To,
The Medical Board,
Office of Chief Medical Officer,
District –Sirsa (Haryana)
This case involves Cadaveric- abbrent pathway
sciatic nerve, the same is described hereinbelow as per available medical literature
:
A
unique case of bilateral sciatic nerve variation within the gluteal compartment
and associated clinical ramifications
Abstract
1.
An abnormal course of a nerve either through or around a muscle
may yield multiple or anomalous muscle innervation. Further, if nerves are
inappropriately trapped within the confines of a muscle or irregular
boundaries, variant emergence of a nerve could give rise to symptoms of an
entrapment neuropathy. Upon routine dissection in the Department of Anatomy at
the American University of Antigua College of Medicine, bilateral variants in
the emergence of the sciatic nerve from the pelvis to the gluteal compartment
were discovered in an elderly adult female cadaver. In the left gluteal
compartment, the sciatic nerve had a high division where the peroneal division
exited the pelvis superior to the piriformis muscle while the tibial division
exited inferior to the piriformis. In the right gluteal compartment, the
peroneal division was observed to have exited the pelvis between a split
piriformis muscle before it joined the tibial division of the sciatic nerve.
Knowledge of such variations in the course of the sciatic nerve may improve
diagnosis and treatment of pathologies in this region.
2.
An abnormal course of a nerve either through or around a muscle
may yield multiple or anomalous muscle innervation. Further, if nerves are
inappropriately trapped within the confines of a muscle or irregular
boundaries, variant emergence of a nerve could give rise to symptoms of an
entrapment neuropathy. Upon routine dissection in the Department of Anatomy at
the American University of Antigua College of Medicine, bilateral variants in
the emergence of the sciatic nerve from the pelvis to the gluteal compartment
were discovered in an elderly adult female cadaver. In the left gluteal compartment,
the sciatic nerve had a high division where the peroneal division exited the
pelvis superior to the piriformis muscle while the tibial division exited
inferior to the piriformis. In the right gluteal compartment, the peroneal
division was observed to have exited the pelvis between a split piriformis
muscle before it joined the tibial division of the sciatic nerve. Knowledge of
such variations in the course of the sciatic nerve may improve diagnosis and
treatment of pathologies in this region.
Implications for Practice:
A.
What is known about this
subject?
Anatomical
variation of nerves and their course may confer a challenge in clinical and
surgical practice for both diagnosis and intervention. This study identifies
between-side variation of nerve location within the gluteal compartments of a
single cadaver.
B.
What new information is offered
in this study?
The
presentation of the variation described shows the piriformis muscle lying
between the two branches of the sciatic nerve in the left gluteal compartment,
and the piriformis muscle being pierced by the common peroneal nerve in the
right gluteal compartment. We also identify the statistical probability of the
occurrence of both of these isolated variations in the same cadaver as
approximately 1/10,000.
C.
What are the implications for
research, policy, or practice?
The
identification of variant sciatic nerve location in the gluteal region may
contribute to improvement in diagnosis and intervention of pathologies in this
area. Further prospective analyses that investigate the rate of occurrence,
associated risk and any potential relationship to morphological variation could
prove helpful for clinicians and surgeons.
Background
3.
Knowledge and analysis of nerve variance is clinically imperative
for several reasons. In the course of a surgical procedure, it is important to
be cognizant of usual morphology in addition to that of morphological
variation. Nerve entrapment as a result of variant nervous pathways in the
lower limb have the potential to lead to piriformis syndrome, sciatica, or
coccygodynia, and may present unique clinical challenges in relation to
selecting the appropriate therapy to alleviate a patient’s pain. Further,
muscle power, tone, and function may be compromised with the occurrence of distal
neuropathy whereby a nerve, being irritated in an abnormal location, loses its
capacity to effectively innervate a distal muscle.
4.
The sciatic nerve is the largest peripheral nerve in the human
body, originating from roots L4–S3. It emerges from the pelvis via the greater
sciatic foramen, running inferior to the piriformis muscle, and entering the
gluteal compartment. The major components of the sciatic nerve include the
common fibular nerve and tibial nerve, respectively. The common fibular nerve
arises from dorsal divisions of ventral rami of L4–S2 while the tibial nerve
arises from ventral divisions of ventral rami of L4-S3. The sciatic nerve
is responsible for the innervation of the posterior compartment of the thigh as
well as all the muscles of the leg and foot.
5.
