Characterization of Patients with Acute Appendicitis in the Elderly

Introduction

The first who drew attention to inflammation of the appendix cecal and gave it the name of acute appendicitis was Vidusenen 1561.1 In 1886 Kronlein performed the first appendectomy for apendicitis perforated the patient died. Later in 1887 T.G. Morton of Philadelphia performed the first successful appendectomy [1,2]. In Cuba, in 1893, Dr. Francisco Plá presented a presentation at the Society of Clinical Studies of Havana, about the first case of acute appendicitis, and it was in 1900 that Dr. Enrique Fortún performed the first appendectomy [1,2]. Acute appendicitis occurs in the elderly with a frequency between 5 and 10%. In those under 65 years of age, mortality is 0.2%, while in those over 65 years of age it is 4.6% [2,3]. Specifically in Cuba, the number of people aged 60 and over has varied from 11 .3% in 1985 to 20.4% in 2018 and 21.3% in 2020. In 2025, Cuba will be the oldest country in America [1]. Acute appendicitis in geriatric patients is a challenge for the surgeon, since this group of patients is always accompanied by comorbid conditions, so any delay in diagnosis and treatment significantly increases the already recognized high morbidity and mortality of abdominal sepsis in the elderly [4]. In accordance with the above , the American Society of Anesthesiology (ASA), presented a classification to define surgical risk, according to the functional limitations caused by coexisting diseases. It is important to point out that when comparing the mortality curves according to the ASA classification, it is concluded that postoperative mortality is more related to coexisting diseases than to chronological age [5]. In addition to this classification, it should be taken into account account that there is a progressive decline in the physiology of the elderly, in such a way that that the physiological reserve that is usually adequate for elective surgery may be insufficient when it comes to an emergency or a postoperative complication [6]. The diagnosis of acute appendicitis is essentially clinical. The Examination of the abdomen is performed by areas where there is less pain. Digital rectal examination should be performed routinely [7]. We must bear in mind that the symptoms are late and nonspecific and that the elderly have low sensitivity to pain and the febrile response is usually discreet [8]. An atypical clinical picture is common in elderly patients [9]. Sometimes it is difficult to establish a definitive diagnosis of acute appendicitis in the geriatric patient [10]. With the purpose of reduce complications and mortality from this disease, it is that the following work is carried out with the objective of characterize the behavior of acute appendicitis in adults in the “Enrique Cabrera” Hospital over a period of ten years.

Methods

An observational, descriptive longitudinal study was carried out retrospectively in the period between January 2011 and December 2020. The patients were studied from their admission until hospital discharge. Universe and sample. The universe was made up of all patients over 60 years of age who underwent surgery for acute appendicitis at the “Enrique Cabrera” General Teaching Hospital, with a total of 114 cases. It was not necessary to use a sampling method, nor to calculate the sample size since we refer to total number of patients over 60 years operated for acute appendicitis. Inclusion criteria. Patients older than 60 years intervened surgically for acute appendicitis. Data processing and analysis. patient information operated for acute appendicitis was obtained from the medical records of the General Surgery Service of the “Enrique Cabrera” Hospital and then transferred to a data collection form that was subsequently processed and analyzed with the Microsoft Office Excel 2010 program. The results were expressed through descriptive statistics in absolute frequencies, percentages and arithmetic mean Ethical parameters. The principles referring to the code of ethics in accordance with the Declaration of Helsinki. It was guaranteed security and confidentiality of the information, clarifying that the data derived from the research would be used for scientific purposes. The study was approved by the Hospital Ethics Committee.

Results

Table 1: Distribution of patients over 60 years operated.

Note: Sources: Information obtained from medical records.

Table 2: Distribution according to clinical picture.

Note: Sources: Information obtained from medical records.

