Nervo isquiático e suas variações: é possível associá-las à síndrome do piriforme?

Barbosa, Ana Beatriz Marques; Santos, Priscele Viana dos; Targino, Vanessa Apolonio; Silva, Nathalie de Almeida; Silva, Yanka Costa de Melo; Gomes, Felippe Barbosa; Assis, Thiago de Oliveira

doi:10.1590/0004-282X20190093

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Arquivos de Neuro-Psiquiatria

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View and Review • Arq. Neuro-Psiquiatr. 77 (9) • Set 2019 • https://doi.org/10.1590/0004-282X20190093 copiar

Nervo isquiático e suas variações: é possível associá-las à síndrome do piriforme?

Autoria SCIMAGO INSTITUTIONS RANKINGS

RESUMO

O nervo isquiático forma-se a partir das raízes do plexo lombosacro e emerge da pelve passando inferiormente ao músculo piriforme, em direção ao membro inferior onde se divide em nervos tibial e fibular comum. Variações anatômicas relativas ao local onde ocorre a divisão desse nervo, bem como do seu trajeto, parecem ser fatores relacionados à síndrome do piriforme.

Objetivo:

Analisar as variações anatômicas do nervo isquiático e suas implicações clínicas.

Materiais e Métodos:

Trata-se de uma revisão sistemática de artigos indexados nas bases de dados PubMed, LILACS, SciELO, SPRINGERLINK, SCIENC DIRECT e LATINDEX. Foram incluídos artigos originais envolvendo as variações do nervo isquiático. Considerou-se para este estudo o nível de divisão do nervo isquiático e o seu trajeto em relação ao músculo piriforme. A coleta foi realizada por dois revisores independentes.

Resultados:

Ao final da busca foram selecionados 12 artigos, caracterizados quanto à amostra, método para avaliar a estrutura anatômica e principais resultados. A variação anatômica mais prevalente foi aquela em que o nervo fibular comum atravessa as fibras do músculo piriforme (33,3%). Três estudos (25%) observaram, ainda, variações anatômicas não classificadas na literatura e em outros três (25%) constatou-se a presença de um músculo piriforme duplo.

Conclusão:

Os resultados desta revisão mostram as variações mais prevalentes do nervo isquiático e apontam para uma possível associação dessa condição com a síndrome do piriforme. Desse modo, essas variações devem ser consideradas durante a semiologia dos distúrbios envolvendo os membros inferiores.

