DOI: 10.14744/scie.2020.59354 Review South. Clin. Ist. Euras. 2021;32(1):86-94 Intrapelvic Causes of Sciatica: A Systematic Review 1 1 1 1 Ahmet Kale, Betül Kuru, Gülfem Başol, Elif Cansu Gündoğdu, 1 1 2 3 Emre Mat, Gazi Yıldız, Navdar Doğuş Uzun, Taner A Usta 1Department of Gynecology and Obstetrics, University of Health Sciences, Kartal Dr. Lütfi Kırdar Training and Research Hospital, İstanbul, Turkey 2Department of Gynecology and Obstetrics, Midyat State Hospital, Mardin, Turkey 3Department of Gynecology and Obstetrics, Acıbadem University, Altunizade Hospital, İstanbul, Turkey ABSTRACT Submitted: 09.09.2020 The sciatic nerve is the nerve of the lower limb. It is derived from spinal nerves, fourth Accepted: 27.11.2020 Lumbar (L4) to third Sacral (S3). The sciatic nerve innervates the muscles of the posterior Correspondence: Ahmet Kale, thigh and additionally has sensory functions. Sciatica is the given name to the pain sourced by SBÜ Kartal Dr. Lütfi Kırdar Eğitim irritation of the sciatic nerve. Sciatica is most commonly induced by compression of a lower ve Araştırma Hastanesi, Kadın lumbar nerve root (L4, L5, or S1). Various intrapelvic pathologies include gynecological, Hastalıkları ve Doğum Kliniği, İstanbul, Turkey vascular, traumatic, inflammatory, and tumoral disorders that may cause sciatica. Intrapelvic E-mail: [email protected] pathologies that mimic disc herniation are quite always ignored. Surgical approach and a functional exploration by laparoscopy or robotic surgery have significantly increased the intrapelvic pathology’s awareness, resulting in sciatica. After a detailed assessment of the patient, which causes intrapelvic pathologies, deciding whether surgical or medical therapy is needed, notable results in sciatic pain remission can be done. Keywords: Endometriosis; intrapelvic cause; pain; schwannoma; sciatica. This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. INTRODUCTION Many intraspinal or extraspinal pathological disturbanc- es along the sciatic nerve can be the reason for sciatica. The sciatic nerve is the nerve of the lower limb. It is the Extraspinal sciatica is often misdiagnosed because rou- longest nerve in the body and approximately 2 cm wide. tine diagnostic tests focus on the lumbar spine. Various It is derived from spinal nerves L4 to S3. The sciatic nerve intrapelvic pathologies include gynecological, vascular, innervates the posterior thigh muscles and besides has traumatic, inflammatory and tumoral disorders may lead sensory functions of the skin of the lateral leg, heel and to sciatica. Another source of intrapelvic sciatica report- whole foot. ed in the literature is endometriosis. Endometriosis is a Sciatica is the name given to pain caused by the sciatic common gynecological condition, described as the occur- nerve’s irritation. Sciatica is manifested by searing pain rence of endometriotic tissue (endometrial glands, stro- down the leg from the lower back along the sciatic nerve ma, or both) outside the uterus. However, endometriosis path. Sciatica ordinarily affects only one side of the body reports involving the sciatic nerve are mostly from di- and can be a result of an underlying injury. Most frequently, rect extension of deeply infiltrative rectovaginal disease sciatica is due to compression of a lower lumbar nerve through the lateral pelvic sidewall. Schwannoma is the root (L4, L5, or S1) that radiates to the knee and is often most prevalent benign nerve sheath tumor that causes accompanied by weakness or numbness of the respective sciatica and may be seen as presacral or retroperitoneal myotome or dermatome. tumors in the pelvis. Kale. Sciatica 87 Sciatica with or without neurologic deficit has a high prev- roscopic decompression. The most common is L5-S1 sci- alence in the general population. The classic diagnostic atica. Eleven consecutive patients suffered from non-neu- workup focuses on pathologies of the spinal cord. When rogenic L5/S1-sciatica; only 36% from an S2 complained of the absence of spinal pathologies is present, treatment is sciatica with some pain in pudendal areas (mostly perianal/ often very limited. Intrapelvic pathologies that mimic disc perineal pain). herniation are quite always skipped. Surgical approach and After neuropelveological workup, pelvic neuro-Magnetic a functional exploration by laparoscopy or robotic sur- Resonance Imaging (MRI) and Doppler-sonography pelvic gery have significantly increased the intrapelvic pathology’s nerves were suspected to be implicated in pain. Laparo- awareness, resulting in sciatic pain. scopic exploration revealed compression of the distal por- In the present review, we reviewed the current litera- tion of the lumbosacral trunk between the linea terminalis ture regarding