Nerve decompression

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A nerve decompression is a neurosurgical procedure to relieve chronic, direct pressure on a nerve to treat nerve entrapment, a pain syndrome characterized by severe chronic pain and muscle weakness. In this way a nerve decompression targets the underlying pathophysiology of the syndrome and is considered a first-line surgical treatment option for peripheral nerve pain. [1] Despite treating the underlying cause of the disease, the symptoms may not be fully reversible as delays in diagnosis can allow permanent damage to occur to the nerve and surrounding microvasculature. Traditionally only nerves accessible with open surgery have been good candidates, however innovations in laparoscopy and nerve-sparing techniques made nearly all nerves in the body good candidates, as surgical access is no longer a barrier.

Contents

Surgical planning

Surgical planning is distinct from diagnosis of entrapment. Diagnosis will focus on a binary decision: does the patient have entrapment or not? A diagnosis may not be enough information for surgery on its own as the area to explore may be too large. Surgical planning seeks to localize the specific area of entrapment to improve surgical outcomes. Identifying the level of entrapment is an important consideration for surgery as decompressing the wrong area will lead to a failed surgery (e.g. performing back surgery for extra-spinal sciatica), [2] [3] failure to treat nerve entrapment early can lead to permanent nerve injury, [4] and the patient may be unnecessarily exposed to surgical complications.

Diagnostic blocks

Illustration of a CT image-guided injection of the pudendal nerve at the pudendal canal CT image guided injection pudendal nerve.png
Illustration of a CT image-guided injection of the pudendal nerve at the pudendal canal

Diagnostic nerve blocks can confirm the clinical diagnosis for chronic pain as well as identify the entrapment site. [5] A diagnostic block is like an inverted palpation in the sense that palpation will cause a sensory nerve to send a signal (action potential) and a block will prevent a sensory nerve from sending a signal. By blocking nerve signals, the pain-contributing nerves can be identified or ruled out. Nerves are predisposed to entrapment in certain anatomical regions such as in an osteofibrous tunnels, through a muscle, adjacent to fibrous tissue. [6] Consequently, knowledge of these anatomical regions as well as peripheral nerve anatomy is an essential component to planning successful diagnostic blocks. [5] Ultrasound is a common form of image-guidance to place the needle properly, but it faces limitations visualizing small and deep nerves. [7] CT- or MRI- guidance are better positioned to access deep nerves as well as identify the anatomic level of the needle. [7]

Imaging

MRI may be used to identify certain causes of entrapment such as a structural lesions pressing on a nearby nerve, but is prone to false negatives/positives and has poor correlation with the clinical examination. [8] A major limitation with MRI is that nerve tissue is resistant to imaging. An advancement of MRI that takes advantage of the tissue properties of nerves, called MR neurography (MRN), provides more detail. MR tractography (MRT) can also be of use in surgical planning as it can identify peripheral nerve abnormalities with a high correlation to intraoperative findings and has higher accuracy than MR neurography alone. [9] MRT uses diffusion tensor imaging to visualize the directional movement of water molecules along nerve tracts. Often an abnormality can be identified along tracts of nerve where water is not diffusing normally along the axis. MRT has been used to identify sacral nerve entrapment by the piriformis muscle, which would otherwise only be diagnosable with exploratory surgery. [10]

List of surgeries

A non-exhaustive list of nerve decompression surgeries includes

Surgical outcomes

Nerve decompressions are still a relatively new surgery, however a picture emerges from looking at the outcomes of some of the most studied nerve decompressions: carpal tunnel release, sciatic nerve decompression, and migraine surgery. Even within these commonly performed surgeries, the measurement of outcomes is not always standardized. Common ways of measuring outcomes are syndrome-specific disability questionnaires (e.g. Boston Carpal Tunnel Questionnaire, [20] Oswestry low back disability questionnaire, [21] and the migraine disability assessment [22] ); visual analog scale (VAS); [23] physical examination findings; [24] and subjective patient satisfaction. [25]

Carpal tunnel release

Carpal tunnel surgery has a clinical success rate of 75-90%. [26] Success is most frequently measured with the Boston Carpal Tunnel Questionnaire, physical examination (sensory function, motor function, pain, electrodiagnostic, trophic function), and patient self-assessments. One study found that while 86% of patients improved, only 26% had complete recovery of clinical and electrodiagnostic findings. Of the functional assessments, pain showed the greatest improvements following surgery. [27] Another study compared carpal tunnel syndrome patients who elected surgery with those who chose not to. 77% of the surgery group said they were cured compared to 16% who did not elect surgery. [28] While some of the success of surgery may just be due to the natural history of the disease, the surgery groups still have an improvement in outcomes over conservative measures. A systematic review found that surgical treatment outweighed the benefits over conservative treatment overall all outcome measures, however conservative treatment caused fewer complications. [29]