Palavras-chave:
Músculo piriforme; nervo ciático; anatomia

Studies	Evaluation criteria
Studies	1	2	3	4	5	6	7	8	9	10	11	12	Total (%)
Ugrenovic et al. (2005)²¹21. Ugrenović S, Jovanović I, Krstić V, Stojanović V, Vasović L, Antić S, et al. [The level of the sciatic nerve division and its relations to the piriform muscle]. Vojnosanit Pregl. 2005 Jan;62(1):45-9. https://doi.org/10.2298/VSP0501045U https://doi.org/10.2298/VSP0501045U...	2	1	2	2	2	NA	2	1	2	2	0	1	77.27
Pokorný et al. (2006)¹⁸18. Pokorný D, Jahoda D, Veigl D, Pinskerová V, Sosna A. Topographic variations of the relationship of the sciatic nerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty. Surg Radiol Anat. 2006 Mar;28(1):88-91. https://doi.org/10.1007/s00276-005-0056-x https://doi.org/10.1007/s00276-005-0056-...	1	1	2	0	2	NA	1	0	1	2	0	1	50.00
Polesello et al. (2013)¹⁹19. Polesello GC, Queiroz MC, Linhares JP, Amaral DT, Ono NK. Anatomical variation of piriformis muscle as a cause of deep gluteal pain: diagnosis using MR neurography and treatment. Rev Bras Ortop. 2013;48(1):114-7. https://doi.org/10.1016/j.rbo.2012.12.001. https://doi.org/10.1016/j.rbo.2012.12.00...	1	1	2	0	1	NA	2	0	2	2	0	2	59.09
Gomes et al. (2014)¹⁴14. Gomes BA, Ramos MR, Fiorelli RK, Almeida CR, Fiorelli SK. Topographic anatomical study of the sciatic nerve relationship to the posterior portal in hip arthroscopy. Rev Col Bras Cir. 2014;41(6):440-4. https://doi.org/10.1590/0100-69912014006010 https://doi.org/10.1590/0100-69912014006...	2	0	2	2	1	NA	2	2	2	2	0	1	72.72
Jacomo et al. (2014)¹⁵15. Jacomo AL, Martinez CA, Saleh SO, Andrade M, Akamatsu FE. Unusual relationship between the piriform muscle and sciatic, inferior gluteal and posterior femoral cutaneous nerves. Int J Morphol. 2014;32(2):432-4. https://doi.org/10.4067/S0717-95022014000200008 https://doi.org/10.4067/S0717-9502201400...	1	0	2	2	1	NA	2	0	1	2	0	1	54.54
Natsis et al. (2014)⁴4. Natsis K, Totlis T, Konstantinidis GA, Paraskevas G, Piagkou M, Koebke J. Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome. Surg Radiol Anat. 2014 Apr;36(3):273-80. https://doi.org/10.1007/s00276-013-1180-7 https://doi.org/10.1007/s00276-013-1180-...	2	1	2	2	2	NA	1	1	2	2	0	2	77.27
Sulak et al. (2014)²⁰20. Sulak O, Sakalli B, Ozguner G, Kastamoni Y. Anatomical relation between sciatic nerve and piriformis muscle and its bifurcation level during fetal period in human. Surg Radiol Anat. 2014 Apr;36(3):265-72. https://doi.org/10.1007/s00276-013-1179-0 https://doi.org/10.1007/s00276-013-1179-...	2	2	1	2	2	NA	2	2	2	2	0	1	81.81
Berihu e Debeb (2015)¹²12. Berihu BA, Debeb YG. Anatomical variation in bifurcation and trifurcations of sciatic nerve and its clinical implications: in selected university in Ethiopia. BMC Res Notes. 2015 Nov;8(633):633. https://doi.org/10.1186/s13104-015-1626-6 https://doi.org/10.1186/s13104-015-1626-...	2	2	1	0	2	NA	2	0	2	2	0	1	63.63
Kabakci et al. (2016)¹⁶16. Kabacki AD, Buyukmumcu M, Yilmaz MT, Cicekcisabi AE, Akin D. Anatomical structure and topographic anatomy of sciatic nerve in human fetuses. J Anat Soc India. 2016;65(suppl 1):25-38. https://doi.org/10.1016/j.jasi.2015.12.001 https://doi.org/10.1016/j.jasi.2015.12.0...	2	2	2	2	2	NA	2	2	2	2	0	1	86.36
Lewis et al. (2016)¹⁷17. Lewis S, Jurak J, Lee C, Lewis R, Gest T. Anatomical variations of the sciatic nerve, in relation to the piriformis muscle. Translational Res Anat. 2016;5(1):15-9. https://doi.org/10.1016/j.tria.2016.11.001 https://doi.org/10.1016/j.tria.2016.11.0...	2	1	1	0	2	NA	2	0	0	2	0	1	50.00
Carnevalli et al. (2017)¹³13. Carnevalli FU, Fagundes LE, Pelozo Junior O, Garbelotti Junior SA. [Piriformis syndrome and its topographical relationships]. In: IX Encontro Latino Americano de Iniciação Cientifica, V Encontro Latino Americano de Pós-Graduação – Universidade do Vale do Paraíva. [s.d.] [cited 2017 Sept 7]. Available from: http://www.inicepg.univap.br/cd/INIC_2005/epg/EPG2/EPG2-9.pdf http://www.inicepg.univap.br/cd/INIC_200...	2	1	1	0	2	NA	1	0	1	2	0	1	50.00
Varenika et al. (2017)²²22. Varenika V, Lutz AM, Beaulieu CF, Bucknor MD. Detection and prevalence of variant sciatic nerve anatomy in relation to the piriformis muscle on MRI. Skeletal Radiol. 2017 Jun;46(6):751-7. https://doi.org/10.1007/s00256-017-2597-6 https://doi.org/10.1007/s00256-017-2597-...	2	1	2	2	2	NA	2	2	2	2	0	1	81.81