As can be seen in Table 1, the age group was comprised of between 60 and 69 years with 64.9%. The male sex was the one with the highest incidence with 54.4%. Abdominal pain was the symptom present in 100% of the patients. patients, typical abdominal pain prevailed in 62 of them (54.4%), only 18 had fever. There were 94 with positive Blomberg’s sign, 80 cases (70.2%) had a painful Mc Burney point, only six had tachycardia, all of which is shown in Table 2. Table 3 shows us that in the 100 leukograms recovered from the medical records, leukocytosis was observed in 78% of 78%. No, we were able to retrieve the results of fourteen leukograms in the medical records. In all cases where it was possible to perform computerized axial tomography, the diagnosis was positive. Most of the patients assessed preoperatively by the fitness classification of the American Society of Anesthesiology corresponded to ASAII 80 cases (70.2%), which is observed in Table 4. Table 5 shows that the most common anatomical-pathological diagnosis frequent was suppurative appendicitis in 74 patients 65.0%. In six of them confirmed appendiceal gangrene 5.2%.

Table 3: Distribution of complementary.

Note: Sources: Information obtained from medical records.

Table 4: Distribution according to physical status classification by the American Society of Anesthesiology.

Note: Sources: Information obtained from medical records.

Table 5: Distribution according to anatomy-pathological stages of inflammation of the cecal appendix.

Note: Sources: Information obtained from medical records.

Discussion

Acute appendicitis occurred more frequently in patients aged between 60 and 69 years, which coincides with that reported by other authors [1,2]. The lower frequency in ages older than 69 years is related to appendicular atrophy due to the involution of the lymphoid tissues of the appendix [2,3]. In the study, the incidence of the disease prevailed in the sex masculine with respect to the feminine. In the reviewed literature, supports that from the sixth decade of life the difference with regarding sex, it ceases to manifest itself [2,7]. The physiological changes that occur with aging modify the functioning of each organ, an example of this is the perception of pain, which is usually less marked with increasing age, the same happens with fever, due to depression senile immune system called immunosenescence [2]. In our patients, the most important symptom was pain. abdominal, different from the younger ones, in which if the sequence of the appearance of pain, first visceral and then somatic.

When diarrhea or constipation is present in the clinical picture, as occurred in two patients in the study, it is related to pelvic or retroileal appendicitis where appendicitis, due to its unusual position near the rectum, generates said symptom [8,10,11]. On physical examination it was found that the signs considered cardinal for the diagnosis of acute appendicitis as they are the sign of Blomberg, painful Mc Burney point and others were manifested, but in a lower frequency than that presented in young people, which coincides with other studies reviewed [2,3,8,9]. The above is explained because the perception of pain decreases, due to The diseases Concomitant cardiovascular events that limit the cardiovascular response, such as increased heart rate. Regarding the laboratory tests, the leukogram reported an acceptable sensitivity to corroborate the suspected diagnosis of inflammatory process of the appendix. The use of abdominal ultrasound is not a routine indication for the diagnosis of acute appendicitis, but it was performed in most patients, as an aid to the differential diagnosis.

The anatomical-pathological study of the appendix showed advanced stages of acute appendicitis, suppurative in most of the 57 patients who underwent surgery. The rate of appendiceal perforation (including perforation and gangrene) was low in the study compared to other investigations reporting rates from 30% to 70% [2,9]. Perforation of the appendix is the single most important predictor of mortality and late diagnosis is the main cause of this. The most common postoperative complication was site infection. operative, which coincides with other studies such as that of González E. and others [12,13]. Study morbidity was low and mortality nil, other sources literature reports it below 1% [2]. In our study, showed a satisfactory postoperative evolution of the patients. Acute appendicitis is a disease that occurs in the elderly patient with attenuated symptoms due to involution of the lymphoid tissues of the appendix, in addition to the physiological changes that occur with aging, which they modify the functioning of each organ [14-16]. In 2025, Cuba will be the oldest country in America and the sagacity and experiences of our surgeons in the diagnosis of this disease, morbidity and mortality will be very low or zero [2].

Conclusion

Patients over 60 years of age who underwent surgery for acute appendicitis were predominantly male, between 60 and 69 years of age, with typical abdominal pain and classic signs of the disease. The suppuration phase of the appendix was mostly confirmed. A favorable evolution of the patients was observed.

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Impact of Climate Change on the Women of Ethiopia

Introduction

Background

Climate change is a universal human rights imperative, a global security threat, and a pervasive economic strain. To date, however, much of the focus of international policymakers and institutions has been confined to the arenas of science and the economy (Heike S [1]). What does gender have to do with climate change? Surely climate change does not discriminate between men and women. First of all, ‘gender’ does not mean exclusively women; but people do (Wambui E [2]).