Sciatic nerve decompression

A systematic review has found that 90% of surgery patients see improved pain scores with scores improving on average from 6.7 preoperatively to 2.1 postoperatively. [15] In the literature, the most common outcome measurement for sciatic nerve decompressions is the visual analog scale, where patients rate their pain on a 100mm horizontal line that gets converted into a numeric score from 0-10 or 0–100. The main disability questionnaires used are the modified Harris Hip score (mHHS) and the Oswestry low back disability questionnaire. One study found that all deep gluteal syndrome surgery patients who were taking narcotics for pre-operative pain (n = 21) no longer needed narcotics for the initial complaint after decompression surgery. [30]

Migraine surgery

A systematic review has found that the improvement is seen in 68-100% of surgery patients and complete migraine elimination is seen in 8-86% of surgery patients. [13] The outcomes are usually measured in migraine intensity, frequency, and duration (an early measurement, the migraine headache index, was just the product of these numerical values). The most common migraine disability questionnaires are the migraine disability assessment (MIDAS), headache impact test (HIT), and migraine specific quality of life questionnaire (MSQ). [31]

One randomized study compared the efficacy of migraine surgery to pharmacologic treatment and found that surgical treatment had a significantly higher success rate than medical treatment. Notably, 36% of patients in the surgical treatment group experienced complete elimination of migraine headaches, compared to and 4% in the medical treatment group. [32] Another randomized study compared surgery to sham surgery. 57% of the surgery group experienced complete elimination of migraine headaches, compared on only 4% of the sham surgery group. [33] A separate study examining outcomes found that there was a bimodal distribution (two main outcomes), where approximately >80% of patients saw either at least an 80% reduction in symptoms or less than 5% reduction. Of the patients seeing significant improvement, the mean improvement was 96%. Of the patients seeing minimal improvement, the average improvement was 0%. [34]

Paying special attention to complete elimination of migraines or measuring outcomes after long follow ups (e.g. years) may be important for assessing the efficacy of migraine surgery because headache research has found a strong placebo effect. [35] A large meta-analysis found that the placebo effect in acute migraine treatments was greatly reduced when the treatment outcome was "pain-free" (9% of patients) compared to "improved" (30% of patients). [36] Studies that have compared migraine surgery to a control group have found similarly low placebo cure rates, both at 4%. [32] [33]

Complications

Complications can be perioperative or postoperative. Among the generic set of surgical complications such as bleeding, infection, scarring, complications from general anesthesia, etc. nerve decompressions come with a risk of nerve injury. A nerve can be directly injured due to transection (cutting), traction (pulling), crush injuries (squeezing), destroying a blood vessel that supplied the nerve, etc. While nerve sparing techniques have been developed to mitigate nerve injury, [37] [38] the radical nature of decompression surgeries cannot eliminate the risk.

In a large national study of carpal tunnel decompression postoperative complications, the serious complications seen were wound dehiscence, wound infection, tendon injury, and neurovascular injury. Serious postoperative complications, defined as requiring re-admittance to a hospital within 90 days, was relatively rare, at 0.1% over approximately 850,000 surgeries. [39]

Endoscopic sciatic nerve decompression has similarly low rates of complication. Two studies with a combined 95 patients found no complications. [40] [30] A systematic review also found a 0% major complication rate and a 1% minor complication rate for the endoscopic approach. [15]

A systematic review on migraine surgeries found a major complication rate of 1% and a liberal estimate on the minor complication rate of approximately 32%. The most common complications were numbness/paresthesia and itching. [13] Another systematic review found the adverse event rate to be 11.6%. [41] One of the challenges in cataloging the complication rate of migraine surgery is that it's a relatively new surgery and so the surgical treatment can be extremely heterogeneous across different surgeons (e.g. remove artery, remove muscle, decompress nerve, remove nerve all across one or more trigger sites). [41]

