Endometriosis of sciatic nerve

Biomedicum, Helsinki24.9.2009

Päivi HärkkiHelsinki University Central Hospital

Patient history 1 27-year old student was sent to orthopedic

hospital in 2005 due to episodic pain in right buttock and tigh lasting for 10 months

X-ray of the spine, MRI of lumbal spine were normal and physiotherapy was offered

pain occured during periods and lasted one week

also pelvic MRI and electromyography were normal

piriformis syndrome was suspected gynaecological consultation was made

Patient history 2 gynaecologocal examination and TVS were

normal cyclic contraseptive pills were changed to

continuous pills as endometriosis was suspected buttock pain decreased with continuous pills laparoscopy was performed in June, 2006 with no

signs of endometriosis contraseptives were discontinued because of

heavy migraine

Patient history 3 symptoms worsened, pain-free time one

week inpostmenstrum in September, 2007 walking was difficult

because of right footdrop pain in right buttock and tigh was 8/10 in

VAS during menstruation private gynaecologist sent her to

neurologist in January, 2008

Patient history 4 in neurology

severe damage in the sciatic and peroneus nerve in electromyography

spinal MRI was normal 4 cm endometriotic lesion in the

course of right sciatic nerve was seen in pelvic MRI

MRI 1

MRI 2

Patient history 5 gynaecological examination and TVS

were normal in May, 2008 pain was continuous, VAS 10/10 discussion with a neurosurgeon: first

laparoscopy and then a second operation by gluteal approach

Surgery laparoscopy in June, 2008

peritoneal endometriosis in broad ja sacrouterine ligaments which were resected

right ovary was adherent to the pelvic side wall with deep endometriosis

peritoneum was opened lateral to the infundibulopelvic ligament, obturator nerve was identified, sciatic nerve was dissected and hard endometriotic lesion was resected around the nerve near the lateral pelvic wall

most of the lesion was behind the piriformis muscle which not able to remove abdominally

1. Laparoscopy

Netter

Possover et al.Minim Invas Neurosurg 2007;50:33-6

ROM= resection obturatoric muscle

SN= sciatic nerve

ON= obturatoric nerve

2. operation by gluteal approach in July

Netter

Piriformis muscle (PM) was resected to find endometriotic lesion

sciatic nerve

PM

Most of the endometriotic lesion was resected

Postoperatively pain decreased significantly progestin-only pills and physiotherapy were

started she still has a peroneusparesis pain increased in January, 2009 and GnRH-

analog was started again and a new MRI was taken

lesion was not seen in MRI 1 year postoperatively

some patient are treated only with GnRH-agonists without surgery in litterature

Pre- and postoperative MRI

preoperative postoperative