Author (year)	Sample	Methods	Main results
Berihu; Debeb (2015)¹²12. Berihu BA, Debeb YG. Anatomical variation in bifurcation and trifurcations of sciatic nerve and its clinical implications: in selected university in Ethiopia. BMC Res Notes. 2015 Nov;8(633):633. https://doi.org/10.1186/s13104-015-1626-6 https://doi.org/10.1186/s13104-015-1626-...	28 corpses (56 lower limbs)	Corpse dissection	75% of the limbs showed normal anatomy of the sciatic nerve. Of the 25% that showed variations, 11% were related to the piriformis muscle, 5% to the trifurcation of the sciatic nerve and 9% to the variation in the sural nerve origin
Carnevalli, et al. (2017)¹³13. Carnevalli FU, Fagundes LE, Pelozo Junior O, Garbelotti Junior SA. [Piriformis syndrome and its topographical relationships]. In: IX Encontro Latino Americano de Iniciação Cientifica, V Encontro Latino Americano de Pós-Graduação – Universidade do Vale do Paraíva. [s.d.] [cited 2017 Sept 7]. Available from: http://www.inicepg.univap.br/cd/INIC_2005/epg/EPG2/EPG2-9.pdf http://www.inicepg.univap.br/cd/INIC_200...	104 gluteal regions of adult cadavers, of both sexes	Corpse dissection	In 87.5% the sciatic nerve emerges undivided and passes under the piriformis muscle; in 11.54% the sciatic nerve emerges divided, and the common fibular nerve traverses the piriformis muscle, and in 0.96% the sciatic nerve exists as the single trunk through the suprapiriform area.
Gomes, et al. (2014)¹⁴14. Gomes BA, Ramos MR, Fiorelli RK, Almeida CR, Fiorelli SK. Topographic anatomical study of the sciatic nerve relationship to the posterior portal in hip arthroscopy. Rev Col Bras Cir. 2014;41(6):440-4. https://doi.org/10.1590/0100-69912014006010 https://doi.org/10.1590/0100-69912014006...	20 corpses, 17 males and 3 females	Corpse dissection	17 corpses had a normal branching pattern, ie, the nerve emerged undivided and passed beneath the piriformis muscle. In 12.5%, the fibular nerve passed inside the belly of piriformis muscle. One cadaver presented with an anatomical variation type 3 in the left hip and type 1 in the right
Jacomo, et al. (2014)¹⁵15. Jacomo AL, Martinez CA, Saleh SO, Andrade M, Akamatsu FE. Unusual relationship between the piriform muscle and sciatic, inferior gluteal and posterior femoral cutaneous nerves. Int J Morphol. 2014;32(2):432-4. https://doi.org/10.4067/S0717-95022014000200008 https://doi.org/10.4067/S0717-9502201400...	One Caucasian corpse of 58 years of age	Corpse dissection	The cadaver showed high division of the sciatic nerve and the presence of an accessory piriformis muscle. The sciatic nerve was divided under the piriformis muscle, whereas the tibial nerve reflected anteriorly to pass between the accessory piriformis and the superior gemellus muscle
Kabakci, et al. (2016)¹⁶16. Kabacki AD, Buyukmumcu M, Yilmaz MT, Cicekcisabi AE, Akin D. Anatomical structure and topographic anatomy of sciatic nerve in human fetuses. J Anat Soc India. 2016;65(suppl 1):25-38. https://doi.org/10.1016/j.jasi.2015.12.001 https://doi.org/10.1016/j.jasi.2015.12.0...	60 fetuses (9 and 40 weeks of gestation)	Corpse dissection	In 82.5% of the cases, the sciatic nerve division was observed in the popliteal fossa, 15.83% above it, and in 1.67% a high division occurred. In addition, in 98.3%, the sciatic nerve was observed exiting below the piriformis muscle as a single trunk and in 1.67% higher divisions were observed
Lewis, et al. (2016)¹⁷17. Lewis S, Jurak J, Lee C, Lewis R, Gest T. Anatomical variations of the sciatic nerve, in relation to the piriformis muscle. Translational Res Anat. 2016;5(1):15-9. https://doi.org/10.1016/j.tria.2016.11.001 https://doi.org/10.1016/j.tria.2016.11.0...	51 corpses (102 lower limbs)	Corpse dissection	89% presented normal anatomy of the sciatic nerve and its path. Two distinct variations were identified: in 8.8%, the common fibular branch was observed passing through the piriformis and in 2.9% the common fibular branch passed over the piriformis