Climate

Climate is the statistics of weather over long periods. It is measured by assessing the patterns of variation in temperature, humidity, atmospheric pressure, wind, precipitation, atmospheric particle count and other meteorological variables in a given region over long periods. Climate differs from weather, in that weather only describes the short-term conditions of these variables in a given region (Wikipedia).

Gender

Gender refers not to male or female but too masculine or feminine- a designation that is largely determined by socialization and cultural norms. Perceptions of gender are deeply rooted, vary widely both within and between cultures, and change over time. But in all cultures, gender determines power and resources for females and males. The increasing acceptance and thrust to incorporate ‘gender; has led to the use of such terms as gender roles, gender discrimination, gender equality and gender mainstreaming, among others. Gender subscriptions all determine power and access to resources in most societies. In the context of climate change, there is the recognition that gender affects interactions with, perceptions and the ways and extent to which one is affected (Connect [3]).

Why are the gender perspectives on climate change becoming a growing issue of concern? The vast majority of academics suggest that women comprise the largest percentage of the world’s poor. It is commonly accepted that climate change exacerbates existing inequalities in both key dimensions: livelihood security, and factors that are fundamental for coping with a change like education and wealth among others (ECA) [4] . As stated in (Jazmin M [5]), the research in London by Essex University in between 1981-2002 found that:

1) Natural disasters lower the life expectancy of women more than that of men;

2) The stronger the disaster, the stronger this effect on the gender gap in life expectancy;

3) The higher women’s socio-economic status, the weaker this effect on the gender gap in life expectancy.

Climate Change: The Inter-Governmental Panel on Climate Change (IPCC) defines Climate change as a change in the state of the climate that can be identified (e.g., by using statistical tests) by changes in the mean and/or the variability of its properties, and that persists for an extended period, typically decades or longer (Heike S [1]). According to the United Nations Framework Convention on Climate Change (UNFCCC), climate change refers to “a change of climate which is attributed directly or indirectly to human activity that alters the composition of the global atmosphere and which is in addition to natural climate variability observed over comparable periods.” (ECA) [4].

Climate change is not a neutral process (Heike S [1]). Climate change is a process that manifests in several ways, including a rise in average temperatures; changes in rainfall patterns leading to floods, droughts, and, in some areas, desertification; extreme and unpredictable weather patterns leading to more numerous and intense natural disasters; and the melting of glaciers and the polar ice-caps, resulting in rising sea-levels and coastal erosion, leaving low-lying areas uninhabitable. Valerie N [6] and ECA [4] indicated that Climate change may be due to natural internal processes or external forcing such as modulations of the solar cycles, volcanic eruptions, and persistent anthropogenic changes in the composition of the atmosphere or land use. Policymakers clearly state that it is a fact that the climate is warming and during the past decades the cause has been mainly anthropogenic (Jazmin M [5]).

Impacts of Climate Change: Climate change impacts, especially rapid-onset events, may result in death, injury, or damage to health through an increase in infectious diseases, physical and mental stress, and the loss of medicinal plants and biodiversity (Mayesha M [7]). The global effects of climate change will negatively impact communities at multiple levels, threatening the security, economic, and human rights conditions of people around the world (USA EPA [8]). Women are disproportionately burdened by these processes, but they also can lead adaptation and create more resilient communities (Mayesha M [7]). Climate change is a global challenge that burdens all of humanity, but not equally (Valerie N [6]). Most women have healthy pregnancies and healthy babies. However, climate change can worsen environmental hazards that threaten the health of pregnant women and increase health risks for the baby (USA EPA [8]). As a study in Maruf Kebele of Central Oromiya region in Ethiopia results indicated that farmers had a good understanding and perception of the impacts of climate change at the local level; many negative impacts of the climate irregularity had been identified by the community, like reduced crop yield, heating/drying up of the environment and soil loss affecting natural plant regeneration from the forest soil seed bank, drying up of streams and springs, the disappearance of trees and plants, the rarity of wild animals and increasing pests/diseases. Farmers were observed to diversify their livelihood options as part of responding to irregularities in the local weather and adopting many steps to change agricultural practices (Olika Belachew [9]). Women and children including old ages are the most vulnerable group of society (ECA) [4]. Hence, as women contribute 80% of the agricultural productivity (Valerie N [6]) which is the backbone of Ethiopian economy (85%); it is better to identify the impacts of climate change on women of our country and find the ways forward to let them either adapt or mitigate the impacts.

