Inferior gluteal pain with sitting, unrelated to ischial bursitis

A 64-year-old woman presented to an academic medical centre with postoperative left ischial pain following a left total hip replacement. Her pain was exacerbated by sitting down and with forward flexion of the spine, and the pain radiated from the left ischial tuberosity to the left perineum, groin and medial thigh. An ischial bursa injection was performed, but only resulted in 1 day of excellent pain relief. A diagnosis of inferior cluneal neuralgia was then made. Subsequent inferior cluneal nerve radiofrequency ablation was performed, and provided sustained 50% relief in pain. The patient had a concomitant sensation of ‘ball like’ pressure at her rectum which was determined to be due to levator ani syndrome. She was prescribed pelvic floor physical therapy and botulinum toxin injection, which resulted in further notable improvement of her symptoms.

A case of postoperative tubercular spondylitis following microdiscectomy for lumbar disc herniation

Background: Postoperative infections are one of the most common complications of spine surgery. However, following a lumbar microdiscectomy, a postoperative infection involving Mycobacterium tuberculosis (MTB) is extremely rare. Case Description: One and half months after a L4-5 microdiscectomy, a 47-year-old immunocompromised male with hepatitis B infection presented with low back and bilateral gluteal pain. The MRI revealed a large intraspinal/paraspinal fluid collection spanning from L4 to S1 along with an anterior epidural collection at L5. The patient underwent a L4 lumbar laminectomy for abscess drainage and wound debridement. After obtaining a positive culture for MTB, four antitubercular drug therapies (ATTs) were started, that is, isoniazid (H), rifampicin (R), ethambutol (E), a. One month later, the patient had minimal pain and no residual neurological deficit. Conclusion: MTB infection, although rare, should be considered among the differential diagnoses of postoperative infections following lumbar spine surgery in immunocompromised patients living in areas where tuberculosis is endemic.

Clinical outcome of sacrospinous fixation following pelvic organ prolapse surgery

Aims: To evaluate the midterm outcome of sacrospinous fixation done during surgical management of pelvic organ prolapse. Methods: This was an interview based cross sectional follow up study done among the patients who underwent sacrospinous fixation procedure along with pelvic organ prolapse surgery in Kathmandu Model Hospital and Paropakar Maternity Hospital. This was conducted between 15 th February 2021 and 15 th April 2021. Post-operative cases 22 to 30 months (average 2 years) from the day of surgery were included. Results: Out of 321 eligible SSF patients from both the hospital, 156 agreed to participate. Among them, 77 (48%) were in 60-69 years of age and 82% were postmenopausal; 33% were more than para 3; 20% had right gluteal pain that was decreased to 1.9% by 2 years; and 20% had some degree of urgency and stress incontinence. Conclusion: Sacrospinous fixation is safe and effective procedure which can be done during pelvic organ prolapse surgery with good success rate and minimal post-operative complications.

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

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.

The piriformis abscess: a case-based review

This study reports a 43 years-old man diagnosed with piriformis pyomyositis. A literature review was conducted by searching MEDLINE via Pubmed for English language case reports, published from 8 th December 2019 to 20th January 2020. Patients' symptoms, laboratory tests, imaging, treatment, and other comorbidities were evaluated. Thirty-two cases diagnosed with piriformis pyomyositis, of which 21 patients developed piriformis abscess (including one new patient added by us) of which 52.4% were female, and the mean age was 26.98 ± 17.5. The most common manifestations were fever, lower back pain, and limited ambulation with increased ESR, CRP, or leukocytosis. Staphylococcus aureus was the most prevalent (57.14%) pathogen isolated. The authors suggested gynecologic manipulations, muscle overuse, and other co-infections as probable risk factors. However, we fail to find any association between these factors and abscess formation (p>0.05). Piriformis abscess should be regarded as a probable diagnosis in patients with gluteal pain, fever, and limited ambulation that have raised inflammatory markers or leukocytosis. MRI and CT scans are beneficial in diagnosing pyomyositis in early-stage. Full recovery is expected with timely antibiotic and surgical treatments.

Superior Cluneal Neuralgia from Iliocostal Impingement Treated with Phenol Neurolysis: A Case Report

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