the intrapelvic causes of sciatica in various and enlarged varicose veins or the sciatic nerve just before pathological conditions and discussed its management. its entry through the great sciatic notch. Enlarged vari- cose veins had typical superior and inferior varicose veins located in the lumbosacral space. Laparoscopic treatment MATERIALS AND METHODS consisted of the separation of the vessels from the nerves A systematic literature search was performed in the and coagulation or transection of them. They found that Pubmed database using medical terms, keywords and their laparoscopic decompression of aberrant pelvic vessels was combinations, including “sciatica”, “intrapelvic cause”, a treatment of choice in patients with intrapelvic sciatica. “laparoscopy” and “gynecologic surgery” dating from its The laparoscopic approach gave the possibility of reduced inception to Sep 2019. The bibliographies of all publica- morbidity and improved results by providing more com- tions were searched for relevant references. Extracted prehensive insight into the operating field with a smaller [1] data were both clinical outcomes and operative tech- intraoperative injury. Lemos et al. described their initial niques. The following information, including publication experience in 13 women who presented with sciatica in date, sample size, patient characteristics, surgical proce- the absence of any apparent spinal or musculoskeletal le- dures and clinical outcomes, were recorded. Many rele- sions. Pelvic MRI neurography visualized superior gluteal vant data were extracted concerning intrapelvic causes veins (SGV). Laparoscopy discovered compression of the of sciatica. A total of 22 articles were found to include lumbosacral nerve roots by aberrant SGV. The average intrapelvic causes of sciatica. time from onset of symptoms to diagnosis was 3.88±3.09 years. All cases that had a variant SGV were ligated lapa- roscopically. The mean operative time was 144.54±55.10 RESULTS min. The average preoperative VAS score (9.62±0.77) de- creased significantly (2.54±2.88) postoperatively. The lapa- Our literature search yielded 22 studies with 120 cases roscopic approach alleviated symptoms with a statistically related to intrapelvic causes of sciatica (Table 1).[1-22] In significant decrease in VAS pain scores and has a 92.3% 1962, 1 case[22] was published followed by 1 in 1976,[21] 2 success rate. It strongly supports the hypothesis that supe- in 1987,[19,20] 1 in 1994,[18] 1 in 1995,[17] 2 in 1996,[15,16] 5 rior gluteal vein variant entrapment against the LS plexus in 1998,[14] 5 in 1999,[11–13] 1 in 2001,[10] 25 in 2002,[9] 1 in resulted in the intrapelvic cause of sciatica’s clinical presen- 2003,[8] 1 in 2012,[7] 11 in 2015,[6] 3 in 2016,[4,5] 46 in 2017,[3] tation. Kale et al.[2] demonstrated their clinical experience 14 to date in 2019,[1,2] The surgical procedures included 27 in a 26-year-old patient who had failed medical therapy laparoscopic decompression of aberrant intrapelvic veins, and presented with persistent sciatica complaints on the 53 intrapelvic sciatic nerve (sacral nerve root) endometrio- right side of her lower limbs for approximately 36 months. sis excisions, one myomectomy, three hysterectomies, two The laparoscopic approach gave the possibility of decom- schwannoma resections, one ovarian cystic endometriosis pression of the vessels’ malformed branches entrapping surgery, six endometriotic nodule excisions, 15 pelvic peri- the sacral plexus nerves at three sites: the lumbosacral toneal pockets excisions, five peritoneal endometriosis ex- trunk, sciatic nerve, and pudendal nerve. The laparoscop- cisions. The medical therapy included three gonadotropin- ic approach was completed successfully with a resolution releasing hormone agonist (GnRH-A), leuprolide acetate of dyspareunia and sciatica at a 6-months follow-up. They plus daily transdermal E2 treatment, one depot medrox- found that laparoscopic management of vascular entrap- yprogesterone treatment, one buserelin acetate, one es- ment of the sacral plexus was a feasible and effective tech- trogen suppression treatment, and one gentamicin and nique in patients with intrapelvic sciatica. Lemos et al.[19] clindamycin treatment (Table 1). In the present review, we reported two cases with catamenial sciatica and urinary analyzed the current literature related to the intrapelvic symptoms who underwent laparoscopic decompression causes of sciatica in various pathological conditions and dis- of intrapelvic aberrant dilated veins on the sciatic nerve cussed its therapy and management. and sacral nerve roots. Patients with catamenial sciatica showed full recovery with resolution of symptoms. Lemos Aberrant intrapelvic veins and sciatica et al. emphasized