Objectives

General Objectives:

i. To identify the impact of climate change on women of different age groups.

Specific Objectives:

i. To describe climate change patterns.

ii. To identify the cross-cutting issues related to climate change.

iii. To identify the direct and indirect impacts of climate change.

iv. To discriminately illustrate the impacts of climate change on women.

v. To indicate the way forward.

Literature Review

Climate Change Pattern

The climate has been changing (cooling and heating) for millennia; however, it is in recent years (some point out the Industrial Revolution as a key milestone) that human practices, such as the burning of fossil fuels and land-use changes among many other actions, have to lead to anthropogenic climate change (Heike S [1]). Carbon dioxide is the most important anthropogenic greenhouse gas; in 2005 the atmospheric concentration of carbon dioxide (379ppm) well exceeded the natural range (180- 300ppm) of the past 650,000 years. The IPCC has a very high degree of confidence that the global average net effect of human activities since 1975 has been one of warming. What is new about anthropogenic climate change, besides its causes, is the speed and scale of change (Jazmin M [5]). In Ethiopia, All animals including humans are panting including man, Trees are used to get shade from the burning sun No need for warmth giving clothes. Irregularly falling rain does not percolate rather erode fertile soils and their seed depriving their re-generation capacity (Olika Belachew [9]).

Cross-Cutting Issues Between Climate Change and Women

Poverty: Climate change is superimposed on existing vulnerabilities and thus affects poor people more (Heike S [1]). It will further reduce access to drinking water; negatively affect the health of poor people to a greater extent by pose a real threat to food security in many countries in Africa, Asia, and Latin America (Jazmin M [5]). The reason why poor people are seriously harmed by climate change is that they are mostly dependent on climatesensitive resources (ECA) [4]. In poor households throughout the world, women go without food for the benefit of their children or male family members. As food prices rise, poor households tend to experience a reduction in the quality or quantity of food they can purchase, with women most likely to make the sacrifice (Connect [3]). Women in African societies are the backbone of the continent’s labor force, especially in agriculture. African women produce approximately 80 percent of the continent’s food. This is because over 60 percent of employed women in sub-Saharan Africa are agriculturally based. However, in time of the environmental degradation caused by the rapid depletion of natural resources, the economic role played by women to support their household and societal well-being is in jeopardy (Valerie N [6]). Climate change impacts are likely to be felt most by the rural poor and particularly women in Ethiopia (Olika Belachew [9]). A study by Nellemann et al. 2011 indicated that organized human trafficking, especially women, is also emerging as a potential risk associated with climate change; which can increase by 20-30% (Jazmin M [5]).

Culture and Traditional Practices: All decision is made by a masculine view of the problem and its solutions. The participation of women in the whole process (including the decision on climate change impacts) at international, national and local levels is very low (Heike S, ECA [1,4]). Gender roles and gender discrimination not only exacerbate women’s and girls’ exposure to cli¬mate risk but also reduce women’s capacity to accommodate their lifestyle to shifts in weather conditions (Valerie N [6]). For example, for households dependent on agriculture, the land is the most important productive asset; yet in many parts of the world, women are denied access to and control over land due to discriminatory laws and customs (ECA) [4]. Women’s traditional roles as the primary users and managers of natural resources, primary caregivers, and laborers engaged in unpaid labor mean they are involved in, and dependent on livelihoods and resources that are put most at risk by climate change (Heike S, ECA [1,4]).