The piriformis muscle assists in forming the posterolateral wall
of the pelvis, attached medially to the sacrum and laterally to the greater
trochanter of the femur. Functionally, the piriformis contracts to provide
external rotation, abduction and extension of the hip, depending on the initial
thigh position. It also assists with hip stabilisation by assisting the
maintenance of the position of the head of the femur in the acetabulum. The
muscle bridges the pelvis, from its attachment at the sacrum, through the
greater sciatic notch, and in doing so is located posterosuperiorly to the
sciatic nerve. The piriformis is innervated by direct branches from the
sacral plexus, specifically arising from S1–S2 nerve roots. It is
relatively uncommon to observe deviation from this schema.
6.
Piriformis syndrome occurs when the sciatic nerve is entrapped by
the piriformis muscle as it exits the sciatic notch in the gluteal region. This
can potentially occur when the piriformis muscle is hypertrophied and mechanically
compromises the adjacent sciatic nerve. Piriformis syndrome is considered as a
differential diagnosis with variations of the sciatic nerve where the sciatic
nerve pierces the piriformis muscle. Pharmacologic interventions used in the
treatment of piriformis syndrome may include intramuscular injections of
steroids, anesthetics, or botulinum toxin.
7.
Peripheral neuropathy involving the sciatic nerve presents with
pain, tingling or numbness in the buttocks, and weakness of muscles innervated
by this nerve. This can sometimes be triggered by activities such as climbing
stairs or running. Most commonly this occurs iatrogenically but may also be due
to other causes. Surgical decompression of the sciatic nerve may provide
variable relief in some cases.
Case details
8.
In the course of routine dissection of an elderly female Caucasian
cadaver, bilateral variants were discovered in the gluteal compartment. In the
right gluteal compartment, the piriformis muscle was found to be bifid (Figure 1). The common
peroneal nerve was found to emerge into the gluteal compartment by piercing the
piriformis muscle, effectively separating it into superior and inferior muscle
slips (Figure 1). The tibial nerve
was found emerging from the lower border of the inferior muscle slip of the
piriformis.
Right
gluteal compartment
9.
On the left side the common peroneal nerve exited the pelvis
superior to the piriformis muscle, while the tibial nerve coursed inferior to
the piriformis muscle. The two divisions subsequently joined distal to their
emergence around the piriformis
Left
gluteal compartment
10.
The nerve supply to the posterior compartment of the thigh, the
flexor compartment of the leg, and the extensor compartment of the leg appeared
to have a regular path and distribution, bilaterally
Right
and left gluteal compartments
Discussion
11.
Bilateral variants in the gluteal compartment appear uncommonly in
most anatomical studies. However, various clinical manifestations may
potentially be associated with altered morphological relations between the
piriformis muscle and the sciatic nerve. Given the asymmetric presentation of
the sciatic nerve’s emergence from the pelvis in this case, variation of the
innervation between the gluteal compartments’ muscles should be
considered. We did not investigate this specifically.
12.
Sciatica, described as lower back, gluteal, and thigh pain, is
experienced as a result of compression or irritation of the sciatic nerve or
its roots. Given the anatomical variation observed and the variable passage of
the sciatic nerve through and around the piriformis muscle, sciatica may have
been present in this individual.
13.
Another clinical ailment in the posterior gluteal region is
coccygodynia, defined as pain in and around the coccyx, typically worsening
when sitting and upon rising from a seated position. Aberrant formation or
presentation of accessory muscle slips of the piriformis muscle, or normal
muscle being split into multiple slips, have been considered to provide a
likely morphological basis for coccygodynia as a result of the unusual relation
between the variant muscle slip and sciatic nerve, or branch thereof. As
it applies to this case study, there was the potential for coccygodynia to have
been present bilaterally in this individual based on the anatomical variations
observed.
14.
The rarity of this case is due to the variation between opposite
gluteal compartments in the same cadaver. Smoll suggested the probability of
observing the presentation in the right gluteal compartment, where the peroneal
division pierced the piriformis, to be 13.8 per cent (829 cases/5,987 total
limb dissections = 0.138). Smoll also indicated the probability of
observing the presentation in the left gluteal compartment, where a split
sciatic nerve encompassed the piriformis, to only be 0.0835 per cent (5
cases/5,987 total limb dissections = 0.000835). Therefore, the probability
of identifying both of these variations within the same cadaver, as is
presented in this case study, is 0.011 per cent or 1 in 10,000 individuals.
Conclusion
15.
Anatomical variants in the pelvic and gluteal regions are of
interest to clinicians to guide accurate diagnosis and
intervention. Visual screening of this zone (such as using ultrasound)
could be of assistance with posterior gluteal pathology, and suspected
piriformis syndrome, to prevent iatrogenic surgical damage, and knowledge of
within-individual variations such as those described are therefore important
for clinical practice.
