背景:据报道,骶棘韧带固定术后即刻的臀痛发生率为12-55%,术后4-6周的臀痛发生率为4-15%。臀肌疼痛的来源通常归因于神经对肛提肌或阴部神经的损伤。尚未彻底检查臀下神经和其他骶神经分支作为臀痛的潜在来源。
目的:这项研究的目的是进一步描述臀下神经和其他神经的解剖结构,这些神经与骶棘韧带联合入路和骶棘韧带固定的相关发现。
方法:对未用臀骨和骨盆入路防腐的女性尸体进行解剖。从骨盆的角度来看,注意到最接近骶棘韧带中点上边界的结构,检查穿通尾骨肌腹面的骶神经。从臀部的角度来看,从坐骨脊柱到阴部的最近距离,臀下,股骨后皮,并测量了坐骨神经。此外,从骶棘韧带的中点到臀下神经的最近距离和该神经的起源被记录。测量骶棘韧带中点的厚度和高度。从骨盆和臀入路评估了在骶棘韧带和骶结节韧带之间延伸的骶神经分支。描述性统计用于数据分析。
结果:检查了14具尸体。从骨盆的角度来看,sc棘韧带中点最接近上边界的结构是S3神经(正中距离,3mm;范围,0-11毫米)。在94%的标本中,来自S3和/或S4的分支穿孔了尾骨肌的腹面。从臀部的角度来看,最接近坐骨脊柱的结构是阴部神经(正中距离,0mm;范围,0-9毫米)。臀下神经到坐骨脊柱和骶棘韧带中点的中位最近距离为28.5mm(范围,6-53毫米)和31.5毫米(范围,10-47毫米),分别。在所有标本中,臀下神经都来自腰骶干和S1神经的背侧表面;在46%的半骨盆中注意到S2的贡献。在它的中点,骶棘韧带中位厚度为5毫米(范围,2-7mm),其中值高度为14毫米(范围,3-22毫米)。在85%的标本中,来自S3和/或S4神经的1至3个分支刺穿或穿过腹侧至骶结节韧带,并穿孔了臀大肌的下部。
结论:骶棘韧带固定术中对臀下神经的损伤不太可能是术后臀痛的原因。相反,来自S3和/或S4的分支神经支配尾骨肌,以及在骶棘韧带和骶结节韧带之间提供臀大肌的分支更可能涉及。彻底了解骶棘韧带周围的复杂解剖结构,限制针头穿透韧带的深度,避免针头出口或进入点延伸到骶棘韧带上方可能会减少神经卡压和术后臀痛。
BACKGROUND: Reported rates of gluteal pain after sacrospinous ligament fixation range from 12-55% in the immediate postoperative period and from 4-15% 4-6 weeks postoperatively. The source of gluteal pain often is attributed to injury to the nerve to levator ani or pudendal nerve. The inferior gluteal nerve and other sacral nerve branches have not been examined thoroughly as potential sources of gluteal pain.
OBJECTIVE: The purpose of this
study was to further characterize anatomy of the inferior gluteal nerve and other nerves that are associated with the sacrospinous ligament from a combined gluteal and pelvic approach and to correlate findings to sacrospinous ligament fixation.
METHODS: Dissections were performed in female cadavers that had not been embalmed with gluteal and pelvic approaches. From a pelvic perspective, the closest structure to the superior border of the sacrospinous ligament midpoint was noted, and the sacral nerves that perforated the ventral surface of coccygeus muscle were examined. From a gluteal perspective, the closest distances from ischial spine to the pudendal, inferior gluteal, posterior femoral cutaneous, and sciatic nerves were measured. In addition, the closest distance from the midpoint of sacrospinous ligament to the inferior gluteal nerve and the origin of this nerve were documented. The thickness and height of the sacrospinous ligament at its midpoint were measured. Sacral nerve branches that coursed between the sacrospinous and sacrotuberous ligaments were assessed from both a pelvic and a gluteal approach. Descriptive statistics were used for data analysis.
RESULTS: Fourteen cadavers were examined. From a pelvic perspective, the closest structure to the superior border of sacrospinous ligament at its midpoint was the S3 nerve (median distance, 3 mm; range, 0-11 mm). Branches from S3 and/or S4 perforated the ventral surface of coccygeus muscles in 94% specimens. From a gluteal perspective, the closest structure to ischial spine was the pudendal nerve (median distance, 0 mm; range, 0-9 mm). Median closest distance from inferior gluteal nerve to ischial spine and to the midpoint of sacrospinous ligament was 28.5 mm (range, 6-53 mm) and 31.5 mm (range, 10-47 mm), respectively. The inferior gluteal nerve arose from dorsal surface of combined lumbosacral trunk and S1 nerves in all specimens; a contribution from S2 was noted in 46% of hemipelvises. At its midpoint, the sacrospinous ligament median thickness was 5 mm (range, 2-7 mm), and its median height was 14 mm (range, 3-22 mm). In 85% of specimens, 1 to 3 branches from S3 and/or S4 nerves pierced or coursed ventral to the sacrotuberous ligament and perforated the inferior portion of the gluteus maximus muscle.
CONCLUSIONS: Damage to the inferior gluteal nerve during sacrospinous ligament fixation is an unlikely source for postoperative gluteal pain. Rather, branches from S3 and/or S4 that innervate the coccygeus muscles and those coursing between the sacrospinous and sacrotuberous ligaments to supply gluteus maximus muscles are more likely to be implicated. A thorough understanding of the complex anatomy surrounding the sacrospinous ligament, limiting depth of needle penetration into the ligament, and avoiding extension of needle exit or entry point above the upper extent of sacrospinous ligament may reduce nerve entrapment and postoperative gluteal pain.