Other procedures

An alternative to a decompression is a nerve resection. [1] When the nerve does not have any motor fibres and loss of sensation is acceptable, removing the nerve in its entirety may be a more "complete" solution as it will address a much wider dermatome (all distal nerve fibres from the point of excision). Nerve decompressions, in contrast, cannot explore the entire course of a nerve and all its branches and so may potentially miss the true entrapment point. For this reason, a nerve resection may be considered after a failed decompression. Examples of nerves that may be good candidates for resection are lateral femoral cutaneous nerve, [42] zygomaticotemporal branch of the trigeminal nerve, [43] the posterior femoral cutaneous nerve, [44] [45] and the middle/superior cluneal nerves. [46]

It's not clear whether a nerve resection is superior to a nerve decompression when both treatments may be suitable. A study on occipital neuralgia in 2017 found that there was not enough data to make a determination. [47] A study on Meralgia Paraesthetica found higher success rates for nerve resection and that most patients were not bothered by numbness following the procedure. [48]

History

The treatment of each peripheral nerve entrapment has its own history, making any single narrative incomplete. [49]

The symptoms of nerve injury in the early 1900s were called nerve palsy (today neuropathy or neuritis are more common terms). [50] The concept of injuries causing nerve palsy was understood at that time. [49] For example, wrist fractures were known to be a cause of nerve palsy through compression, and this could be treated by liberating the nerve. [49] [51] It was freeing the nerve after post-traumatic injuries that early nerve decompressions occurred. However, non-traumatic causes of nerve palsy were less clear, in some cases having no known explanation (idiopathic). The development of carpal tunnel syndrome to explain idiopathic tardy median nerve palsy formalized the concept of nerve compression at anatomic areas of narrowing, and influenced the development of other tunnel syndromes. [52] [53] This expanded the indications for nerve decompression both to idiopathic neuropathies as well as many parts of the body that exhibited anatomic areas of narrowing in the vicinity of a nerve.

Nerve decompressions have benefited from advances in technology and peripheral nerve surgery. For example, use of the operating microscope (surgery that uses this microscope is now known as microsurgery) was important to the development of the Jannetta procedure for trigeminal neuralgia. [54] Endoscopic surgery was an important advancement, as this allowed greatly expanded surgical access compared to open surgery. In particular, endoscopic surgery gave much better access to the pudendal nerve as well as the sciatic nerve, and allowed the possibility of decompressing the sacral plexus. [18] [16] [30] The use of image-guided diagnostic nerve blocks provided better capabilities to identify the entrapped nerve as well as the site of entrapment, leading to more accurate diagnosis and reducing the need for surgical exploration. [7] [55] The use of magnetic resonance neurography (MRN) and diffusion tensor imaging (DTI) have allowed better visualization of nerves, at times identifying the site of entrapment without the need for extensive surgical exploration. [9] [56] Robot-assisted surgery is still in the early stages, not yet achieving widespread use for nerve decompressions or even for peripheral nerve surgery, however it can provide dexterity, precision, and stability not possible by hand. [57]

1878: first ulnar nerve decompression. [50] However, it did not gain much traction at the time.

1933: first published carpal tunnel surgery for post-traumatic compression [58]

1946: first carpal tunnel surgery for idiopathic compression [59] [49]

1958: cubital tunnel surgery described [60] [50]

1962: tarsal tunnel surgery described [52]

1967: Janetta procedure for trigeminal neuralgia [61]

1989: endoscopic carpal tunnel surgery [62]

1992: Magnetic resonance neurography described. [63] First clinical study on nerve decompressions to relieve symptoms of diabetic peripheral neruopathy. [64] [65]

1994: Diffusion tensor imaging described [66]

1997 endoscopic pudendal nerve decompression [67]

2000: correlation found between brow lifts and migraine reduction. This is the precursor to modern migraine surgery. [68]

2003: arthroscopic piriformis muscle release [69]

2005: Magnetic resonance neurography and image-guided injections used in a clinical research study to improve nerve decompression outcomes [14]

2010: endoscopic sciatic nerve decompression [30]

2015: laparoscopic sacral plexus decompression; [18] robotic pudendal nerve decompression [70]

Society and culture

Controversy

Surgical nerve decompression has caused controversy across various medical specialties. The controversy is generally over the interpretation of available evidence and quality of evidence necessary to consider nerve decompression as a valid treatment option for specific diseases/syndromes.

