Sciatic Nerve Decompression Periprocedural Care

Updated: Sep 22, 2015
  • Author: Andrew I Elkwood, MD, MBA, FACS; Chief Editor: Jorge E Alvernia, MD  more...
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Periprocedural Care

Equipment

In most cases, standard surgical instruments alone can be used. Fiberoptic retractors and illumination are especially helpful when high dissection of the nerve is planned or other difficulties are anticipated. As with any surgery in which significant bleeding may be encountered, vascular instruments should always be on hand or readily available.

Although controversial, an endoscopic approach warrants endoscopic equipment. Specifics as to ports, scopes, and individual instruments are up to the particular surgeon's preference.

In instances involving possible nerve grafting, resection, or intrafascicular microneurolysis, an operating microscope, microsurgical instruments, microsuture, and fibrin glue should be available. Cases involving neuroma-in-continuity, tumors, or difficult dissections may require intraoperative nerve monitoring, conduction studies, and electromyography. In those instances, the proper personnel need to be available.

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Patient Preparation

Anesthesia

Although it is theoretically possible to perform sciatic nerve decompression with spinal or epidural anesthesia, general anesthesia is almost always used. This is especially true if intraoperative nerve monitoring is to be performed, as regional anesthesia may limit some monitoring modalities. In addition, if nerve monitoring is to be performed, the use and timing of specific anesthetic agents should be preplanned with the anesthesia staff.

Positioning

Patients are typically placed in a well-padded prone position with moderate hip flexion. A modified lateral decubitus position can also be used. Prone cases, particularly those anticipated to be of long duration, mandate the use of a urinary catheter.

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Monitoring & Follow-up

Long-term follow-up is mostly clinical. Cases that are mainly due to a neurapraxia of the nerve should improve significantly in 3 months or less. In cases in which Wallerian degeneration has occurred, a clinician should follow the migrating Tinel sign, which moves at or about the standard 1 mm per day. Stalled migration of a Tinel sign may be troublesome and may require reoperation.

Patients may also have a concomitant compression syndrome (ie, tarsal tunnel syndrome). Nerve conduction velocities may also have a role, but, ultimately, clinical assessment is key. Patients may continue to improve over the course of a year or more. Secondary procedures, such as tendon transfer, should typically not be entertained until improvement has reached a plateau.

Physical therapy is particularly important in patients with palsy. Keeping joints supple, strength building, range of motion, re-education, and desensitization are to be pursued when necessary. For patients with palsy such as foot drop, proper splinting and range-of-motion maintenance are also very important. It is important to avoid a return of function that is stunted by a plantar flexion contracture.

Hip flexion and prolonged ischial pressure should be avoided. Sitting is the least desirable position. Ambulation and prone positioning should be encouraged.

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