Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis

Background: Superior cluneal neuralgia (SCN) is an increasingly recognized yet still frequently overlooked cause of chronic lumbosacral and buttock pain. While historically attributed generally to iatrogenic iliac crest injury (bone marrow biopsy or bone graft harvest), more recently it is recognized as occurring in the absence of any trauma, with idiopathic entrapment resulting in compression neuropathy. Iliocostal impingement syndrome (IIS) is an even less commonly considered condition whereby the lower costal margin repetitively contacts and irritates the iliac crest, primarily occurring unilaterally and owing to severe scoliosis, but also in the context of severe vertebral column height loss. Case Report: We report here a case of an elderly woman with a 3-inch reported height loss over the decades who had suffered with chronic and intractable right lumbosacral and gluteal pain, and whom, on the basis of physical examination, we diagnosed presumptively with both SCN and with IIS as the underlying pathophysiologic mechanism. After undergoing successful diagnostic fluoroscopically guided superior cluneal nerve block, she was offered phenol denervation and enjoyed 9 months of reported 90% improvement in her symptoms, with gradual return to baseline over the next couple months. She has subsequently undergone repeat phenol denervation twice, with similarly good results. We believe this to be the first documented application of phenol neurolytic technique to SCN, and in the case of iliocostal impingement we argue that surgical release/resection or even peripheral nerve stimulation may not be effective owing to underlying compression/irritation diathesis from the inevitable pressure of the costal margin upon the iliac crest. Conclusion: In this case report, we also briefly summarize the current literature on SCN and compare phenol neurolysis to other therapeutic modalities. Key words: Superior cluneal nerves, neuralgia, iliocostal impingement, phenol, denervation

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Laparoscopic complete sacrocolpopexy mesh removal for right-sided gluteal pain and recurrent mesh erosion

International Urogynecology Journal ◽

10.1007/s00192-019-04088-4 ◽

2019 ◽

Vol 31 (2) ◽

pp. 411-413

Author(s):

Aditi Siddharth ◽

Rufus Cartwright ◽

Simon Jackson ◽

Natalia Price

Keyword(s):

Mesh Erosion ◽

Mesh Removal ◽

Gluteal Pain

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Laparoscopic Sacrocolpopexy Mesh Removal for Persistent Lumbosacral and Right-sided Gluteal Pain Possibly Caused by Nerve “entrapment”

10.21203/rs.3.rs-543673/v1 ◽

2021 ◽

Author(s):

Li Yan ◽

Lu Bin Liu ◽

Cheng Zhi Zhao

Keyword(s):

Scar Tissue ◽

Synthetic Mesh ◽

Nerve Entrapment ◽

Sexual Life ◽

Laparoscopic Sacrocolpopexy ◽

Tissue Formation ◽

Cure Rate ◽

Mesh Removal ◽

Mesh Placement ◽

Gluteal Pain

Abstract Background: Laparoscopic sacrocolpopexy (LSC), which is an important procedure for vault prolapse, has the advantages of high cure rate, low recurrence rate and little impact on sexual life. Few nerve entrapment complications have been reported in the literature.Case presentation: A 48-year-old woman developed persistent lumbosacral and right-sided gluteal pain after the LSC. During diagnostic laparoscopy, we found that the fixation site deviated by approximately 1.5 cm from the middle of the sacral promontory, the anterior surface of the first sacral vertebra. Hence we removed most of the mesh carefully. S1 nerve “entrapment” caused by this deviation, accompanied by the tissue fibrosis and scar tissue formation, may have been the main cause of pain. The patient’s symptoms resolved after surgical intervention. Conclusions: Our case emphasizes that sacral nerve entrapment is a potential complication of retroperitonealized synthetic mesh placement during sacrocolpopexy. We hope that this report can serve as a reference for dealing with similar situations. For skilled laparoscopists, laparoscopic mesh removal is safe and feasible, but attention should be paid to avoid damage to vessels, ureters and other important organs.

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Radiographic Prevalence Of Sacroiliac Joint Abnormalities And Clinical Outcomes In Patients With Femoroacetabular Impingement Syndrome

Orthopaedic Journal of Sports Medicine ◽

10.1177/2325967119s00424 ◽

2019 ◽

Vol 7 (7_suppl5) ◽

pp. 2325967119S0042

Author(s):

Vignesh Prasad Krishnamoorthy ◽

Kyle Kunze ◽

Jourdan M. Cancienne ◽

Edward Beck ◽

Lauren Elizabeth O’Keefe ◽

...

Keyword(s):

Femoroacetabular Impingement ◽

Sacroiliac Joint ◽

Imaging Modality ◽

Impingement Syndrome ◽

Joint Surface ◽

Harris Hip Score ◽

Femoroacetabular Impingement Syndrome ◽

History Of ◽

Gluteal Pain ◽

Si Joint

Objectives: Patients with femoroacetabular impingement syndrome (FAIS) typically present with a gradual onset of groin pain. They may also presentwith gluteal pain, which can be related to posterior acetabular impingement or posterior joint degeneration secondary to FAIS or more commonly aberrant gait mechanics secondary to abnormal hip morphology. Gluteal pain is also a common presenting symptom in patients with sacroiliac joint (SIJ) problems. The date, the literature on the correlation between SIJ pathology and FAIS has been limited. As such, the purpose of the current study id to quantify the prevalenceof SIJ abnormalities FAIS patients using imaging modalities and to compare outcomes based on SIJ abnormalities. Methods: Radiographs, CT and MRI scans of 1,009 consecutive patients who underwent primary hip arthroscopy for FAIS from January 2012 to January 2016 were identified. Exclusion criteria included patients undergoing bilateral or revision surgery, history of dysplasia, and less than two-year follow-up. On radiographs, SIJ joints were graded using modified New York criteria for spondyloarthropathy. CT scans and MRIs were reviewed for joint surface erosions, subchondral sclerosis, joint-space narrowing, pseudo-widening, bone marrow edema, and ankylosis. Patients with SIJ abnormalities were matched 1:2 to patients without SIJ abnormalities by age and BMI. Outcomes included the hip outcome score- activities of daily living (HOS-ADL), sports-subscale (HOS-SS), modified Harris hip score (mHHS), and visual analog scales (VAS) for pain and satisfaction. Results: 743 patients were included; 187 (25.2%) demonstrated SIJ changes. 164 (87.7%) had radiographic changes, 88 (63.3%) on CT, and 125 (66.8%) on MRI. SI changes on any imaging modality were correlated with pain to palpation (PTP) of the SI joint (r=0.11; p=0.004) on physical exam. History of SI pain was correlated with PTP of the SI joint (r=0.21; p<0.001). After matching, patients without SIJ abnormalities had significantly greater HOS-ADL (95.4 vs. 90.6;p=0.001), HOS-SS (91.1 vs. 77.5;p<0.001), and mHHS (91.3 vs. 84.5;p<0.001) scores and significantly less VAS pain (10.9 vs. 25.7;p<0.001) than those with abnormalities. Patients without SIJ abnormalities had greater odds of achieving the MCID for the HOS-ADL (Odds ratio [OR]=2.91, 95%confidence interval [95% CI]=1.5-5.5;p=0.001) and for the HOS-SS (OR=2.83, 95% CI = 1.6-4.9;p<0.001), but not for the mHHS (OR=1.73, 95% CI = 0.93-3.2; p=0.081). Conclusion: There is a high prevalence of SIJ abnormalities in patients with FAIS. Patients with abnormalities may expect inferior outcomes and persistent post-operative pain. [Table: see text]

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