Superior Gluteal Nerve Anatomy and Its Injuries: Aiming for a More Secure Surgical Approach of the Pelvic Region (original) (raw)
Related papers
Superior gluteal nerve: safe area in hip surgery
Surgical and Radiologic Anatomy, 2004
Injuries to the superior gluteal nerve are very bad complications in hip surgery. An exact knowledge of its course may be helpful in avoiding such problems. Nineteen half pelvises from ten male and female adult cadavers were dissected. Dissections revealed that the nerve divided into two (89.48%) or three (10.52%) branches after leaving the pelvis. The more caudal branch was responsible for innervation of tensor fascia latae. The distance and the angle from the entry points of all branches of the superior gluteal nerve into the deep surface of the gluteus medium and minimus muscles to the mid-point of the superior border of the greater trochanter were measured. The branch that innerved the tensor fascia latae was also followed. These data were subjected to several statistical tests. Based on these findings, and in order to prevent nerve damage, we propose to define a 2–3 cm safe area above the great trochanter.
Acta neurochirurgica, 2010
Background: Dissecting through the gluteus maximus muscle by splitting its fibers, instead of complete sectioning of the muscle, is faster, involves less damage to tissues, and diminishes recovery time. The objective of the current paper is to present a clinical series of sciatic nerve lesions where the nerve was sufficiently exposed via the transgluteal approach. Methods: We retrospectively selected 18 traumatic sciatic nerve lesions within the buttock, operated upon from January 2005 to December 2009, with a minimum follow-up of 2 years. In all patients, a transgluteal approach was employed to explore and reconstruct the nerve. Results: Ten males and eight females, with a mean age of 39.7 years, were studied. The etiology of the nerve lesion was previous hip surgery (n = 7), stab wound (n = 4), gunshot wound (n = 3), injection (n = 3), and hip dislocation (n = 1). In 15 (83.3%) cases, a motor deficit was present; in 12 (66.6%) cases neuropathic pain and in 12 (66.6%) cases sensory alterations were present. In all cases, the transgluteal approach was adequate to expose the injury and treat it by neurolysis alone (10 cases), neurolysis and neurorrhaphy (4 cases), and reconstruction with grafts (4 cases; three of these paired with neurolysis). The mean pre-and postoperative grades for the tibial nerve (LSUHSC scale) were 1.6 and 3.6, respectively; meanwhile, for the peroneal division, preoperative grade was 1.2 and postoperative grade was 2.4. Conclusions: The transgluteal approach adequately exposes sciatic nerve injuries of traumatic origin in the buttock and allows for adequate nerve reconstruction without sectioning the gluteus maximus muscle.
Surgical Neurology International, 2012
Background: Dissecting through the gluteus maximus muscle by splitting its fibers, instead of complete sectioning of the muscle, is faster, involves less damage to tissues, and diminishes recovery time. The objective of the current paper is to present a clinical series of sciatic nerve lesions where the nerve was sufficiently exposed via the transgluteal approach. Methods: We retrospectively selected 18 traumatic sciatic nerve lesions within the buttock, operated upon from January 2005 to December 2009, with a minimum follow-up of 2 years. In all patients, a transgluteal approach was employed to explore and reconstruct the nerve. Results: Ten males and eight females, with a mean age of 39.7 years, were studied. The etiology of the nerve lesion was previous hip surgery (n = 7), stab wound (n = 4), gunshot wound (n = 3), injection (n = 3), and hip dislocation (n = 1). In 15 (83.3%) cases, a motor deficit was present; in 12 (66.6%) cases neuropathic pain and in 12 (66.6%) cases sensory alterations were present. In all cases, the transgluteal approach was adequate to expose the injury and treat it by neurolysis alone (10 cases), neurolysis and neurorrhaphy (4 cases), and reconstruction with grafts (4 cases; three of these paired with neurolysis). The mean pre-and postoperative grades for the tibial nerve (LSUHSC scale) were 1.6 and 3.6, respectively; meanwhile, for the peroneal division, preoperative grade was 1.2 and postoperative grade was 2.4. Conclusions: The transgluteal approach adequately exposes sciatic nerve injuries of traumatic origin in the buttock and allows for adequate nerve reconstruction without sectioning the gluteus maximus muscle.