A study by the London School of Economics in the UK analyzed disasters in 141 countries and found that boys are likely to receive preferential Women’s and girls’ acute vulnerability in disasters is due to a host of gendered factors, including cultural or religious restrictions on female mobility, as well as differences in the socialization of girls which means they may not be equipped with the same survival skills as their brothers (Connect [3]). Women in Bangladesh did not leave their houses during floods because it was regarded as culturally inappropriate and that those who did were unable to swim (Connect [3]). In developing countries “women are already at the receiving end of indoor pollution (Heike S [1]). Women and girls encounter barriers to accessing healthcare services due to a lack of economic assets to pay for healthcare, as well as cultural restrictions on their mobility, which may prohibit them from traveling to seek healthcare (ECA) [4]. Women and men are affected differently by conflicts. Women bear the responsibility for the survival of the family during and after conflicts. Their workload increases in crises, while their income-generating opportunities decrease simultaneously. Family responsibilities tie women to a particular geographical location and limit their opportunities to migrate. As women make up the majority of the poor, they are least able to adapt to changing conditions or rebuild their livelihoods after destruction. Above all, they are most vulnerable to sexual abuse and sexual violence during wars and natural disasters (Valerie N [6]).

Women’s Physical Ability: Gender, like poverty, is a crosscutting issue in climate change and needs to be recognized as such (Heike S [1]). But Women can have a more difficult time than men during recovery. (Jazmin M). In Sri Lanka, swimming and tree climbing are taught mainly to boys; this helped males cope better than females when the tsunami hit (Heike S [1]). Women made up 55-70% of the Banda Aceh (Indonesia) tsunami deaths, and in the worst affected village Kuala Cangkoy, in the North Aceh district, 80% of the deaths were women. According to BBC News online, of the 2003 French heatwave toll of 15,000, about 70% were women (Jazmin M [5]). Women’s mortality related to heatwaves is higher than the mortality of men and they are more affected by UV lights than men (Heike S [1]). Women’s immunity and physical ability are challenged by the burden of multidirectional responsibilities (ECA) [4].

Policy: Clearly, women and girls have important knowledge and insights to contribute to climate change responses (Connect [3]). Higher rates of illiteracy among women and girls and lack of access to information on climate change also exacerbate exposure to climate risk (Connect [3]). Girls interviewed in the Lalibela district of Ethiopia reported the time they spent fetching water increased substantially each day during drought periods. Fetching water could take up to six hours a day, whereas previously it had taken around two hours. This makes it increasingly difficult for girls to go or remain and succeed in school (Connect [3]). The unfair location of women in the power-holding and decision making hierarchy which enhances susceptibility to climate change has led to the issue being deemed one of justice – gender justice or as some may say, gender injustice (ECA, Jazmin M [4,5]). Women in Sub-Saharan societies make up an estimated 70% of those living below the poverty line (Valerie N [6]), the one who contribute 80% of agricultural production (ECA) [4] and a majority of family responsibility (Valerie N [6]); yet they are often left out of the discussions and planning on environmental issues even though they may sometimes be in the most appropriate position to overcome their misery (Valerie N [6]).

Direct and Indirect Impacts of Climate Change on Women

There are many direct and indirect ways by which human beings are affected by climate change (Heike S., 2004) (Figure 1).

Figure 1: Relationship between climate change impacts on human security and vulnerability of women (Source: [WEDO 2008 presented in Dankelman et al.] (Jazmin M [5]).

Impact of Climate Change on Water Resources: Climate change would particularly impact women and girls because of their distinct roles concerning water use. Women and girls generally assume primary responsibility for collecting water for drinking, cooking, washing, hygiene and raising small livestock, while men use water for irrigation or livestock farming and industries (ECA, Jazmin M, et al. [4-6]). These distinct roles mean that women and men often have different needs and priorities in terms of water use. This knowledge is quite significant in the context of climate change (ECA) [4]. In drought-prone areas affected by desertification, for example, the time absorbed by water collection will increase as women and children (mostly girls) will have to travel greater distances (6Km as mentioned in Jazmin M [5]) to find water (ECA, Valerie N, Mayesha M [4,6,7]); it can take them up to 6hrs. This is time that could be spent in school, earning an income or participating in public life. Walking long distances to fetch water can expose women and girls to harassment or sexual assault, especially in areas of conflict; there are many accounts of women and girls being attacked when searching for water in refugee camps around Darfur. In urban areas, water collection is also an issue as women and girls may spend hours queuing for intermittent water supplies (ECA) [4].

Impact of Climate Change on atmospheric Pollution: African women are not only victims of natural resource depletion but also pollution to which they can grossly contribute (Valerie N [6]). Some more facts: An estimated 150,000 deaths were caused in the year 2000 due to climate change. A further 5.5 million healthy years of life were lost worldwide due to debilitating diseases caused by climate change“, revealed a study carried out by WHO in December of 2003. In Europe this past summer, for example, an estimated 20,000 people died due to extremely hot temperatures. During heat waves, excess mortality is greatest in the elderly and women (Heike S [1]).