Critics

Critics generally believe the results of specific nerve decompression surgeries are attributable to either the placebo effect (patient expectations influencing outcomes) or natural history (patients getting better on their own). [71] [72] [73] Critics sometimes reject the validity of nerve decompression surgery because the thesis of nerve compression conflicts with preexisting theories about how certain diseases work. [71] [73] In diabetic peripheral neuropathy (treatable in some cases with multiple nerve decompressions [73] ) and migraines (migraine surgery is a nerve decompression [74] ), critics dispute the interpretation of the results because the majority of studies are of retrospective case series (reports of surgeries performed in the past) rather than prospective randomized controlled trials (RCTs), and so any positive results of surgery could be influenced by methodological flaws such as lack of proper control groups. [75] [76] [77] Critics may believe that given the lack of RCTs on nerve decompression surgery, and the known risk of surgical complications (however small), nerve decompression should not be recommended. [71]

Proponents

Proponents have alleged that the success of treating previously untreatable patients validates decompression as a treatment. [72] [14] [78] That RCTs in surgical research have ethical issues, as a proper control group would receive a placebo surgery and be exposed to surgical complications. [78] [65] That prospective RCTs should not be the only way to reason about whether a therapy is effective given the challenges in using RCTs to study surgery (a suggested alternative is to compare surgery to the best existing treatments). [78] [65] That potential bias in existing studies doesn't account for the large, reproducible effects of nerve decompression, so the results should not be discounted just because the studies aren't RCTs. [78] That the improvement from surgery is clearly much larger than the studied magnitude of the placebo effect, and so cannot be explained by it. [72] [78] That suggesting surgery is placebo is a double standard when these same treatment-resistant patients do not benefit from the placebo effect of failed non-surgical treatments and even prior failed surgical treatments. [72] [78] Proponents have noted that nerve compressions are seen in many other nerves, and that we should expect to see some number of patients with entrapments of any given peripheral nerve. [78] Proponents have asserted that some critics have gone beyond healthy skepticism, exaggerated proponents' claims, argued against positions the proponents did not make, levied non-constructive criticism, and misinterpreted the placebo effect in ways not supported by peer-reviewed research. [72] [78]

See also

Related Research Articles

<span class="mw-page-title-main">Carpal tunnel syndrome</span> Compression of the median nerve in the wrist

Carpal tunnel syndrome (CTS) is a nerve compression syndrome associated with the collected signs and symptoms of compression of the median nerve at the carpal tunnel in the wrist. Carpal tunnel syndrome is an idiopathic syndrome but there are environmental, and medical risk factors associated with the condition. CTS can affect both wrists.

Pudendal nerve entrapment (PNE), also known as Alcock canal syndrome, is an uncommon source of chronic pain in which the pudendal nerve is entrapped or compressed in Alcock's canal. There are several different types of PNE based on the site of entrapment anatomically. Pain is positional and is worsened by sitting. Other symptoms include genital numbness, fecal incontinence and urinary incontinence.

Diabetic neuropathy includes various types of nerve damage associated with diabetes mellitus. The most common form, diabetic peripheral neuropathy, affects 30% of all diabetic patients. Symptoms depend on the site of nerve damage and can include motor changes such as weakness; sensory symptoms such as numbness, tingling, or pain; or autonomic changes such as urinary symptoms. These changes are thought to result from a microvascular injury involving small blood vessels that supply nerves. Relatively common conditions which may be associated with diabetic neuropathy include distal symmetric polyneuropathy; third, fourth, or sixth cranial nerve palsy; mononeuropathy; mononeuropathy multiplex; diabetic amyotrophy; and autonomic neuropathy.

<span class="mw-page-title-main">Peripheral neuropathy</span> Nervous system disease affecting nerves beyond the brain and spinal cord

Peripheral neuropathy, often shortened to neuropathy, refers to damage or disease affecting the nerves. Damage to nerves may impair sensation, movement, gland function, and/or organ function depending on which nerve fibers are affected. Neuropathies affecting motor, sensory, or autonomic nerve fibers result in different symptoms. More than one type of fiber may be affected simultaneously. Peripheral neuropathy may be acute or chronic, and may be reversible or permanent.

Neuropathic pain is pain caused by a lesion or disease of the somatosensory nervous system. Neuropathic pain may be associated with abnormal sensations called dysesthesia or pain from normally non-painful stimuli (allodynia). It may have continuous and/or episodic (paroxysmal) components. The latter resemble stabbings or electric shocks. Common qualities include burning or coldness, "pins and needles" sensations, numbness and itching.