Summry of Treatment
16.
Patient’s USG report was of 3rd sept. 2016 at Dhaliwal
Hospital Mandi Dabwali. So Patient had taken treatment from other doctor.
Patient came to my hospital on 4thSeptember 2016 at 7:15 p.m with complaints of
(1) Pain Abdomen, (2) Vomiting, and (3) Weakness. Patient Admitted in
1st Notice that he came with pain in Rt. Leg as notice given to us. After
prescribing inj. Diclo by me I/M, Patient Refuse due to pain in his rt.Leg. These
things are in written in the documents.
Chronological events
1. USG at
dhaliwal Hospital by Self on 3rd September, 2016
2. Patient
came to Aastha Hospital on 4th September, 2016 at 7:15P.M. Patient
Left After 2Hours.
3. Patient
went to Bikaner Hospital on 5th September, 2016 at 1:00a.m.
4. Patient went
to Janta Hospital (Quack) By self Decisen
5. Patient
went to Life line Hospital on 10th September, 2016.
6. Patient
went to Medical College Faridkot
7. Patient
went to Singla Neuro Hospital on 16th September, 2016.
8. Patient
went to PGI Chd. On 10th October, 2016.
17.
The liability of a doctor arises not when the patient has suffered
any injury, but when the injury has resulted due to the conduct of the doctor,
which has fallen below that of reasonable care. In other words, the doctor is
not liable for every injury suffered by a patient. He is liable for only those
that are a consequence of a breach of his duty. Hence, once the existence of a duty
has been established, the plaintiff must still prove the breach of duty and the
causation. In case there is no breach or the breach did not cause the damage,
the doctor will not be liable. In order to show the breach of duty, the burden
on the plaintiff would be to first show what is considered as reasonable under
those circumstances and then that the conduct of the doctor was below this
degree. It must be noted that it is not sufficient to prove a breach, to merely
show that there exists a body of opinion which goes against the
practice/conduct of the doctor.
18.
The law, like medicine,
is an inexact science. One cannot predict with certainty an outcome in many
cases. It depends on the particular facts and circumstances of the case, and
also the personal notions of the Judge who is hearing the case. However, the
broad and general legal principles relating to medical negligence need to be
understood. Before dealing with these principles two things have to be kept in
mind:
I.
Judges are not experts
in medical science, rather they are laymen. This itself often makes it somewhat
difficult for them to decide cases relating to medical negligence. Moreover,
Judges usually have to rely on the testimonies of other doctors, which may not
be objective in all cases. Since like in all professions and services, doctors
too sometimes have a tendency to support their own colleagues who are charged
with medical negligence. The testimony may also be difficult to understand for
a Judge, particularly in complicated medical matters and
II.
A balance has to be
struck in such cases. While doctors who cause death or agony due to medical
negligence should certainly be penalized, it must also be remembered that like
all professionals doctors too can make errors of judgment but if they are punished
for this no doctor can practice his vocation with equanimity. Indiscriminate
proceedings and decisions against doctors are counter productive and are no
good for society. They inhibit the free exercise of judgment by a professional
in a particular situation.
ADDITIONAL SUBMISSION
Sciatic
Nerve Injury Following Intramuscular Injection: A Case Report and Review of the
Literature
Discussion
19.
When
giving gluteal injections, it is safest to use the upper outer quadrant. The
choice of site for injection must be based on good clinical judgment, using the
best evidence available and individualized client assessment. There is wide
agreement in the literature that the ventrogluteal site is preferable (Small,
2004). Review of the literature on relevant injection procedure found that
injury to the sciatic nerve is associated with use of the dorsogluteal site for
injection, because the sciatic nerve commonly courses this site (Fig. 1).
Anatomy of the
sciatic nerve in the gluteal region
20.
Ndiaye,
Sakho, Fall, Dia, and Sow (2004) performed sciatic nerve gluteal dissection on
10 fresh adult African cadavers, on both sides. The nerve pathway was 19 times
out of 20 in the subpiriformis canal. In all cases the pathway was identical,
with an oblique and vertical portion running down through the
ischio-trochanteric channel. The cutaneous projection of the sciatic nerve was
distant from the upper lateral quadrant of the buttock.
21.
The
site of injection is the crucial factor in determining the degree of nerve
fiber injury. The degree of injury varies significantly, depending upon the
specific agent injected. The most severe injuries have been associated with
widespread axonal and myelin degeneration (Gentili, Hudson, and Hunter, 1980a).