Surgical and Radiologic Anatomy, 2009
The position of the inferior gluteal nerve (IGN) makes it vulnerable to iatrogenic injury during posterior and posterolateral approaches to the hip. Although the posterior approach has been reported to be the most frequently used technique, it is most likely to be associated with damage to the IGN. As there is scant information in the literature regarding the course and the anatomic relationships of the IGN, we aimed to investigate the anatomic course of the IGN and define the anatomical landmarks that can be used by surgeons during posterior approaches to the hip. Thirty-six gluteal regions from adult fixed cadavers were used for this study. A triangular-shaped anatomic area that contains the IGN was defined. This geometric area was formed by connecting the following points: posterior inferior iliac spine (PIIS) (apex), ischial tuberosity (IT) and greater trochanter (GT). This triangle can further be divided into two, the upper triangle being the "danger zone" since it contains the IGN and its branches. The closest mean distance between the point of IGN origin and the PIIS, IT and the GT was 3.2, 4.8 and 5.4 cm, respectively. In all specimens, the nerve entered the deep surface of the gluteus maximus approximately 5.4 cm from the apex of the GT and approached the GT as close as 0.8 cm, on average. Based on our study, dividing the gluteus maximus with standard techniques may damage the IGN. Posterior minimally invasive approaches to the hip should take into account the point of entry of the IGN into the gluteus maximus. Localization of the IGN by using the anatomic triangle defined in this study may decrease surgical morbidity.
Superior gluteal nerve: a new block on the block?
Brazilian Journal of Anesthesiology (English Edition), 2016
Background and objectives: The superior gluteal nerve is responsible for innervating the gluteus medius, gluteus minimus and tensor fascia latae muscles, all of which can be injured during surgical procedures. We describe an ultrasound-guided approach to block the superior gluteal nerve which allowed us to provide efficient analgesia and anesthesia for two orthopedic procedures, in a patient who had significant risk factors for neuraxial techniques and deep peripheral nerve blocks. Clinical report: An 84-year-old female whose regular use of clopidogrel contraindicated neuraxial techniques or deep peripheral nerve blocks presented for urgent bipolar hemiarthroplasty in our hospital. Taking into consideration the surgical approach chosen by the orthopedic team, we set to use a combination of general anesthesia and superficial peripheral nerve blocks (femoral, lateral cutaneous of thigh and superior gluteal nerve) for the procedure. A month and a half post-discharge the patient was re-admitted for debriding and correction of suture dehiscence; we performed the same blocks and light sedation. She remained comfortable in both cases, and reported no pain in the post-operative period. Conclusions: Deep understanding of anatomy and innervation empowers anesthesiologists to solve potentially complex cases with safer, albeit creative, approaches. The relevance of this block in this case arises from its innervation of the gluteus medius muscle and posterolateral portion of the hip joint. To the best of our knowledge, this is the first report of an ultrasound-guided superior gluteal nerve block with an analgesic and anesthetic goal, which was successfully achieved.
Safe Distance for Superior Gluteal Nerve and its Relation with Thigh Length: A Cadaveric Study
The Internet Journal of Human Anatomy, 2011
Superior gluteal nerve emerges through the greater sciatic foramen above the piriformis muscle. The nerve curves upwards and forwards between the gluteus medius and minimus muscles, supplies both of them and ends by supplying the tensor fasciae latae muscle, from its deep surface. During hip surgeries, this nerve often gets injured resulting in complications. An exact knowledge of its course is helpful in avoiding such injuries. The aims of this study are to find the distance of the most inferior branch of superior gluteal nerve from the tip of the greater trochanter; to find the correlation of this distance with the length of thigh and also to find the safe zone where the chances of injury to superior gluteal nerve, during hip surgeries, would be minimal. 20 lower limbs of formalin fixed cadavers were subjected to dissection for their superior gluteal nerve. The distance of the most inferior branch of superior gluteal nerve from the tip of the greater trochanter was measured in the anterior third, middle third and posterior third of the gluteus medius muscle. The correlation between these distances and the thigh length was evaluated. The range of distance from tip of the greater trochanter to superior gluteal nerve was found to be 4.0-8.3 cm (mean 6.0 cm) in the anterior third, 5.0-7.6 cm (mean 5.9 cm) in the middle third and 5.0-7.8 cm (mean 6.2 cm) in the posterior third of gluteus medius muscle. From the tip of the greater trochanter a distance of 4.0 cm in the anterior third; and 5.0 cm in the middle third and posterior third of the gluteus medius muscle, can be considered safe for the superior gluteal nerve, in hip surgeries. The results of the present study also showed that the there was no statistically significant correlation between distance of most inferior branch of superior gluteal nerve from the tip of the greater trochanter and thigh length.
