The aim of the study was to describe and analyze sciatic nerve variation especially the higher division within the lesser pelvis and its different routes of exit from pelvis. The sciatic nerve (SN) separates into its branches, the tibial and common peroneal nerves, outside the pelvis. However, it may rarely be separated within the pelvis. In such cases, the tibial nerve and the common peroneal nerve may leave the pelvis through different routes. These variations may cause nerve compressions under other anatomic structures, resulting in non-discogenic sciatica. 86 gluteal regions were examined in 43 formalin-fixed adult cadavers from different medical colleges of Gujarat region. From the study we found higher division of sciatic nerve bilaterally mainly in the female which is very rare and unilateral higher division of sciatic nerve which is also rare. The differences in the exit routes of these two nerves are important for surgeons, as this is the area of frequent surgical manipulation, nerve injury during deep intramuscular injections in gluteal region, failed sciatic nerve block in anesthesia and injury during posterior hip operations.

A variation in the high division of the sciatic nerve and its relation with piriformis muscle

OBJECTIVE: The sciatic nerve (SN) separates into its branches, the tibial and common fibular nerves, outside the pelvis. However, it may rarely be separated within the pelvis. In such cases, the tibial nerve and the common fibular nerve may leave the pelvis through different routes. These variations may cause nerve compressions under other anatomic structures, resulting in non-discogenic sciatica. The aim of this study was to define the level of the SN exit and of the SN division. MATERIAL and METHOD: 50 gluteal regions were examined in 25 formalin-fixed adult male cadavers. RESULTS: In 52% of the cases, the SN exited the pelvis as a whole nerve without any division, whereas in 48% a high division was observed. Branches of the SN left the pelvis through the infrapiriform foramen (IP) as two separate nerves In 24%. One branch of the SN left the pelvis through the IP and other through a different route in another 24%. CONCLUSION: The differences in the exit routes of these two nerves are important in clarifying the clinical etiology of nondiscogenic sciatica. These variations require reviewing the piriformis syndrome.

Variations in the High Division of the Sciatic Nerve and Relationship Between the Sciatic Nerve and the Piriformis Siyatik Sinirin Yüksek Divizyon Varyasyonlar› ve Piriformis-Siyatik Sinir ‹liflkisi

We report a very rare case of two different types of high divisions of sciatic nerve (SN) on either side of a 33-year-old female cadaver with unilateral divided piriformis muscle. Here SN of either side divided into tibial and common fibular nerves within pelvis and entered into gluteal region. On the right side both divisions passed below piriformis, but on the left side the common fibular nerve passed between two divisions of divided piriformis, while tibial nerve passed below the inferior piriformis. What is rare is not high division of SN, but to find two different types of high divisions of SN on either side of same cadaver with unilateral bifid piriformis as found here. To our knowledge, there is no literature describing this kind of variation. Also seen was an unusual finding of unilateral high origin of genicular branch of left common fibular nerve. This combination of variations makes this case the most interesting and unique of its kind. © IJAV. 2011; 4: 63–66.

/pdf/a-rare-case-of-bilateral-high-division-of-sciatic-nerve-of-1yl0ay4389.pdf

A rare case of bilateral high division of sciatic nerve (of different types) with unilateral divided piriformis and unusual high origin of genicular branch of common fibular nerve

Background: The sciatic nerve is derived from the lumbo-sacral plexus, It is the thickest nerve in the whole body, 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 usually ends halfway down the back of the thigh by dividing into the tibial and common peroneal nerves, and these terminal branches supply the leg and foot. The position of division of this nerve varies, it may occur within the pelvis, gluteal region, upper and ,mid thigh, and distal thigh ,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, hence the need for healthcare workers to have adequate appreciation of the applied anatomy of the nerve. The main objective of the study was to determine the level of bifurcation of the sciatic nerve above the transverse popliteal crease among Ugandans at Mulago Hospital Complex. Methods: This was a cross-sectional descriptive study conducted at the Department of Anatomy, School of Biomedical sciences, Makerere University and Mulago Hospital mortuary. Eighty adult cadavers were dissected in the gluteal region and posterior thigh to establish the level of bifurcation of the sciatic nerve above the transverse popliteal crease, and the distance from the crease was measured in cm using a caliper calibrated in millimeters. Results: Eighty left lower limbs of 56 male and 24 female adult cadavers were dissected to expose the sciatic nerve one side of the body was dissected to control for left to right variations, however in another study, the variations on two sides would be compared.., The heights of the cadavers ranged from 145 to 182 cm with a mean of 162.8 cm. The nerves bifurcated in the gluteal region and posterior thigh in 62 cadavers (77.5%) and 18 in the pelvis (22.5%). Of the 62 nerves that bifurcated higher in the pelvis, the level of bifurcation ranged between 3.8 and 32.5 cm but most of the bifurcations occurred between 3.8 and 12 cm above transverse popliteal crease. In four of the nerves that exited the gluteal region after bifurcation, the nerves reunited before the final bifurcation occurred in the thigh. Conclusions: The Bifurcation of the sciatic nerve occurs at variable distances from the transverse popliteal crease and appreciation of these variations is essential. More than 22% of all nerves leave the pelvis as two separate nerves and therefore the sciatic nerve trunk cannot be wholly traced or used for anesthetic block in the gluteal region or thigh for procedures in the leg and foot. Only 62 individuals (77.5%) had sciatic nerves in the gluteal region and thigh, and within this group, the vertical distance of bifurcation ranged between 3.8 and 32.5 cm transverse popliteal crease.