Impact of Climate Change on Biodiversity: Britain, climate change could become the greatest threat to biodiversity. The study predicts that the current rate of climate change will lead to the extinction or endangerment of 15-37 percent of the world’s plant and animal species by 2050, the largest mass extinction since the disappearance of the dinosaurs. Global warming is causing such rapid habitat change that thousands of species will simply be unable to adapt; thousands more will be left stranded in small habitat pockets with nowhere else to go (Valerie N [6]). In general women’s mortality related to heatwaves is higher than the mortality of men (Heike S [1]). Most of these women depend on wood fuels for cooking. Males in the family help in cutting trees without planting new ones. The problem with this is that deforestation increases the time women continue depending on these trees. Also, the time devoted to searching for wood fuels could be used for other valuable activities, such as watering their vegetables, helping their kids with school homework or simply doing other businesses that could generate some income for their households (Valerie N [6]). The depletion of forest resources would be exacerbated by climate change and would increase the burden on women to gather fuelwood, food, fodder and medicinal plants. Women and girls would have to walk longer distances and spend more time securing forest resources, thereby reducing the likelihood of their engagement in educational and alternative livelihood opportunities.

Impact of Climate Change on Energy sources: In many developing countries, especially in the poorest areas, most energy currently comes from traditional biomass fuels such as wood, charcoal and agricultural wastes – and collecting and managing these fuels is a strict ‘women’s business’. Linkages between energy supplies and gender roles are strongest in countries with low availability of basic electricity and modern fuels, and a high dependence on biomass fuels for cooking, heating, and lighting. In these countries, especially in Asia and Africa, cultural traditions make women responsible for gathering fuel and providing food, even when this involves long hours of performing heavy physical labor. These activities substantially increase women’s physical burdens, damage their health, and take up time that could otherwise be spent on caring for their families, educating themselves and their children, and engaging in income-generating activities (ECA [4]). On the contrary, in developing countries the main providers, managers and users of energy in the households are women; however, organizations that make decisions affecting energy policies are male-dominated (Jazmin M [5]).

Impact of Climate Change on Agricultural Productivity: In some regions of Sub-Saharan Africa, rural women traditionally devote time and effort to the land. As stated earlier herein, women account for approximately 70-80 percent of the agricultural labor force and they produce 60 to 80 percent of the food. Most of these women depend on wood fuels for cooking. Males in the family help in cutting trees without planting new ones. The problem with this is that deforestation increases the time women continue depending on these trees. Also, the time devoted to searching for wood fuels could be used for other valuable activities, such as watering their vegetables, helping their kids with school homework or simply doing other businesses that could generate some income for their households (Valerie N [6]).

Conclusion and Recommendations

Women should be given priority of access to clean water resources, its utilization, and sanitation coverage (Jazmin M, et al. [4,5,7]). Stakeholders have to provide financial aids equitably; by enhancing women’s income generation sources. Water sources should be developed in the vicinity at least for the women to easily access it. Women should get protection and first-hand services both before and after risks are happening in the ways that equip them to mitigate or adapt the impacts of climate change on water resources. Furthermore, women have to get pieces of training that help them defend violence. Harmful traditional practices depriving women of utilizing water sources have to end. And the unbalanced burden of water collection, provision, and utilization of women has to be shared by each family member. Violence on women has to get due attention (ECA) [4]. The spirit of care and equitable labor sharing practices has to be developed in developing countries (Mayesha M [7]). The human rights (women’s rights) dimension of water is recognized and respected, as water is indispensable for leading a healthy life in human dignity. In this context, ethics should guide water resources management, including for water supply and sanitation; (ECA) [4]. Women and gender experts are consulted and are involved in decision-making in the water sector and the design and management of water and sanitation policies and programs. Policies and programmers must draw on the existing body of knowledge on gender and water, to inform interventions; A gender perspective, which seeks to include an understanding of gender roles and relations and how these affect and are affected by water and sanitation interventions, is mainstreamed into adaptation options; Local water sources are provided to free up time for women to engage in income-generating activities, by reducing the time required to fetch water and making domestic tasks faster to complete, as well as to impact positively on school attendance. Actual and potential risks of attacks on women and girls, who are obliged to walk long distances in search of water are highlighted in decision-making and planning processes to come up with strategies that prevent these dangers, and to justify the costs associated with the provision of local water supplies. Awareness has to be given about all the above issues by providing need-based pieces of training for the respective community members. Access to education for women should be easy and get priority (Jazmin M [5]). Women have better indigenous knowledge for adaptation to climate change; utilization of this knowledge and mainstreaming in the curriculum is crucial (Mayesha M [7]).