The distance of the gluteal nerve in relation to anatomical landmarks: an anatomic study
Archives of Orthopaedic and Trauma Surgery, 2017
Introduction Gluteal insufficiency is of concern with lateral approaches to total hip arthroplasty. Damage to the branches of the superior gluteal nerve may cause degeneration of the innervated muscles. The direct anterior approach exploits the intermuscular and internerval interval between tensor fasciae latae laterally and sartorius and rectus femoris muscle medially. In this study, the distance of the superior gluteal nerve in relation to anatomical landmarks was determined. Materials and methods Two experienced surgeons implanted trial components in 15 alcohol glycerol fixed cadavers with 30 hips. The trials were removed, and the main branch of the superior gluteal nerve and muscular branches of the nerve were exposed from lateral. Results No visual damage to the main nerve branches and the location of the nerve in relation to the greater trochanter were noted by an experienced surgeon. The superior gluteal nerve and its muscular branches crossed the muscular interval between the gluteus medius and tensor fasciae latae muscles at a mean distance of 39 mm from the tip of the greater trochanter. Conclusions The direct anterior approach for total hip arthroplasty minimizes the risk of injuring the superior gluteal nerve, which may result in a gluteal insufficiency. Special care should be paid on avoiding overstretching the tensor fasciae latea muscle using minimum force on retractors during surgery and by taking care of the entrance point of the superior gluteal nerve to the tensor fasciae latae.
International Urogynecology Journal, 2008
Our objective was to document variations in the topography of pelvic floor nerves (PFN) and describe a nerve-free zone adjacent to the sacrospinous ligament (SSL). Pelvic floor dissections were performed on 15 female cadavers. The course of the PFN was described in relation to the ischial spine (IS) and the SSL. The pudendal nerve (PN) passed medial to the IS and posterior to the SSL at a mean distance of 0.6 cm (SD=±0.4) in 80% of cadavers. In 40% of cadavers, an inferior rectal nerve (IRN) variant pierced the SSL at a distance of 1.9 cm (SD=±0.7) medial to the IS. The levator ani nerve (LAN), coursed over the superior surface of the SSL-coccygeus muscle complex at a mean distance of 2.5 cm (SD=±0.7) medial to the IS. Anatomic variations were found which challenge the classic description of PFN. A nerve-free zone is situated in the medial third of the SSL.
Pelvic Pain of Pudendal Nerve Origin: Surgical Outcomes and Learning Curve Lessons
Journal of Reconstructive Microsurgery, 2015
Reconstructive microsurgery may directly involve the pudendal nerve during vaginal reconstruction, 1-4 groin hydradenitis suppurativa reconstruction, 5,6 rectal reconstruction, 7-9 transgender reconstruction, 10-12 inferior gluteal artery perforator flaps for breast reconstruction, 13-16 labial reconstruction, 17-19 salvage procedures after gynecologic mesh interventions for urinary incontinence, 20-22 and following urologic procedures such as prostatectomy. Injury to the branches of the pudendal nerve results in pain syndromes that have proven difficult to treat, with success rates for the most commonly done surgical approach having an expectation that 70% of patients will improve by > 2 on a 10-point Likert scale, and just 20% achieving an excellent result (►Table 1). Recognizing that peripheral nerve surgery is the basis for treatment of refractory pelvic pain related to the pudendal nerve, it is incumbent for the reconstructive microsurgeon to approach the problem from the standpoint of (1) determining that the pudendal nerve is the nerve primarily transmitting Keywords ► pudendal nerve ► neurolysis ► neuroma