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What is Endoscopic Surgery for Deep Gluteal Syndrome?

Deep gluteal syndrome (DGS) is an underdiagnosed medical condition characterized by symptoms of excruciating pain, numbness, and tingling in the buttock, hip, or posterior thigh area that can radiate down the back of the leg. The symptoms are caused by compression of the sciatic nerve in the subgluteal space by the piriformis muscle in the buttock area due to muscular hypertrophy, trauma to the hip or pelvis, or anatomical abnormalities.

Endoscopic surgery for deep gluteal syndrome is a minimally invasive surgical procedure employed for the treatment of deep gluteal syndrome, where the compressed sciatic nerve is decompressed to relieve symptoms of DGS.

Anatomy of the Gluteal Muscles

The gluteal muscles are a major group of muscles located at the back of the pelvis that form the buttocks and help in the stability of the hip. The gluteal muscles are comprised of three muscles: gluteus maximus, gluteus medius, and the gluteus minimus. These muscles facilitate in abduction, extension, internal and external rotational movements of the hip.

Indications for Endoscopic Surgery for Deep Gluteal Syndrome

Endoscopic surgery for deep gluteal syndrome is indicated when conservative treatment fails to alleviate symptoms of DGS. Some of the indications for the endoscopic surgical intervention for DGS include:

  • Piriformis syndrome
  • Sciatic nerve entrapment
  • Lumbar herniated disc with sciatica
  • Pudendal nerve entrapment
  • Non-discogenic sciatica
  • Ischiofemoral impingement
  • Distal foraminal entrapment

Preparation for Endoscopic Surgery for Deep Gluteal Syndrome

Preoperative preparation for endoscopic surgery for deep gluteal syndrome will involve the following steps:

  • A thorough examination by your doctor to check for any medical issues that need to be addressed prior to surgery.
  • Depending on your medical history, social history, and age, routine blood work and imaging may be ordered for safely conducting surgery.
  • You will be asked if you have any allergies to medications, anesthesia, or latex.
  • You should inform your doctor of any medications, vitamins, or supplements that you may be taking.
  • You should refrain from medications or supplements such as blood thinners, aspirin, or anti-inflammatory medicines for a week or two prior to surgery.
  • You should refrain from alcohol or tobacco at least 24 hours prior to surgery.
  • You should not consume any solids or liquids at least 8 hours prior to surgery.
  • Arrange for someone to drive you home as you will not be able to drive yourself post surgery.
  • A written consent will be obtained from you after the surgical process has been explained in detail.

Procedure Involved During Endoscopic Surgery for Deep Gluteal Syndrome

The main objective of the procedure is to surgically release the piriformis muscle to decompress the sciatic nerve and provide substantial pain relief. In general, endoscopic intervention for deep gluteal syndrome will involve the following steps:

  • You will be administered anesthesia and placed in a lateral position on the table.
  • Your surgeon identifies the greater trochanter of the femur (thigh bone), and the posterolateral and accessory lateral portals are marked and created.
  • The posterolateral portal is utilized for placing the endoscopic camera, and the accessory lateral portals are utilized for electrocautery and miniature instruments.
  • Using standard endoscopic technique, the trochanteric bursa is located and bursectomy is carried out via the accessory portal to expose the piriformis muscle.
  • Dissection is then performed to expose the sciatic nerve from the surrounding tissue adhesions.
  • The piriformis tendon is identified and isolated using electrocautery.
  • The sciatic nerve is then located near the piriformis and portions of the sciatic nerve are decompressed.
  • Once the sciatic nerve is completely isolated, complete piriformis muscle release is performed using electrocautery, releasing the entrapped sciatic nerve.
  • The instruments are removed, and the surgical incisions are closed in layers and a sterile dressing is applied.

Postoperative Care Instructions and Recovery

The recovery process involves at least 6 months of rehabilitation. In general, postoperative care instructions and recovery involves the following:

  • You will be transferred to the recovery area to be monitored until you are awake from the anesthesia.
  • Your nurse will monitor your blood oxygen level and other vital signs as you recover.
  • Do not weight bear for at least 24 hours. You are encouraged to walk with assistance as frequently as possible to prevent blood clots.
  • You are advised to keep your leg elevated while resting to prevent swelling and pain.
  • You will notice some pain and discomfort in the hip area. Medications will be provided for comfort.
  • Medications will also be prescribed as needed for symptoms associated with anesthesia, such as vomiting and nausea.
  • Keep your surgical site clean and dry. Instructions on surgical site care and bathing will be provided.
  • Refrain from smoking as it can negatively affect the healing process.
  • Eating a healthy diet rich in vitamin D is strongly advised to promote healing and a faster recovery.
  • Refrain from strenuous activities or lifting heavy objects for the first couple of months. Gradual increase of activities over a period of time is recommended.
  • An individualized physical therapy protocol is designed to strengthen the piriformis and gluteal muscles and to optimize pelvic alignment and hip function.
  • You will be able to return to your normal activities in a couple of months; however, return to sports may take 4 to 6 months.
  • A follow-up appointment will be scheduled to monitor your progress.

Advantages of Endoscopic Surgery for Deep Gluteal Syndrome

Some of the advantages of the endoscopic approach versus a standard approach include:

  • Minimal blood loss
  • Smaller incisions
  • Minimal postoperative pain
  • Minimal dissection required for visualization of the sciatic nerve
  • Provides complete visualization of the sciatic nerve
  • Provides better visualization of the bursa at the time of bursectomy

Risks and Complications

Endoscopic surgery for deep gluteal syndrome is a relatively safe procedure; however, as with any surgery, there are risks and complications that can occur, such as:

  • Infection
  • Damage to adjacent soft tissue structures
  • Deep vein thrombosis (DVT)
  • Anesthetic complications
  • Instability
  • The American Board of Orthopedic Surgery
  • The Hip Preservation Society
  • American Academy of Orthopedic Surgeons
  • American Medical Association
  • Arthroscopy Association of North America