Sciatic Nerve Injury

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Definition/Description

It is characterized by trauma to the sciatic nerve via intramuscular injection at gluteal region (dorsogluteal site), nerve compression and stretch during sugery.[1][2][3]

Sciatic Nerve Injury is otherwise known as Sciatic neuropathy or injection palsy.[4][5] It describes a situation where there is a loss of movement and or lack of sensation at the affected lower extremity with or without pain. Stress or damage to the sciatic nerve that serves majority of muscle groups in the lower limb, result to this dysfunction.

The insult affect just a single nerve, hence, it is also referred to a Peripheral neuropathy called mononeuropathy. And occurs more in children[2] and young adults.

Clinically Relevant Anatomy

Sciatic nerve is the largest nerve in the human body (with nerve root L4,L5,S1,S2,S3) and the continuation of the sacral plexus. The sciatic nerve is the most lateral structure emerging through the greater sciatic foramen inferior to the piriformis. Medial to it are the inferior gluteal nerve and vessels, the internal pudendal vessels, and the pudendal nerve. It crosses the posterior surface of the ischium, crosses obturator internus, with its gemelli, quadratus femoris and descends on adductor magnus.The sciatic divides into its terminal branches, the tibial and common peroneal nerves, usually just below the mid-thigh, although a higher division is not uncommon.[6][7]

[8]Figure 1

Epidemiology/Etiology

Injection palsy can begin suddenly or hours following damage to the sciatic nerve. Misplaced intramuscular injection at the gluteal region is the most common cause of injury and it is attributed to either frequent injections or poor techniques as a result of inadequately trained staff or unqualified staff. [1][2][4]
It affects more males than females with a ratio of 2.7:1.[9] Within a period of two years, Pakistan recorded annual incidence of six (6) million chldren.[1] For overview of nerve injury

Clinical Presentation/Characteristics

The persistent and most reported symptoms are pain and abnormal gait pattern.[4] However, pain intensity is difficult to quantity or rate particularly in the Pediatric population but facial expression is quite helpful. Others include;

  • Foot drop[10][11]
  • External rotation and abduction contracture of the hip[10]
  • Equinovarus or Equinus deformity[10]
  • Muscular weakness/atrophy[11]
  • Motor and sensory deficit such as paresthesia and numbness[4][2]

Diagnostic Procedures

Sciatic neuropathy is more of a clinical diagnosis. Well detailed subjective and objective examination is the golden rule. In recent times, debate on the use of imaging modalities is on the fast pace. Electro-diagnostic studies are;

Medical Management

In most cases, symptoms of sciatic nerve injury does not respond to the use of non steriodal anti-inflammatory drugs (NSAIDS), opiods and myorelaxants.[5] However, the use of methyl prednisolone via transscaral block was effective to manage the neuropathic pain, motor and sensory decifits.[5] In addition, a recent study showed beneficial use of methyprednisolone via both intravenous and oral routes.[3]

Surgery is opted for patients that did not improve beyond 3 months of sustaining injection palsy[13]. Common procedures include neurolysis[13][11] and grafting[12] with serial clinical and electrophysiological monitoring. Patients with foot deformity can opt for elongation of the tendon Achilles, osteotomy and capsulotomy.[10] Although, there are conflicting findings comparing conservative and surgical interventions.

Physical Therapy Management

Conservative means is the first line approach for the management of patients with sciatic nerve injury. Exercise prescription, electrical muscle stimulation, massage therapy, use of physical agents and splinting are beneficial with good outcomes.[13][11][12][10][9] Physiotherapists or Physical therapists should ensure thorough evaluation through out the course of the treatment. Good clinical judgement, decision making skills and experience are quite important for effective rehabilitation.

Differential Diagnosis

References

  1. 1.0 1.1 1.2 Cornwall, J. Are nursing students safe when choosing gluteal intramuscular injection locations? AMJ 2011, 4, 6, 315-­‐321
  2. 2.0 2.1 2.2 2.3 Mishra P, Stringer MD. Sciatic nerve injury from intramuscular injection: a persistent and global problem. Int J Clin Pract, October 2010, 64, 11, 1573–1579
  3. 3.0 3.1 3.2 3.3 3.4 Altıntaş A, Gündüz A, Kantarcı F,  Gözübatık Çelik G, Koçer N, Kızıltan ME. Sciatic neuropathy developed after injection during curettage. A Case Report. Agri 2016;28(1):46–48
  4. 4.0 4.1 4.2 4.3 4.4 Toopchizadeh V, Barzegar M, Habibzadeh A. Sciatic Nerve Injection Palsy in Children, Electrophysiologic Pattern and Outcome: A Case Series Study. Iran J Child Neurol. Summer 2015;9(3):69-72.
  5. 5.0 5.1 5.2 Evren Eker H, Yalcin Cok O,  Aribogan A. A Treatment Option for Post-Injection Sciatic Neuropathy: Transsacral Block with Methylprednisolone. A Case Report. Pain Physician 2010; 13:451-456
  6. Moore KL, Dalley AF. Clinically Oriented Anatomy, 5th Edition. 2006 Pg 621
  7. Ellis H. Clinical Anatomy: A revision and applied anatomy for clinical students. 11th Edition. 2006 Pg 253-254
  8. Dayananda L, Belaval V V, Raina A, Chandana R. Intended intramuscular gluteal injections: Are they truly intramuscular?. J Postgrad Med [serial online] 2014 [cited 2017 Aug 16];60:175-8. Available from: http://www.jpgmonline.com/text.asp?2014/60/2/175/132334
  9. 9.0 9.1 Geyik S, Geyik M, Yigiter R, Kuzudisli S, Saglam S, Elci MA, Yilmaz M. Preventing Sciatic Nerve Injury due to Intramuscular Injection: Ten-Year Single-Center Experience and Literature Review. Turk Neurosurg 27(4):636-640, 2017
  10. 10.0 10.1 10.2 10.3 10.4 Napiontek M, Ruszkowski K. Paralytic drop foot and Gluteal fibrosis after intramuscular injection. J Bone Joint Surg [Br] 1993; 75-B: 83-5
  11. 11.0 11.1 11.2 11.3 11.4 Brown BA: Sciatic injection neuropathy. Calif Med 116: 13-15, May 1972
  12. 12.0 12.1 12.2 12.3 Ong MJF, Lim GHT, Kei PL. Clinics in diagnostic imaging (140). Singapore Med J 2012; 53(8): 551–555
  13. 13.0 13.1 13.2 Arindhom Kakati, Dhananjaya Bhat, Bhagavathula Indira Devi, Dhaval Shukla J Neurosci Rural Pract. 2013 Jan-Mar; 4(1): 13–18. doi: 10.4103/0976-3147.105603
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