Diagnosis and Management of Sciatic Endometriosis at the Greater sciatic Foramen: a Case Report

Abstract

Sciatic endometriosis is a rare condition in which endometrial tissue invades or compresses the lumbosacral plexus and/or sciatic nerve and causes sciatic pain, which is often cyclical. Its diagnosis depends on the recognition of signs and symptoms atypical to common degenerative lumbar disorders and its treatment requires timely and coordinated care. A 26-year-old woman presented to a chiropractor at a hospital-based outpatient clinic with a 6-month exacerbation of radiating pain and paresthesia from the right gluteal region into the leg and foot. She was previously treated for over 3 months for suspected lumbosacral radiculopathy with physical therapy. Multisegmental neurologic deficits inconsistent with her prior lumbar imaging prompted further investigation. Pelvis and hip MRI identified a 7×5 cm mass extending through the greater sciatic foramen which compressed and infiltrated the lumbosacral plexus, sciatic nerve, and superior gluteal nerve, and was confirmed via biopsy to be endometriosis. Referral and co-management with a neurologist and obstetrician resulted in a conservative strategy of hormone therapy with the option of having surgical excision if needed. Sciatic endometriosis is a rare disorder that may be misdiagnosed due to its tendency to mimic common lumbar disorders. This case highlights the role of a chiropractor coordinating care for a complex disorder that benefits from early diagnosis for optimal management. It also illustrates how integration of chiropractors into a hospital system can facilitate their ability to manage neuro-musculoskeletal disorders as they can easily refer to and communicate with other medical specialties within the network.

Endometriose no nervo ciático: o papel dos exames de imagem no diagnóstico

“…Além disso, se apresentava de forma progressiva, podendo demorar anos para piora do quadro. (Arányi et al, 2016;Capek et al, 2016;Cimsit, Yoldemir, Akpinar, 2016;Cottier et al, 1995;De Sousa et al, 2015;Kondo et al, 2012;Lomoro et al, 2019;Moeser et al 1995;Moura et al, 2020;Teixeira, 2011;Trager et al, 2021).…”

“…(Capek et al, 2016;Cottier et al, 1995;Moeser et al, 1995;Moura et al, 2020) A demonstração da endometriose em nervo ciático pela RM geralmente se dá em hipersinal nas sequências T1 e T2 e com aparecimento de um halo periférico que fica hipointenso ou pode vir como uma massa hipointensa com zonas centrais de hiperintensidade em T1 e T2. (Capek et al, 2016;Cottier et al, 1995;Kondo et al, 2012;Lomoro et al, 2019;Moura et al, 2020;Pham et al, 2010;Trager et al, 2021). Esses achados são explicados pela presença do conteúdo endometrial no qual no interior deles encontramos a metemoglobina, uma forma da hemoglobina mais tardia e não funcional o que irá caracterizar a presença de hiperintensidade em T1 e T2.…”

“…Esses achados ajudam a diagnosticar endometriose em tecido nervoso. (De Sousa et al, 2015;Lomoro et al, 2019;Pham et al, 2010;Trager et al, 2021). em T2 e além disso, esses tumores realçam após injeção de contraste com gadolínio.…”

“…em T2 e além disso, esses tumores realçam após injeção de contraste com gadolínio. Tais achados destoam daqueles vistos na endometriose ciática onde encontramos hipersinal em T1 e T2 e ausência de alteração após uso de contraste (Arányi et al, 2016;Capek et al, 2016;Cottier et al, 1995;De Sousa et al, 2015;Moura et al, 2020;Trager et al, 2021).…”