Arteriogram showing the active bleed in the inferior gluteal artery before and after embolisation. 

Contexts in source publication

Context 1

... sciatic paralysis can be secondary to three main mechanisms: stretching, 13 compression 1 and severance. 15 Acute compression of the sciatic nerve is most often secondary to a postoperative haematoma 5 ; but, in exceptional circumstances, it can be secondary to a traumatic arterial injury. We present the first case of traumatic sciatic paralysis secondary to compartment syndrome of the buttock caused by inferior gluteal artery rupture. We are proposing a decision algorithm designed to optimise the medical and surgical care provided and limit sequelae. Mr X was a 25-year-old male, athletic and with no previous history. He was involved in a snow-boarding accident and suffered a blunt force impact to the left buttock. He rapidly experienced swelling and burning pain radiating along the back of his left lower extremity. At initial clinical examination, 2 h after the trauma, no haemodynamic abnormality was observed, but there was a painful swelling in the left buttock with fluctuating paraesthesia in the territory of the common fibular nerve, without associated motor symptoms. Pelvic X-rays showed no fracture. The angiogram revealed a haematoma in the buttock muscles (Fig. 1) without active bleeding. In view of the fluctuating nature of the neurological symptoms and the absence of motor effects, the patient was hospitalised for analgesic treatment and hourly neurological monitoring. Fifteen hours after the trauma, the patient’s condition worsened rapidly, with increased hypoaesthesia and the onset of motor deficit of the common fibular nerve. Under general anaesthetic and with the patient in prone position, we carried out a fasciotomy through a direct posterior, longitudinal incision and evacuated a compressive haematoma (approximately 1.5 l). Intra-operatively, the sciatic nerve was found to be contused and bleeding and there was active arterial bleeding from the greater sciatic notch. As the bleeding could not be controlled, it was packed with a haemostatic mesh until an arteriogram could be performed. This showed bleeding from one branch of the inferior gluteal artery (Fig. 2); selective embolisation was performed, with success. Due to the delay (2 h) between the initial surgery and embolisation, there remained a haematoma in the buttock compressing the sciatic nerve and potentially compromising neurological recovery. It was decided that further surgery should be performed, through the same incision, and this allowed the evacuation of a residual 1-l haematoma. The transfusion of 7 units of packed red blood cells and 2 units of fresh frozen plasma was necessary during the first 24 h. The postoperative course was uneventful, with complete disappearance of motor symptoms but persistence of moderate paraesthesia in the territory of the common fibular nerve. The patient was able to return home on the seventh postoperative day. Six days after the initial trauma, there was no motor or sensory disturbance. This favourable outcome did not justify the performance of an electromyogram. Sciatic neuropathy after pelvic trauma without fracture occurs in around 5% of cases 7 ; most of the time it is not severe and has a favourable outcome. However, true traumatic sciatic paralysis is possible and can be caused by three mechanisms: severance (neurotmesis), which has a very unfavourable outcome, 15 stretching (axonotmesis), which has an uncertain functional prognosis depending on radicular lesions, 13 and compression 1,5,8,16,11,17,21,2,20 (neurapraxia), which has a more favourable prognosis if appropriate, early treatment is administered. In our case, the sciatic nerve was compressed after leaving the pelvis and running between the gluteus maximus and the lateral rotator muscles. 14 At this point, arterial damage can lead to intramuscular bleeding and compressive compartment syndrome. 6 Only three cases of ruptured superior gluteal artery complicated by compartment syndrome of the buttock have been described after pelvic trauma without fracture 4,12,3 and none after rupture of the inferior gluteal artery, which is deeper and less exposed to trauma. 12,10 The gluteal compartment is large: arterial rupture can remain asymptomatic for several hours before it becomes clinically manifest through rapid, progressive damage to the sciatic nerve. 1,16,20,4 Initially, the patient presented with only moderate paraesthesia in the territory of the common fibular nerve; the motor dysfunction did not occur until 12 h later. One of the difficulties is therefore the late diagnosis. After trauma to the buttock, rapid swelling, severe throbbing pain and neurological dysfunction upon examination in the territory of the sciatic nerve should prompt suspicion of gluteal compartment syndrome. At first, the absence of clear symptoms of dysfunction did not suggest that surgery was necessary. When symptoms worsened, surgery was decided upon because the initial computed tomography (CT) angiography had not detected an active bleed. After any blunt gluteal trauma, the first step is to prevent haemodynamic shock, before performing a standard X-ray to identify any fracture of the pelvis or hip (Fig. 3). In the event of systemic sensory or motor neurological dysfunction, a CT angiogram 4,12 is carried out to look for a haematoma or an active bleed. Some people suggest using a Doppler ultrasound. 22 The advantage of this is that it can be performed immediately in the resuscitation room. There are, however, many disadvantages: operator-dependent techniques, false negatives for patients in pain who are difficult to mobilise and the risk of delaying therapeutic action. If there is an active bleed, it needs to be precisely located with arteriography followed by selective embolisation 4,12,3,22 which has advantages. It can be performed immediately, further reducing the time to treatment and the risk of haemorrhage which can threaten the patient’s chances of survival. 4,3,9 It also enables the haemorrhage to be more effectively controlled, 9 provided the necessary technical equip- ment and an interventional radiologist are available. Decom- pressive fasciotomy is the second-line treatment and is more likely to be carried out if there is neurological deficit at initial examination. Surgery is also an option if embolisation fails. On the other hand, very few physicians would advocate decompressive fasciotomy as first-line treatment with surgical ligature in the event of a ruptured gluteal artery. 19 This type of surgery carries a risk of haemorrhage 19 (major bleeding that cannot be controlled due to retraction of the artery into the pelvis) and infection 18 (length of the procedure, high risk of bleeding and the possibility of cutaneous or muscle tissue necrosis after arterial ligature). In the absence of neurological symptoms or in the event of a non-contributory neurological examination, hourly neurological monitoring is indicated. 20 The mere presence of a non-compressive haematoma does not, in our opinion, justify surgical intervention. On the other hand, even if the initial tests do not show a bleed, any rapid worsening or onset of neurological symptoms requires the performance of a CT angiogram to check for an active bleed. Ultimately, compression of an artery by a haematoma or an arterial spasm, particularly where treated with vasopressors, may disguise a bleed that should be treated by selective embolisation followed by a decompressive ...

Context 2

... 1.5 l). Intra-operatively, the sciatic nerve was found to be contused and bleeding and there was active arterial bleeding from the greater sciatic notch. As the bleeding could not be controlled, it was packed with a haemostatic mesh until an arteriogram could be performed. This showed bleeding from one branch of the inferior gluteal artery (Fig. 2); selective embolisation was performed, with success. Due to the delay (2 h) between the initial surgery and embolisation, there remained a haematoma in the buttock compressing the sciatic nerve and potentially compromising neurological recovery. It was decided that further surgery should be performed, through the same incision, and ...