Women should get adequate income sources (eg. Carbon trading, green business, etc) and access to resources that help them adapt to the challenges of atmospheric pollution and hence climate change. Women should get adequate nutrition enabling them to withstand the dangers of air pollution. Women are the most victims of indoor air pollution; adequate, adaptation mechanisms have to be available (Valerie N [6]). Family members have to share equal responsibility in waste management procedures (Valerie N [6]) and household activities that could put women in danger (ECA) [4]. Climate change is fundamentally an issue of human dignity, and is, therefore, inseparable from human Rights (Mayesha M [7]); due attention has to be paid for women. Women play a great role in maintaining biodiversity; there should be financial supports and income generation mechanisms from this activity (Valerie N [6]). Home garden crops such as Enset or false banana, potato, carrot, beetroot, cabbage, garlic, shallot, onion, sweet potato and sugar cane (for chewing) are managed by the women, now have a high contribution to the household income (Olika Belachew [9]). Only during recent years, many women folks also adopting growing wild/semi-wild herbal spices in their home gardens for marketing. Another important component in the traditional system gaining importance during recent years was identified as home/ agro-forestry—a very wide range of plant types for diverse uses getting prominence like guava and mango for marketing and home consumption; also an array of domestic animals are increasing especially chicken with higher market prices of eggs and live birds (Olika Belachew [9]) traditional articles made by women from selected grass species also contribute to homestead income (Olika Belachew [9]).

Women’s abilities are recognized and are incorporated into disaster relief efforts to change gendered roles and perception of rights; and that (ECA) [4]. Women have to get adequate protection in physical or physiological happenings that put them in danger Culture. Cultural or traditional practices that put women in danger have to come to an end. Gender-specific disaster reduction policies are formulated to address the effects of climate change in disasterprone areas, as well as pragmatic national and international interventions to ensure food, energy, and water security, economic resilience and security of place/habitat, particularly for poor and migrating women and their families (ECA) [4]. Amendments have to be made in traditional practices that hinder women from defending themselves from natural hazards including freedom of migration (Senay Habtezion [10]). Women have to get adequate access to sources of information (Senay Habtezion [10]). There has to be adequate and indiscriminate data concerning women’s exposure, risk, and defense mechanism towards natural disasters (Senay Habtezion [10]). A gender-based approach to the study and analysis of climate change and natural disasters is conducted, and that research is supported by sex-disaggregated data (ECA) [4]. Has to be involved in policy formulation and decision making forums (Senay Habtezion [10]).

Women’s empowerment is provided through the capacity building before, during and after climate-related disasters, as well as through their active involvement in disaster anticipation, early warning, and prevention, being part of their resilience building (ECA) [4]. Institutional capacity to mainstream gender in global and national climate change and Disaster Risk Reduction (DRR) policies and operations, is enhanced through the development of gender policies, gender awareness, gender capacity and expertise, and the development and application of relevant mechanisms and tools (ECA) [4]. Women, including those from poor rural villages, are more involved in making energy decisions and plans. Energy policies and interventions should recognize women’s roles in the energy sector and build on their expertise and influence, to effectively promote sustainable economic and social progress. Greater attention is paid to gender in energy investments and initiatives to involve women more in the energy sector and different ways so that they can manage their energy supplies, their businesses, and their lives more effectively and productively. Investments are made in improved fuels and equipment, as much as in access to electricity.