/pdf/levels-of-bifurcation-of-the-sciatic-nerve-among-ugandans-at-1zy1396k2t.pdf

Levels of Bifurcation of the Sciatic Nerve among Ugandans at School of Biomedical Sciences Makerere and Mulago Hospital Uganda

El nervio ciatico es el mas largo y grueso del cuerpo. Se forma en la pelvis, a partir de las raices nerviosas L4-S3, a partir del nervio tibial y el peroneal envueltos por un epineuro comun, sale de la pelvis por el foramen ciatico mayor y baja por la parte posterior de la pierna, inervando la parte posterior del muslo, la parte baja de la pierna y el pie. Habitualmente sale de la pelvis por debajo del musculo piriforme, sin embargo, han sido descritas diferentes variaciones anatomicas respecto a la relacion entre nervio y musculo. (Figura 13). Suele dividirse en sus dos ramas en la parte inferior del muslo o en la fosa poplitea, pero puede dividirse en la pelvis o a diferentes alturas del muslo (Figura 5) Las variaciones anatomicas del nervio ciatico con respecto a su relacion con el musculo piriforme pueden derivar en patologias como el sindrome piriforme y deben tenerse en cuenta para evitar lesionar el nervio a la hora de realizar cirugias pelvicas, artroplastias de cadera, inyecciones intramusculares y canulaciones de la arteria femoral en cirugias cardiacas.
Las variaciones anatomicas respecto al nivel de bifurcacion del nervio ciatico deben tenerse en cuenta a la hora de realizar bloqueos anestesicos en la fosa poplitea, ya que, si el nervio presenta una division alta, se produciria una anestesia parcial de la extremidad inferior.
El desarrollo embrionario de las estructuras nerviosas, musculares y oseas se encuentra descrito en la bibliografia. Sin embargo, no se ha establecido el momento en que se define la relacion anatomica del nervio ciatico y el musculo piriforme.
OBJETIVOS ? Clasificar la relacion del nervio ciatico y el musculo piriforme a lo largo del desarrollo embrionario y en la poblacion adulta, segun el criterio de Beaton, 1937. Patron A: Nervio ciatico por debajo de musculo. Patron B: nervio peroneal perfora el musculo. patron C: Nervio peroneal por encima del musculo. Patron D: nervio ciatico perfora el musculo. Patron E: Nervio tibial perfora el musculo. Patron F: Nervio ciatico por encima del musculo.
? Describir a que nivel tiene lugar la division del nervio ciatico a lo largo de la pierna.
? Estudiar en que momento se determina la relacion anatomica entre el nervio ciatico y el musculo piriforme.
MATERIAL Y METODOS ? Diseccion de ambas regiones gluteas en 59 cadaveres adultos y estudio de cortes histologicos de 13 fetos y 21 embriones humanos, registrando la relacion del nervio con el musculo piriforme y el nivel de division del nervio.
? Realizacion de un metaanalisis basado en la bibliografia previa.
RESULTADOS Y CONCLUSIONES ? El patron A es el mas habitual (85-90%), seguido del B (10-15%), C ( < 2%), D ( < 1%), F ( < 1%) y E ( < 0.1%) y en todos los tipos de muestras, asi como en la bibliografia previa.
? El nervio ciatico presenta una division alta el 25% de los casos y baja en el 75% de los casos, tanto en nuestras muestras como en la bibliografia previa.
? La relacion anatomica entre el nervio ciatico y el musculo piriforme se establece en la octava semana del desarrollo embrionario.

Estudio anatómico embriológico del nervio ciático, y su relación con el músculo piriforme

In a 62-year-old male cadaver, high division of the sciatic nerve was observed bilaterally. Additionally, on the right side of the same cadaver, the common peroneal nerve passed just inferior to the piriformis muscle and the tibial nerve emerged inferior to the gemellus superior, between the gemellus superior and obturator internus muscles. Then, both of the nerves coursed posterior to the obturator internus, gemellus inferior and quadratus femoris muscles. The gemellus superior muscle, lying just posterior to the tibial nerve may cause to the symptoms of sciatica, because of the compression of the tibial nerve between the gemellus superior and obturator internus muscles. This pathology may lead to a new syndrome; the gemellus superior syndrome, just like the piriformis syndrome. As a conclusion, in the etiology and pathogenesis of sciatica, in addition to the priformis muscle, the abnormalities of the other gluteal external rotator muscles of the hip joint must also be taken into consideration by the clinicians. MR imaging of this region will be very helpful for the accurate diagnosis of this type of pathologies.

/pdf/a-case-of-bilateral-high-division-of-the-sciatic-nerves-au4n3imn5f.pdf

A case of bilateral high division of the sciatic nerves, together with a unilateral unusual course of the tibial nerve

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A case of bilateral high division of the sciatic nerves, together with a unilateral unusual course of the tibial nerve