ORIGINAL ARTICLE

Impact Factor : 0.1870 ISSN No :2231-5063

Monthly Multidisciplinary Research Journal

GoldenResearch Thoughts

Chief EditorDr.Tukaram Narayan Shinde

PublisherMrs.Laxmi Ashok Yakkaldevi

Associate EditorDr.Rajani Dalvi

HonoraryMr.Ashok Yakkaldevi

Vol II Issue IX March 2013

Mohammad HailatDept. of Mathmatical Sciences, University of South Carolina Aiken, Aiken SC 29801

Abdullah SabbaghEngineering Studies, Sydney

Catalina NeculaiUniversity of Coventry, UK

Ecaterina PatrascuSpiru Haret University, Bucharest

Loredana BoscaSpiru Haret University, Romania

Fabricio Moraes de AlmeidaFederal University of Rondonia, Brazil

George - Calin SERITANPostdoctoral Researcher

Hasan BaktirEnglish Language and Literature Department, Kayseri

Ghayoor Abbas ChotanaDepartment of Chemistry, Lahore University of Management Sciences [ PK ]Anna Maria ConstantinoviciAL. I. Cuza University, Romania

Horia PatrascuSpiru Haret University, Bucharest, Romania

Ilie Pintea,Spiru Haret University, Romania

Xiaohua YangPhD, USANawab Ali KhanCollege of Business Administration

Flávio de São Pedro FilhoFederal University of Rondonia, Brazil

Kamani PereraRegional Centre For Strategic Studies, Sri Lanka

Janaki SinnasamyLibrarian, University of Malaya [ Malaysia ]

Romona MihailaSpiru Haret University, Romania

Delia SerbescuSpiru Haret University, Bucharest, Romania

Anurag MisraDBS College, Kanpur

Titus Pop

Pratap Vyamktrao NaikwadeASP College Devrukh,Ratnagiri,MS India

R. R. PatilHead Geology Department Solapur University, Solapur

Rama BhosalePrin. and Jt. Director Higher Education, Panvel

Salve R. N.Department of Sociology, Shivaji University, Kolhapur

Govind P. ShindeBharati Vidyapeeth School of Distance Education Center, Navi Mumbai

Chakane Sanjay DnyaneshwarArts, Science & Commerce College, Indapur, Pune

Awadhesh Kumar ShirotriyaSecretary, Play India Play (Trust),Meerut

Iresh SwamiEx - VC. Solapur University, Solapur

N.S. DhaygudeEx. Prin. Dayanand College, Solapur

Narendra KaduJt. Director Higher Education, Pune

K. M. BhandarkarPraful Patel College of Education, Gondia

Sonal SinghVikram University, Ujjain

G. P. PatankarS. D. M. Degree College, Honavar, Karnataka

Maj. S. Bakhtiar ChoudharyDirector,Hyderabad AP India.

S.Parvathi DeviPh.D.-University of Allahabad

Sonal Singh

Rajendra ShendgeDirector, B.C.U.D. Solapur University, Solapur

R. R. YalikarDirector Managment Institute, Solapur

Umesh RajderkarHead Humanities & Social Science YCMOU, Nashik

S. R. PandyaHead Education Dept. Mumbai University, Mumbai

Alka Darshan ShrivastavaShaskiya Snatkottar Mahavidyalaya, Dhar

Rahul Shriram SudkeDevi Ahilya Vishwavidyalaya, Indore

S.KANNANPh.D , Annamalai University,TN

Satish Kumar Kalhotra

Editorial Board

International Advisory Board

IMPACT FACTOR : 0.2105

Welcome to ISRJISSN No.2230-7850

Indian Streams Research Journal is a multidisciplinary research journal, published monthly in English, Hindi & Marathi Language. All research papers submitted to the journal will be double - blind peer reviewed referred by members of the editorial Board readers will include investigator in universities, research institutes government and industry with research interest in the general subjects.

