPubMedGoogle Scholar
  52. 52.
    Issack PS, Kreshak J, Klinger CE, Toro JB, Buly RL, Helfet DL. Sciatic nerve release following fracture or reconstructive surgery of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90(Suppl 2 Pt 2):227–37.CrossRefPubMedGoogle Scholar
  53. 53.
    Uchio Y, Nishikawa U, Ochi M, Shu N, Takata K. Bilateral piriformis syndrome after total hip arthroplasty. Arch Orthop Trauma Surg. 1998;117:177–9.CrossRefPubMedGoogle Scholar
  54. 54.
    Porta M. A comparative trial of botulinum toxin type A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. Pain. 2000;85:101–5.CrossRefPubMedGoogle Scholar
  55. 55.
    Papadopoulos EC, Khan SN. Piriformis syndrome and low back pain: a new classification and review of the literature. Orthop Clin North Am. 2004;35:65–71.CrossRefPubMedGoogle Scholar
  56. 56.
    Filler AG. Piriformis and related entrapment syndromes: diagnosis & management. Neurosurg Clin N Am. 2008;19:609–622, vii.CrossRefPubMedGoogle Scholar
  57. 57.
    Chakravarthy J, Ramisetty N, Pimpalnerkar A, Mohtadi N. Surgical repair of complete proximal hamstring tendon ruptures in water skiers and bull riders: a report of four cases and review of the literature. Br J Sports Med. 2005;39:569–72.CrossRefPubMedPubMedCentralGoogle Scholar
  58. 58.
    Orava S. Hamstring syndrome. Oper Tech Sports Med. 1997;5:143–9.CrossRefGoogle Scholar
  59. 59.
    Wood DG, Packham I, Trikha SP, Linklater J. Avulsion of the proximal hamstring origin. J Bone Joint Surg Am. 2008;90:2365–74.CrossRefPubMedGoogle Scholar
  60. 60.
    Martin H. Clinical examination and imaging of the hip. In: Byrd J, Guanche C, editors. AANA advanced arthroscopy: the hip. Philadelphia: Saunders; 2010.Google Scholar
  61. 61.
    Martin HD, Kelly BT, Leunig M, Philippon MJ, Clohisy JC, Martin RL, Sekiya JK, Pietrobon R, Mohtadi NG, Sampson TG, Safran MR. The pattern and technique in the clinical evaluation of the adult hip: the common physical examination tests of hip specialists. Arthroscopy. 2010;26:161–72.CrossRefPubMedGoogle Scholar
  62. 62.
    Martin HD, Kivlan BR, Palmer IJ, Martin RL, Hatem M. Diagnostic accuray of clinical tests for sciatic nerve entrapent in the gluteal region. Knee Surg Sports Traumatol Arthrosc. 2013;22(4):882–8.CrossRefPubMedGoogle Scholar
  63. 63.
    Migliorini S, Merlo M. The hamstring syndrome in endurance athletes. Br J Sports Med. 2011;45:363.CrossRefGoogle Scholar
  64. 64.
    Labat JJ, Riant T, Robert R, Amarenco G, Lefaucheur JP, Rigaud J. Diagnostic criteria for pudendal neuralgia by pudendal nerve entrapment (Nantes criteria). Neurourol Urodyn. 2008;27:306–10.CrossRefPubMedGoogle Scholar
  65. 65.
    Fishman LM, Wilkins AN. Piriformis syndrome: electrophysiology vs. anatomical assumption. In: Fishman LM, Wilkins AN, editors. Functional electromyography. New York: Springer; 2011.CrossRefGoogle Scholar
  66. 66.
    Jawish RM, Assoum HA, Khamis CF. Anatomical, clinical and electrical observations in piriformis syndrome. J Orthop Surg Res. 2010;5:3.CrossRefPubMedPubMedCentralGoogle Scholar
  67. 67.
    Katirji B. Electrodiagnostic approach to the patient with suspected mononeuropathy of the lower extremity. Neurol Clin. 2002;20:479–501, vii.CrossRefPubMedGoogle Scholar
  68. 68.
    Petchprapa CN, Rosenberg ZS, Sconfienza LM, Cavalcanti CF, Vieira RL, Zember JS. MR imaging of entrapment neuropathies of the lower extremity. Part 1. The pelvis and hip. Radiographics. 2010;30:983–1000.CrossRefPubMedGoogle Scholar
  69. 69.
    Chappell KE, Robson MD, Stonebridge-Foster A, Glover A, Allsop JM, Williams AD, Herlihy AH, Moss J, Gishen P, Bydder GM. Magic angle effects in MR neurography. AJNR Am J Neuroradiol. 2004;25:431–40.PubMedGoogle Scholar
  70. 70.
    Kim SJ, Hong SH, Jun WS, Choi JY, Myung JS, Jacobson JA, Lee JW, Choi JA, Kang HS. MR imaging mapping of skeletal muscle denervation in entrapment and compressive neuropathies. Radiographics. 2011;31:319–32.CrossRefPubMedGoogle Scholar
  71. 71.
    Barton PM. Piriformis syndrome: a rational approach to management. Pain. 1991;47:345–52.CrossRefPubMedGoogle Scholar
  72. 72.
    Benzon HT, Katz JA, Benzon HA, Iqbal MS. Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology. 2003;98:1442–8.CrossRefPubMedGoogle Scholar
  73. 73.
    Pace JB, Nagle D. Piriform syndrome. West J Med. 1976;124:435–9.PubMedPubMedCentralGoogle Scholar
  74. 74.
    Hanania M, Kitain E. Perisciatic injection of steroid for the treatment of sciatica due to piriformis syndrome. Reg Anesth Pain Med. 1998;23:223–8.CrossRefPubMedGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2019

Authors and Affiliations

  • Hal D. Martin
    • 1
  • Juan Gómez-Hoyos
    • 2
    • 3
    • 4
  1. 1.Medical and Research Director, Hip Preservation Center, Baylor University Medical CenterDallasUSA
  2. 2.International Consultant, Hip Preservation Center / Baylor Scott and White Research InstituteBaylor University Medical CenterDallasUSA
  3. 3.Department of Orthopaedic Surgery - Health ProviderClínica Las Américas / Clínica del CampestreMedellinColombia
  4. 4.Professor - School of Medicine - Sports Medicine ProgramUniversidad de AntioquiaMedellínColombia

Personalised recommendations