Pathological alterations in the nerve were evident as early as 30 minutes
following injection injury (Gentili et al., 1980b).
22.
Although
postinjection injury can occur in both adults and children, children appear to
be at higher risk (Krasnikova, 1986). Fatunde and Familusi (2001) did a
retrospective study of all children with a diagnosis of sciatic nerve injury
during a 12-year period. They examined 27 children, 5 months-12 years of age,
with a diagnosis of postinjection sciatic nerve injury. The drugs administered
to 17 patients included chloroquine, novalgin, paraldehyde, procaine
penicillin, and sulfadoxine-pyrimethamine. However, the most neurotoxic agents
tested in a previous study appear to be penicillin G, diazepam, and
chlorpromazine (Yaffe, Pri-Chen, Lin, Engel, & Modan, 1986). The postulated
mechanisms of injury include direct needle trauma, secondary constriction by scar,
and direct nerve fiber damage, due to both axon and Schwann cell, with a
breakdown in the blood-nerve barrier by neurotoxic chemicals in the injected
agent (Gentili et al., 1980b; Villarejo & Pascual, 1993)
23.
Neurological
sequelae can range from minor transient sensory disturbance to severe sensory
disturbance and paralysis, with poor recovery (Villarejo & Pascual, 1993).
In one study, seven patients (26%) presenting with foot drop had had recent IM
injections in the buttock. An additional 20 patients (74%) presented much later
(Fatunde & Familusi, 2001). In fact, gluteal IM injection that led to
sciatic nerve injury most often presented as paralytic drop foot (Mayer &
Romain, 2001; Sobel, Huang, & Wieting, 1997).
24.
Children
who present with drop foot may later develop gluteal fibrosis (diagnosed 5.1
years after the injections). In contrast, sciatic nerve palsy, presenting as
equinovarus or equinus deformity, was diagnosed on average 3.8 months after the
intragluteal injections (Napiontek & Ruszkowski, 1993). Cavovarus and
calcaneocavus foot deformities have also been reported (Bigos & Coleman,
1984).
25.
Medical
treatments including administration of vitamins and alphachymotrypsine have
been tried with varying results, depending on the extent of the lesion. Early (within
2 months) physiotherapy may provide a better chance of recovery (Bourrel &
Souvestre, 1982). Our patient presented 12 months after nerve injury and, thus,
his chances of recovery were small.
26.
The
recommended treatment ranges from a conservative approach to immediate
operative exposure and irrigation and has included early neurolysis or delayed
exploration with neurolysis or resection and anastomosis (Villarejo &
Pascual, 1993). Of 190 patients with gluteal sciatic nerve injuries in one
retrospective study, the injuries were caused by injection in 164 patients
(86.32%). Fifteen were treated by conservative means, and the other 175 had
surgical intervention. Neurolysis was performed in 160 cases, epineural
neurorrhaphy in 12 cases, nerve grafting in 2 cases, and nerve exploration but
no repair in 1 case. Late-stage functional reconstruction of the foot and ankle
was performed in 23 cases. Follow-up of 151 patients for an average 8.5 years
revealed excellent to good nerve recovery (i.e., 57% and 78% in the early and
late stage, respectively). We believe that neurolysis should be performed as
soon as possible in cases of injection injury (Huang, Yan, & Lei, 2000).
27.
Epineural
neurorrhaphy should be performed in cases of nerve rupture. Functional
reconstruction of the foot and ankle should be carried out in the late stage
for the improvement of the limb function, if a surgical team is available for
this purpose (Huang et al., 2000). If performed within 24 hours after injury,
neurolysis may prevent the occurrence of paralysis (Mayer & Romain 2001;
Yaffe et al., 1986). Our patient was offered physiotherapy rather than surgical
treatment because of his late presentation. To date, his improvement has been
minimal.
28.
The
implications for nurses include the need to learn and practice safe injection
technique. Nurses must also assess for complications (both immediate and long
term), and educate patients.
From the facts and circumstances, it is clear like light of the
day that no case is made out prima facie on account of medical negligence,
therefore the complaint filed, may please rejected in the larger interest of
Justice.
Dr. Sharvan Kumar Bansal,
MBBS,
Consulting pediatrician,
Opposite Shri Salasar Temple,
New Grain Market Road,
Main Dabwali Road,
Near Maruti Showroom,
Sirsa – 125 055 (Haryana)
Vodafone : 088139 54354
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