Superior gluteal vein syndrome: an intrapelvic cause of sciatica

Abstract

The role of malformed or dilated branches of iliac vessels in causing pelvic pain is not well understood. Such vessels may entrap nerves of the lumbosacral (LS) plexus against the pelvic sidewalls, producing symptoms not typically encountered in gynecological practice, including sciatica and refractory urinary and/or anorectal dysfunction. We describe cases of sciatica in which laparoscopy revealed compression of the LS plexus by variant superior gluteal veins (SGVs). In demonstrating an improvement in patient symptoms after decompression, we identify this neurovascular conflict as a potential intrapelvic cause of sciatica. This study is a retrospective case series (Canadian Task Force Classification II-3). Nerve decompression laparoscopies were performed in São Paulo, Brazil. Thirteen female patients undergoing laparoscopy for sciatica with no clear spinal or musculoskeletal causes were included in this study. In all cases, we identified LS entrapment by aberrant SGVs, and performed decompression by vessel ligation. The average preoperative visual analog scale score of 9.62 ± 0.77 decreased significantly to 2.54 ± 2.88 post-operatively (P < 0.001). The success rate (defined as ≥ 50% improvement in visual analog scale score) was 92.3%, over a follow-up of 13.2 ± 10.6 months. Our case series demonstrates a high success rate and significant decrease in pain scores after laparoscopic intrapelvic decompression, thereby identifying pelvic nerve entrapment by aberrant SGVs as a potential yet previously unrecognized cause of sciatica. This intrapelvic neurovascular conflict—the SGV syndrome—should be considered in cases of sciatica with no identifiable spinal or musculoskeletal etiology.

Intrapelvic causes of sciatica: A systematic review

“…Our literature search yielded 22 studies with 120 cases related to intrapelvic causes of sciatica (Table 1). In 1962, 1 case [22] was published followed by 1 in 1976, [21] 2 in 1987, [19,20] 1 in 1994, [18] 1 in 1995, [17] 2 in 1996, [15,16] 5 in 1998, [14] 5 in 1999, [11][12][13] 1 in 2001, [10] 25 in 2002, [9] 1 in 2003, [8] 1 in 2012, [7] 11 in 2015, [6] 3 in 2016, [4,5] 46 in 2017, [3] 14 to date in 2019, [1,2] The surgical procedures included 27 laparoscopic decompression of aberrant intrapelvic veins, 53 intrapelvic sciatic nerve (sacral nerve root) endometriosis excisions, one myomectomy, three hysterectomies, two schwannoma resections, one ovarian cystic endometriosis surgery, six endometriotic nodule excisions, 15 pelvic peritoneal pockets excisions, five peritoneal endometriosis excisions. The medical therapy included three gonadotropinreleasing hormone agonist (GnRH-A), leuprolide acetate plus daily transdermal E2 treatment, one depot medroxyprogesterone treatment, one buserelin acetate, one estrogen suppression treatment, and one gentamicin and clindamycin treatment (Table 1).…”

“…The laparoscopic approach gave the possibility of reduced morbidity and improved results by providing more comprehensive insight into the operating field with a smaller intraoperative injury. Lemos et al [1] described their initial experience in 13 women who presented with sciatica in the absence of any apparent spinal or musculoskeletal lesions. Pelvic MRI neurography visualized superior gluteal veins (SGV).…”

“…Patients with catamenial sciatica showed full recovery with resolution of symptoms. Lemos et al emphasized that in the presence of sciatic or perineal pain radiating to the lower limbs in the absence of a spinal disorder and lower urinary tract symptoms; the [1] Kale et al 2019 [2] Possover et al 2017 [3] Tsai et al 2016 [4] Lemos et al 2016 [5] Possover et al 2015 [6] Lemos et al 2012 [7] Tong et al 2003 [8] Vilos et al 2002 [9] Murata et al 2001 [10] Fedele et al 1999 [11] Bodack et al 1999 [13] Siera et al 1999 [12] A 26-year-old patient presented with complaints of persistent sciatica and pudendal neuralgia.…”

“…Lemos et al 2019 [1] Kale et al 2019 [2] Possover et al 2017 [3] Tsai et al 2016 [4] Lemos et al 2016 [5] Possover et al 2015 [6] Tong et al 2003 [8] Vilos et al 2002 [9] Murata et al 2001 [10] Fedele et al 1999 [11] Lemos et al 2012 [7] All cases had a variant superior gluteal vein that was ligated intraoperatively.…”

Should we hunt a metric?

“…The paper by Lemos et al on the superior glutaeal vein syndrome was a real find. Intrapelvic neurovascular conflict should definitely be considered in cases of sciatica but with no identifiable musculoskeletal aetiology [26]. I am a glutton for anatomy, too, so much enjoyed the paper from Plante et al [27] on the anatomical variants of rectus femoris motor innervation.…”