Natsis, et al. (2014)⁴4. Natsis K, Totlis T, Konstantinidis GA, Paraskevas G, Piagkou M, Koebke J. Anatomical variations between the sciatic nerve and the piriformis muscle: a contribution to surgical anatomy in piriformis syndrome. Surg Radiol Anat. 2014 Apr;36(3):273-80. https://doi.org/10.1007/s00276-013-1180-7 https://doi.org/10.1007/s00276-013-1180-...	147 Caucasian corpses (294 lower limbs)	Corpse dissection	A typical anatomical pattern was found in 93.6%. In 4.1%, the common fibular nerve and the tibial nerve passed below a double piriformis. In 0.3%, both nerves penetrated the piriformis. In 0.3% both nerves passed above the piriformis and 1.4% presented anatomical variations not classified
Pokorný, et al (2006)¹⁸18. Pokorný D, Jahoda D, Veigl D, Pinskerová V, Sosna A. Topographic variations of the relationship of the sciatic nerve and the piriformis muscle and its relevance to palsy after total hip arthroplasty. Surg Radiol Anat. 2006 Mar;28(1):88-91. https://doi.org/10.1007/s00276-005-0056-x https://doi.org/10.1007/s00276-005-0056-...	91 corpses		In 73.1% of the cases, the sciatic nerve followed its normal pattern. In 14.3% it was divided into its terminal branches above the piriformis. One branch going through the muscle, the other under it
Polesello, et al. (2013)¹⁹19. Polesello GC, Queiroz MC, Linhares JP, Amaral DT, Ono NK. Anatomical variation of piriformis muscle as a cause of deep gluteal pain: diagnosis using MR neurography and treatment. Rev Bras Ortop. 2013;48(1):114-7. https://doi.org/10.1016/j.rbo.2012.12.001. https://doi.org/10.1016/j.rbo.2012.12.00...	One female patient, 42 years old	Magnetic resonance imaging	An accessory muscle belly of the left piriformis was observed, and the common fibular branch passed between its fibers and the standard piriformis muscle
Sulak, et al. (2014)²⁰20. Sulak O, Sakalli B, Ozguner G, Kastamoni Y. Anatomical relation between sciatic nerve and piriformis muscle and its bifurcation level during fetal period in human. Surg Radiol Anat. 2014 Apr;36(3):265-72. https://doi.org/10.1007/s00276-013-1179-0 https://doi.org/10.1007/s00276-013-1179-...	20 sciatic nerves in human fetuses	Corpse dissection	In 98% of cases, on both sides, the sciatic nerve passed below the piriformis muscle (normal pattern). And in the other 2% variant formations occurred, which could be related to piriformis syndrome
Ugrenovic, et al. (2005)²¹21. Ugrenović S, Jovanović I, Krstić V, Stojanović V, Vasović L, Antić S, et al. [The level of the sciatic nerve division and its relations to the piriform muscle]. Vojnosanit Pregl. 2005 Jan;62(1):45-9. https://doi.org/10.2298/VSP0501045U https://doi.org/10.2298/VSP0501045U...	100 human fetuses in various gestational periods and for both sexes	Corpse dissection	In 72.5% of the cases the normal anatomical pattern was verified (bilaterally 66%). In 27.5%, there was a high division of this nerve in the gluteal region. In addition, 96% of the nerve left the pelvis through the infrapiriform foramen, while in 4% variations of the sciatic nerve in relation to the piriformis muscle were detected
Varenika, et al. (2017)²²22. Varenika V, Lutz AM, Beaulieu CF, Bucknor MD. Detection and prevalence of variant sciatic nerve anatomy in relation to the piriformis muscle on MRI. Skeletal Radiol. 2017 Jun;46(6):751-7. https://doi.org/10.1007/s00256-017-2597-6 https://doi.org/10.1007/s00256-017-2597-...	755 exams	Magnetic resonance imaging	The normal anatomy patterns were found in 87% of cases. The other 13% showed one of the divisions of the sciatic nerve passing through the piriformis, and the other division passing below

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[1] Correspondence: Thiago de Oliveira Assis; Departamento de Biologia / UEPB; Rua Domitila Cabral de Castro, s/n - Universitário, Campina Grande - PB, 58429-600 Campina Grande PB, Brasil; E-mail: thiago.oa@hotmail.com