<span class="mw-page-title-main">Occipital neuralgia</span> Medical condition

Occipital neuralgia (ON) is a painful condition affecting the posterior head in the distributions of the greater occipital nerve (GON), lesser occipital nerve (LON), third occipital nerve (TON), or a combination of the three. It is paroxysmal, lasting from seconds to minutes, and often consists of lancinating pain that directly results from the pathology of one of these nerves. It is paramount that physicians understand the differential diagnosis for this condition and specific diagnostic criteria. There are multiple treatment modalities, several of which have well-established efficacy in treating this condition.

Microvascular decompression (MVD), also known as the Jannetta procedure, is a neurosurgical procedure used to treat trigeminal neuralgia, a pain syndrome characterized by severe episodes of intense facial pain, and hemifacial spasm. The procedure is also used experimentally to treat tinnitus and vertigo caused by vascular compression on the vestibulocochlear nerve. As the goal of the Jannetta procedure is to relieve (vascular) pressure on the trigeminal nerve, it is a specific type of a nerve decompression surgery.

<span class="mw-page-title-main">Tarsal tunnel syndrome</span> Compression of the tibial nerve in the foot

Tarsal tunnel syndrome (TTS) is a nerve compression syndrome or nerve entrapment syndrome causing a painful foot condition in which the tibial nerve is entrapped as it travels through the tarsal tunnel. The tarsal tunnel is found along the inner leg behind the medial malleolus. The posterior tibial artery, tibial nerve, and tendons of the tibialis posterior, flexor digitorum longus, and flexor hallucis longus muscles travel in a bundle through the tarsal tunnel. Inside the tunnel, the nerve splits into three segments. One nerve (calcaneal) continues to the heel, the other two continue on to the bottom of the foot. The tarsal tunnel is delineated by bone on the inside and the flexor retinaculum on the outside.

Meralgia paresthetica or meralgia paraesthetica is pain or abnormal sensations in the outer thigh not caused by injury to the thigh, but by injury to a nerve which provides sensation to the lateral thigh.

A neurectomy, or nerve resection is a neurosurgical procedure in which a peripheral nerve is cut or removed to alleviate neuropathic pain or permanently disable some function of a nerve. The nerve is not intended to grow back. For chronic pain it may be an alternative to a failed nerve decompression when the target nerve has no motor function and numbness is acceptable. Neurectomies have also been used to permanently block autonomic function, and special sensory function not related to pain.

<span class="mw-page-title-main">Superior cluneal nerves</span> Sensory nerves

The superior cluneal nerves are pure sensory nerves that innervate the skin of the upper part of the buttocks. They are the terminal ends of the L1-L3 spinal nerve dorsal rami lateral branches. They are one of three different types of cluneal nerves. They travel inferiorly through multiple layers of muscles, then traverse osteofibrous tunnels between the thoracolumbar fascia and iliac crest.

<span class="mw-page-title-main">Ulnar neuropathy at the elbow</span> Medical condition

Idiopathic ulnar neuropathy at the elbow is a condition where pressure on the ulnar nerve as it passes through the cubital tunnel causes ulnar neuropathy. The symptoms of neuropathy are paresthesia (tingling) and numbness primarily affecting the little finger and ring finger of the hand. Ulnar neuropathy can progress to weakness and atrophy of the muscles in the hand. Symptoms can be alleviated by the use of a splint to prevent the elbow from flexing while sleeping.

Migraine surgery is a surgical operation undertaken with the goal of reducing or preventing migraines. Migraine surgery most often refers to surgical nerve decompression of one or several nerves in the head and neck which have been shown to trigger migraine symptoms in many migraine sufferers. Following the development of nerve decompression techniques for the relief of migraine pain in the year 2000, these procedures have been extensively studied and shown to be effective in appropriate candidates. The nerves that are most often addressed in migraine surgery are found outside of the skull, in the face and neck, and include the supra-orbital and supra-trochlear nerves in the forehead, the zygomaticotemporal nerve and auriculotemporal nerves in the temple region, and the greater occipital, lesser occipital, and third occipital nerves in the back of the neck. Nerve impingement in the nasal cavity has additionally been shown to be a trigger of migraine symptoms.

<span class="mw-page-title-main">Magnetic resonance neurography</span>

Magnetic resonance neurography (MRN) is the direct imaging of nerves in the body by optimizing selectivity for unique MRI water properties of nerves. It is a modification of magnetic resonance imaging. This technique yields a detailed image of a nerve from the resonance signal that arises from in the nerve itself rather than from surrounding tissues or from fat in the nerve lining. Because of the intraneural source of the image signal, the image provides a medically useful set of information about the internal state of the nerve such as the presence of irritation, nerve swelling (edema), compression, pinch or injury. Standard magnetic resonance images can show the outline of some nerves in portions of their courses but do not show the intrinsic signal from nerve water. Magnetic resonance neurography is used to evaluate major nerve compressions such as those affecting the sciatic nerve (e.g. piriformis syndrome), the brachial plexus nerves (e.g. thoracic outlet syndrome), the pudendal nerve, or virtually any named nerve in the body. A related technique for imaging neural tracts in the brain and spinal cord is called magnetic resonance tractography or diffusion tensor imaging.