RNI MAHMUL/2011/38595

Address:-Ashok Yakkaldevi 258/34, Raviwar Peth, Solapur - 413 005 Maharashtra, IndiaCell : 9595 359 435, Ph No: 02172372010 Email: ayisrj@yahoo.in Website: www.isrj.net

Title : VARIABLE RELATION OF SCIATIC NERVE TO PIRIFORMIS MUSCLE – A CASE REPORT. Source:Golden Research Thoughts [2231-5063] ANUJ JAIN yr:2013 vol:2 iss:9

KEY-WORDS:

Sciatic nerve, common peroneal nerve, tibial nerve, piriformis muscle .

INTRODUCTION

The sciatic nerve is derived from the lumbo-sacral plexus. It is the thickest nerve in the whole body and it exits the gluteal region through the lower part of the greater sciatic foramen. It is the main innervator of the posterior thigh, the leg and foot. It normally ends at the superior angle of popliteal fossa by dividing into the tibial and common peroneal nerves, and these terminal branches supply the leg and foot. Its injury, if it involves the whole nerve, may lead to loss of sensation, in posterior thigh, whole leg, and foot, with loss of function of all muscles in posterior thigh, whole leg and the foot. And this results into failure to dorsiflex the foot a condition referred to as foot drop. The level of bifurcation of the sciatic nerve above the transverse popliteal crease is useful during sciatic nerve block (Chukwuanukwu et al, 2007). High level of sciatic nerve division is a relatively rare phenomena and it may be the cause of an incomplete block of the sciatic nerve (Prakash et al, 2010). Hence the need for healthcare workers to have adequate appreciation of the applied anatomy of the nerve. Preoperative nerve imaging and extra operative diligence in the gluteal region and the back of the thigh are recommended (Ogeng'o et al, 2011).

CASE REPORT

During the routine dissection classes for the first year medical students, we found a rare variation in the division of sciatic nerve, in the left gluteal region of an approximately 60 years old male cadaver of Indian origin. The dissection of this region was carried out according to the instructions by Cunningham's manual of practical anatomy (Romanes, 2004). In the present case, the common peroneal component of the sciatic nerve emerged dorsally above the superior border and tibial component emerged from the inferior

Abstract:

The sciatic nerve normally leaves the pelvis by passing through the greater sciatic foramen below piriformis. However, it may divide into its common peroneal and tibial nerve components within the pelvis and its relationship with piriformis than becomes variable. In this paper, we describe a new anatomical variation in which the common peroneal nerve passed superior, and the tibial nerve inferior, to the piriformis muscle. Anatomical variations such as this, may contribute to piriformis syndrome, non-discogenic sciatica, coccygodynia, muscle atrophy, failure of sciatic nerve block and it may be of considerable help to the orthopaedic surgeons.

VARIABLE RELATION OF SCIATIC NERVE TO PIRIFORMIS MUSCLE – A CASE REPORT.

ANUJ JAIN

Assistant Professor, Department of Anatomy, U.P. Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India.

Available online at www.aygrt.isrj.net

ORIGINAL ARTICLE

Volume 2, Issue. 9, March. 2013Golden Research Thoughts

ISSN:-2231-5063

GRT

border of fleshy part of piriformis muscle (Fig. 1). Both the components joined together near the inferior border of piriformis muscle and traverse downwards between the ischial tuberosity and greater trochanter of femur, to divide again 2 cm inferior to the level of ischial tuberosity (Fig. 2). The inferior gluteal artery and nerve were lying medial to the sciatic nerve. The course and branching pattern of sciatic nerve on the right side was normal.

