Optimizing sciatic nerve exposure: Insights from a multicenter experience and review of the literature

The sciatic nerve, the thickest and longest in human body, is vulnerable to diverse lesions along its course through four distinct regions. Its deep location and surrounding structures may complicate surgical access. Despite multiple approaches described, few indexed publications offered detailed analyses or clear guidelines for optimal exposure.

To describe and evaluate the effectiveness, indications and anatomical considerations of surgical approaches to the sciatic nerve, based on a multicenter case series and a comprehensive literature review.

A retrospective multicenter analysis of patients undergoing surgical exposure of the sciatic nerve between 2005 and 2018 at six tertiary neurosurgical centers in Uruguay, Argentina, Mexico, Spain, Italy and United Arab Emirates. A total of 137 procedures were included. Approaches assessed included the Stookey, transgluteal, infragluteal, posterior mid-thigh and popliteal routes. Outcomes analyzed included feasibility of surgical exposure, functional capacity, cosmetic results, and complication rates. A complementary narrative literature review of publications from the past century was conducted using international health-science databases.

Lesions included traumatic, iatrogenic, compressive, and tumor-related etiologies. Of the 137 patients, 132 underwent a single approach and 5 combined routes. The modified transgluteal approach demonstrated fewer complications and faster recovery, making it preferable for proximal lesions. The popliteal approach required careful vascular consideration, particularly in gunshot injuries. Combined approaches enhanced exposure in selected cases.

Optimal sciatic nerve exposure requires tailoring the surgical approach to lesion location and etiology. Detailed knowledge of regional anatomy supports choosing the least invasive yet effective route, minimizing morbidity and maximizing functional recovery.