Gemelli-obturator complex in the deep gluteal space: an anatomic and dynamic study Ramon Balius, Antonio Susín, Carles Morros, Montse Pujol, Dolores Pérez- Cuenca & Xavier Sala-Blanch Skeletal Radiology Journal of the International Skeletal Society A Journal of Radiology, Pathology and Orthopedics ISSN 0364-2348 Skeletal Radiol DOI 10.1007/s00256-017-2831-2 1 23 Your article is protected by copyright and all rights are held exclusively by ISS. This e- offprint is for personal use only and shall not be self-archived in electronic repositories. If you wish to self-archive your article, please use the accepted manuscript version for posting on your own website. You may further deposit the accepted manuscript version in any repository, provided it is only made publicly available 12 months after official publication or later and provided acknowledgement is given to the original source of publication and a link is inserted to the published article on Springer's website. The link must be accompanied by the following text: "The final publication is available at link.springer.com”. 1 23 Author's personal copy Skeletal Radiology https://doi.org/10.1007/s00256-017-2831-2 SCIENTIFIC ARTICLE Gemelli-obturator complex in the deep gluteal space: an anatomic and dynamic study Ramon Balius1,2 & Antonio Susín3 & Carles Morros4 & Montse Pujol1,5 & Dolores Pérez-Cuenca4 & Xavier Sala-Blanch6,7 Received: 7 July 2017 /Revised: 5 October 2017 /Accepted: 16 November 2017 # ISS 2017 Abstract Objective To investigate the behavior of the sciatic nerve during hip rotation at subgluteal space. Materials and methods Sonographic examination (high-resolution ultrasound machine at 5.0–14 MHZ) of the gemelli-obturator internus complex following two approaches: (1) a study on cadavers and (2) a study on healthy volunteers. The cadavers were examined in pronation, pelvis-fixed position by forcing internal and external rotations of the hip with the knee in 90° flexion. Healthy volunteers were examined during passive internal and external hip rotation (prone position; lumbar and pelvic regions fixed). Subjects with a history of major trauma, surgery or pathologies affecting the examined regions were excluded. Results The analysis included eight hemipelvis from six fresh cadavers and 31 healthy volunteers. The anatomical study revealed the presence of connective tissue attaching the sciatic nerve to the structures of the gemellus-obturator system at deep subgluteal space. The amplitude of the nerve curvature during rotating position was significantly greater than during resting position. During passive internal rotation, the sciatic nerve of both cadavers and healthy volunteers transformed from a straight structure to a curved structure tethered at two points as the tendon of the obturator internus contracted downwards. Conversely, external hip rotation caused the nerve to relax. Conclusion Anatomically, the sciatic nerve is closely related to the gemelli-obturator internus complex. This relationship results in a reproducible dynamic behavior of the sciatic nerve during passive hip rotation, which may contribute to explain the pathological mechanisms of the obturator internal gemellus syndrome. Keywords Deep gluteal syndrome . Gemelli-obturator internus complex . Sciatic nerve . Obturator internal gemellus syndrome Introduction Electronic supplementary material The online version of this article The sciatic nerve arises from the lumbosacral plexus, from (https://doi.org/10.1007/s00256-017-2831-2) contains supplementary roots L4– S2. This nerve typically runs from its origin, at the material, which is available to authorized users. greater sciatic foramen, to the popliteal fossa, where it divides into two branches. Along this route, two areas with clearly * Ramon Balius [email protected] defined pathways can be distinguished: one in the deep gluteal space, and the other at the level of the thigh. In the gluteal 1 ’ Consell Català de l Esport, Generalitat de Catalunya, space, the sciatic nerve is protected from the sacrum by the Barcelona, Spain pyramidal muscle, and later from the ischium by the gemellus 2 Sports Medicine Department, Clínica Diagonal, Barcelona, Spain muscles (superior and inferior), the obturator internus, and, 3 Math Department, UPC-BarcelonaTech, Barcelona, Spain finally, the quadratus femoris muscle. This deep pathway to 4 Anesthesiology, Reanimation and Pain Therapy, Clínica Diagonal, the gluteus maximus is mainly characterized by the nerve’s Barcelona, Spain curved layout until reaching the second part of the route, at the 5 Facultad de Fisioteràpia, Universitat Internacional de Catalunya, Sant level of the thigh [1, 2]. Upon reaching the thigh, the sciatic Cugat del Vallés, Spain nerve takes on a rectilinear route, deep