Anterior interosseous syndrome is a medical condition in which damage to the anterior interosseous nerve (AIN), a distal motor and sensory branch of the median nerve, classically with severe weakness of the pincer movement of the thumb and index finger, and can cause transient pain in the wrist.

<span class="mw-page-title-main">Pronator teres syndrome</span> Medical condition

Pronator teres syndrome is a compression neuropathy of the median nerve at the elbow. It is rare compared to compression at the wrist or isolated injury of the anterior interosseous branch of the median nerve.

<span class="mw-page-title-main">Nerve compression syndrome</span> Symptoms resulting from chronic, direct pressure on a peripheral nerve

Nerve compression syndrome, or compression neuropathy, or nerve entrapment syndrome, is a medical condition caused by chronic, direct pressure on a peripheral nerve. It is known colloquially as a trapped nerve, though this may also refer to nerve root compression. Its symptoms include pain, tingling, numbness and muscle weakness. The symptoms affect just one particular part of the body, depending on which nerve is affected. The diagnosis is largely clinical and can be confirmed with diagnostic nerve blocks. Occasionally imaging and electrophysiology studies aid in the diagnosis. Timely diagnosis is important as untreated chronic nerve compression may cause permanent damage. A surgical nerve decompression can relieve pressure on the nerve but cannot always reverse the physiological changes that occurred before treatment. Nerve injury by a single episode of physical trauma is in one sense an acute compression neuropathy but is not usually included under this heading, as chronic compression takes a unique pathophysiological course.

<span class="mw-page-title-main">Carpal tunnel surgery</span> Surgery to relieve carpal tunnel syndrome

Carpal tunnel surgery, also called carpal tunnel release (CTR) and carpal tunnel decompression surgery, is a nerve decompression in which the transverse carpal ligament is divided. It is a surgical treatment for carpal tunnel syndrome (CTS) and recommended when there is constant (not just intermittent) numbness, muscle weakness, or atrophy, and when night-splinting no longer controls intermittent symptoms of pain in the carpal tunnel. In general, milder cases can be controlled for months to years, but severe cases are unrelenting symptomatically and are likely to result in surgical treatment. Approximately 500,000 surgical procedures are performed each year, and the economic impact of this condition is estimated to exceed $2 billion annually.

Peripheral mononeuropathy is a nerve related disease where a single nerve, that is used to transport messages from the brain to the peripheral body, is diseased or damaged. Peripheral neuropathy is a general term that indicates any disorder of the peripheral nervous system. The name of the disorder itself can be broken down in order to understand this better; peripheral: in regard to peripheral neuropathy, refers to outside of the brain and spinal cord; neuro: means nerve related; -pathy; means disease. Peripheral mononeuropathy is a disorder that links to Peripheral Neuropathy, as it only effects a single peripheral nerve rather than several damaged or diseased nerves throughout the body. Healthy peripheral nerves are able to “carry messages from the brain and spinal cord to muscles, organs, and other body tissues”.

<span class="mw-page-title-main">Deep gluteal syndrome</span> Medical condition

Deep gluteal syndrome describes the non-discogenic extrapelvic entrapment of the sciatic nerve in the deep gluteal space. In simpler terms this is sciatica due to nerve irritation in the buttocks rather than the spine or pelvis. It is an extension of non-discogenic sciatic nerve entrapment beyond the traditional model of piriformis syndrome. Where sciatic nerve irritation in the buttocks was once thought of as only piriformis muscle, it is now recognized that there are many other causes. Symptoms are pain or dysthesias in the buttocks, hip, and posterior thigh with or without radiating leg pain. Patients often report pain when sitting. The two most common causes are piriformis syndrome and fibrovascular bands, but many other causes exist. Diagnosis is usually done through physical examination, magnetic resonance imaging, magnetic resonance neurography, and diagnostic nerve blocks. Surgical treatment is an endoscopic sciatic nerve decompression where tissue around the sciatic nerve is removed to relieve pressure.

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