DISCUSSION

Normally the sciatic nerve emerges below the inferior border of piriformis muscle. Divisions of Sciatic nerve passing above and below the Piriformis muscle have been described in 3.3 % of cases (Beaton and Anson, 1937) . As seen in present case, division of sciatic nerve into two parts within the pelvis such that a part of it also emerging from the superior border of the muscle and lying superficial to it may lead to piriformis syndrome and its incomplete block. The probable basis for this pelvic division is the separate existence of the nerves during embryonic development (Mandiola et al, 1986). In such cases the nerve is commonly injured during the administration of intragluteal injections. Piriformis syndrome, a term first coined by (Robinson et al, 1993) affects 5-6% of patients referred for the treatment of back and leg pain(Byrd et al, 1995; Welch et al, 1986). It has been attributed to entrapment of sciatic nerve as it exits the greater sciatic notch in the gluteal region (Parziala et al, 1996a ; Porla M. 2000). Under normal circumstances when it exits between piriformis and gemellus superior, the entrapment may be due to a myospasm or contracture of either of these two muscles (Barton PM, 1991a). The myospasm or contracture of piriformis muscle itself can lead to pain along back of thigh to the knee, loss of sensations or numbness and tingling in the sole of foot (Rich and McKeag, 1992a). The compression of the nerve in such cases further increases on internal rotation of the thigh (Pecina M, 1979a). This particular syndrome can often mimic its more notorious counterpart called as sciatica which is due to discogenic involvement and is often misdiagnosed as the same (Sridhara and Izzo, 1985) and the main difference between the sciatica and the piriformis syndrome is in the cause. Sciatica is directly due to a lumbar disc pressing on sciatic nerve as it exits in the intervertebral foramen in the lumbar region. What both of these components have in common is that both can produce pain, numbness and tingling below the knee and into the foot (Pecina M, 1979b; Rich and McKeag, 1992b). Accordingly, the management of the patient changes. In sciatica, the treatment is targeted at the spine while in piriformis syndrome the piriformis muscle may be thinned, divided or excised. Obturator internus, gemelli and quadratus femoris muscle can compensate for the loss of piriformis function because these muscles share common insertions with the piriformis muscle (Barton PM, 1991b; Parziala et al, 1996b). Sciatic nerve division into tibial and common peroneal components at a higher level can result in the involvement of only one out of the two divisions from sciatic neuropathy. A high division may also account for frequent failures reported with the popliteal block. As in this block the tip of the needle is positioned next to the main trunk of the sciatic nerve before its separation into the tibial nerve and common peroneal nerve, injection of local anesthetic in the vicinity of only one of these components may result in an incomplete block (Vloka et al, 2001). The knowledge regarding the level of division of the sciatic nerve and the location where it leaves the pelvis is of great importance. The abnormal passage of the common peroneal component of sciatic nerve above piriformis may facilitate its compression.

REFERENCES

Barton PM. 1991a, b. Piriformis syndrome: A rational approach to management. Pain, 47:345–52.Beaton IE, Anson JB.1937. The relation of the sciatic nerve and its subdivisions to the piriformis muscle. Anat Rec, 70: 1–5.Byrd JC, Edenfi eld WJ, Shields DJ, Dawson NA. 1995. Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. J Clin Oncol,13:1800-16.Chukwuanukwu TOG, Ukoha UU, Chukwujekwu IE, Asomugha AL, Oanusi A, Anyabolu AE, Ashaolu JO. 2007. Bilateral thigh division of sciatic nerve: incidence and clinical implication in Nigeria. Trop J Med Res, 11: 12–13.J.A. Ogeng'o, H. El-Busaidy, P.M. Mwika, M.M. Khanbhai, J. Munguti. 2011. Variant anatomy of sciatic nerve in a black Kenyan population. Folia Morphol.Vol. 70, No. 3: 175–179.Mandiola El, Hernandez PH, Hofer UP, Crovetto E, Ortega E .1986. Variaciones anatomicas del origin del nervio isquiatico (en fetos humanos termino) An Anat Norm, 4: 40–43.Parziala JR, Hudgins TH, Fishman LM. 1996a, b. The piriformis syndrome. Am J Orthop, 25:819–23.Pecina M.1979a, b. Contribution to the etiological explanation of the piriformis syndrome. Acta Anat (Basel), 105:181–7.

2Golden Research Thoughts • Volume 2 Issue 9 • March 2013

VARIABLE RELATION OF SCIATIC NERVE TO PIRIFORMIS MUSCLE – A ......