into the long section of 6 Anatomy and Embryology Unit, Faculty of Medicine, Universitat of the biceps femoris. Barcelona, Barcelona, Spain Due to anatomical variations, repeated microtraumas, or 7 Department of Anesthesiology, Hospital Clínic, Barcelona, Spain just the passing of years (aging), characteristic clinical cases Author's personal copy Skeletal Radiol occur due to nervous dysfunction, like, for example, second- Ultrasound scanning was performed with an Aplio 500 ary pseudo-sciatica, or dysfunction caused by entrapment of (TUS-500 5.0 Platinum Series, manufactured by Toshiba the sciatic nerve at the level of the piriformis muscle, known Medical Systems Corporation in Nasu, Japan) using a high- as pyramidal syndrome [3–5]. Recently, it has been observed frequency linear array probe (PLT 1005BT), 5.0–14 MHz fre- that the sciatic dysfunction in the pelvis was not only caused quency range. Most commonly used 2D frequency was dif- by different types of conflict with the pyramidal muscle, but ferential harmonic of 14 MHz (diffTHI 14 MHz). The depth there were also conflicts at other levels, giving rise to the used was 5 cm, with a single focus at 1.8 cm and a dynamic concept of deep gluteal syndrome [1, 2, 6]. One of these range of 65 dB. A sonographic examination of the long-axis causes is sometimes attributed to the gemelli-obturator sciatic nerve was performed. Internal and external rotations of internus complex [7–9]. the hip were performed with the knee at 90° flexion, while the On the other hand, there is an increasing interest in sciatic nerve was observed by ultrasound in order to evaluate neurodynamics as a therapeutic instrument and to preserve its behavior. The scans were performed by one of the authors health. Currently, there are neurodynamic assessments guid- (R.B.), with over 23 years of experience in musculo-skeletal ing rehabilitators to perform preventive treatments focused on sonography. Ultrasound images obtained were saved in image the major nerves [10]. Thus, different studies have assessed and video formats. how articular movements affect the normal biomechanics of After obtaining the images, the corresponding anatomical the sciatic nerve in the thigh [11–17]orthepelvis[18]. dissection was performed (Fig. 1). A dissection in planes of However, these studies were exclusively focused on flexion- the specimens was performed by two experienced anatomists extension movements of the coccyx-femoral joint. (CM and XSB). The skin and superficial fascia of the gluteal Given the anatomical layout of the sciatic nerve in the area were removed first, followed by sectioning of the gluteus gemelli-obturator internus complex, and based on maximus lateral third, about 3–4 cm of its femoral insertion. neurodynamics previous studies showing Bgliding^ of this By removing the superficial planes, the sciatic nerve was freed nerve during the flexion-extension of the hip, we attempted from its posterior and internal relations and attachments basi- to assess the sciatic nerve’s behavior at this level with hip cally through the inferior gluteal nerve and vessels, and from rotation maneuvers. The hypothesis was that the gemelli- the posterior skin nerve of the thigh. Superior relationships obturator internus complex is closely related to the sciatic (with the superior gluteal nerve and vessels) as well as nerve, thus providing a specific, reproducible and constant mean-caudal relationships (with the nerve and pudendal ves- behavior for these neuromuscular structures during internal sels) were kept intact. Internal and external rotation maneu- and external rotations of the hip. vers of the hip were subsequently performed, similarly to those carried out with ultrasound. Nerve movements were assessed in relation to its muscle/tendon support in the gemelli-obturator internus complex. Anatomical images Materials and methods Anatomical and US studies in cadavers The study included fresh cadavers of both adult men and women, with no surgical history of lumbar spine, pelvis or hip, and without history of inflammatory medical pathologies (osteoarthritis). The study on cadavers was approved by the Ethics and Research Committee of the School of Medicine at the University of Barcelona, and carried out in the Human Anatomy lab of the School of Medicine at the University of Barcelona. The cadavers were kept at a temperature of 4 °C for 36 h, until reaching the usual screening results for the safety of the cadaver handlers. The cadavers were placed in prone position, with a 10-cm cushion located in the pelvic area, causing a 10–15° flexion of the coccyx-femoral joint, with the pelvis fixed in a support. The cadavers were kept in Fig. 1 Anatomical dissection of the gluteal area. a Superficial gluteal the dissection lab, at