Porla M. 2000. A comparative trial of botulinum toxin type A and methylprednisolone for the treatment of myofascial pain syndrome and pain from chronic muscle spasm. Pain, 85:101–5.Prakash BAK, Devi MN, Sridevi NS, Rao PK, Singh G. 2010. Sciatic nerve division: a cadaver study in the Indian population and review of literature. Singapore Med J, 51: 721–723.Rich B, McKeag D. 1992a, b. When sciatica is not a disc disease: detecting piriformis syndrome in active patients. Phys. Sports Med, 20:104–15.Robinson, Traweek ST, Arber DA, Rappaport H, Brynes RK. 1993. Extramedullary myeloid cell tumours: an immunohistochemical and morphologic study of 28 cases. Am J Surg Pathol, 17:1011-19.Romanes GJ. 2004. Cunningham's manual of practical anatomy. 15th Ed. New York: Oxford University Press, 232-233.Sridhara CR, Izzo KL. 1985. Terminal sensory branches of the superficial peroneal nerve: an entrapment syndrome. Arch. Phys. Med. Rehabil, 66:789–91.Vloka J D, Hadzic A, April E, Thys DM. 2001. The division of sciatic nerve in the popliteal fossa; Anatomical implications for popliteal nerve blockade. Ana Analg, 92:215-7.Welch P, Grossi C, Carroll A.1986. Granulocytic sarcoma with an indolent course and destructive skeletal disease: tumour characterization with immunologic markers, electron microscopy, cytochemistry and cytogenetic studies. Cancer, 57:1005-10.

LEGENDS

Figure 1. Dissection of left gluteal region showing the variable relation of sciatic nerve to piriformis muscle. SNCPC – sciatic nerve common peroneal component; SNTC – sciatic nerve tibial component; P – piriformis muscle; NOI – nerve to obturator internus; SN – sciatic nerve; IGA – inferior gluteal artery; IGN – inferior gluteal nerve; PCNT – posterior cutaneous nerve of thigh; PN- peroneal nerve; IPA- internal pudendal artery; QF- quadratus femoris muscle.

Figure 2. Dissection of left gluteal region showing the higher division of sciatic nerve. PT – piriformis tendon; SNCPC – Sciatic nerve common peroneal component; PMFP- piriformis muscle fleshy part; SNTC – sciatic nerve tibial component; SN – sciatic nerve; HDSN- higher division of sciatic nerve.

3Golden Research Thoughts • Volume 2 Issue 9 • March 2013

Figure-1.

VARIABLE RELATION OF SCIATIC NERVE TO PIRIFORMIS MUSCLE – A ......

4Golden Research Thoughts • Volume 2 Issue 9 • March 2013

Figure-2.

ANUJ JAINAssistant Professor, Department of Anatomy, U.P. Rural Institute of Medical Sciences and Research, Saifai, Etawah, Uttar Pradesh, India.

VARIABLE RELATION OF SCIATIC NERVE TO PIRIFORMIS MUSCLE – A ......

ORIGINAL ARTICLE

Publish Research ArticleInternational Level Multidisciplinary Research Journal

For All Subjects

Dear Sir/Mam, We invite unpublished research paper.Summary of Research Project,Theses,Books and Books Review of publication,you will be pleased to know that our journals are

Associated and Indexed,India

¬

¬OPEN J-GATE International Scientific Journal Consortium Scientific

Associated and Indexed,USA

?

?Index Copernicus?Publication Index?Academic Journal Database?Contemporary Research Index?Academic Paper Databse?Digital Journals Database?Current Index to Scholarly Journals?Elite Scientific Journal Archive?Directory Of Academic Resources?Scholar Journal Index?Recent Science Index?Scientific Resources Database

EBSCO

Golden Research Thoughts 258/34 Raviwar Peth Solapur-413005,Maharashtra

Contact-9595359435E-Mail-ayisrj@yahoo.in/ayisrj2011@gmail.com

Website : www.isrj.net