In this regard, women should be engaged at a higher level in the dissemination of new energy technologies and in the effective management of natural resources. Women are empowered to benefit from lucrative projects under the Clean Development Mechanism (CDM). The introduction of the programme of activities (PoA) under the CDM is expected to greatly enhance the opportunities for African countries to access the CDM. The programmatic CDM aims to aggregate geographically dispersed activities that would have been difficult to undertake as traditional, stand-alone CDM projects. Potential activities include: Off-grid renewable energy projects, such as run-of-river hydro and wind power, the use of biomass residues, capturing methane emissions from landfill dumps or animal waste for electricity generation. These can play a valuable role in bringing energy to rural communities and stimulating rural industries. Energy efficiency projects that can save individuals and organizations money and generate additional revenues in the form of CDM carbon credits. This includes mitigating carbon emissions by using fuel-efficient cookstoves and solar water heaters for domestic purposes, and the installation of compact fluorescent light bulbs in public sector offices.

The dependence on rain-fed agriculture has to be shifted in the way enabling the women to improve their productivity and income generation mechanisms (Valerie N [6]). Priority should be given to women in agroforestry processing and land ownership (Valerie N [6]). Women should have adequate time and responsibility in their household as well as outside. Women should not be restricted in expenditures for food and other household matters (Valerie N [6]). As farming alone often cannot sustain rural families, the off-farm economy is an increasingly important source of household income (Valerie N [6]). Should get adequate time for training and education (Valerie N [6]). Women of Sub-Saharan rural women do not have equal access to employment opportunities. Women should get adequate protection from physical, chemical or other hazardous situations facing from their role in agricultural activities (Valerie N [6]). Women have to get priority in credit services. Should get adequate training on modern agricultural productions (Valerie N [6]). African women through training by sensitizing them on issues related to climate change, such as building up their resilience, teaching them how to harvest rainwater, maintaining their land, modern farming (e.g., Till or no-till the soil), composting versus burning dry grass, landfilling with waste, cutting and planting trees, etc. (Valerie N [6]). Women should get priority in facilities and services important in disasters and gender-based violence [11-14].

Climate change as a human security issue is researched and integrated into human rights frameworks, mechanisms, and legislation, including UN Resolution 1325, which calls for greater participation of women in all aspects of conflict prevention, resolution, and management, including peace-building. Women fully participate and contribute to decision-making and leadership related to the nexus of climate change and conflict to ensure effective and socially-just climate change interventions and the prevention of related conflicts. This should include climate change mitigation and adaptation, natural resources management, conflict prevention, management, and peacebuilding. Awareness on the links between climate change, conflict, and their gender dimension is increased, that conflict is integrated into climate change adaptation taking into account that women and men would be impacted differently and that the international community learns from recent events that demonstrate how women are disproportionately affected during conflict and post-conflict situations. Early warning systems are comprehensive, involve women and take into account their concerns, to ensure that timely measures, such as mediation and preventive diplomacy, can be undertaken to avert violent crises. Since many causes of conflict, including inequality and exclusionary politics, have their roots in weak governance, measures to prevent conflict and its recurrence have a better hence of succeeding if they are accompanied by actions promoting effective, inclusive and legitimate governance (including climate governance at all levels) that adequately involves women and youth and effectively address their concerns.

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Posterior Hip and Buttock Pain: Relation to Deep Gluteal Syndrome

Introduction

The article begins with the following Advance Organizer Quiz to Retrieve, Use, and Organize the Materials presented in this paper. Advance organizer – please answer true or false to the following questions:
a. Identifying the site of origin and location about the hip joint is a useful method to classify hip pain. TRUE
b. The deep gluteal space borders posteriorly by the gluteus maximus, anteriorly by the posterior acetabular column, hip joint capsule and proximal femur, laterally by the lateral lip of the lina aspera and the gluteal tuberosity and superiorly the inferior margin of the sciatic notch. TRUE
c. Deep gluteal syndrome (DGS) involves compression of the sciatic or pudendal nerve by any anatomical structure within the deep gluteal space. TRUE
d. Piriformis syndrome is a prevalent subtype of DGS. TRUE
e. Patients who participate in competitive sports have an increased risk of developing proximal hamstring syndrome. TRUE
f. Definitive imaging findings have yet to be established in piriformis syndrome. TRUE
g. Use of advanced magnetic resonance neurography (MRN) techniques and endoscopic correlation has increased awareness of the anatomy and pathologic conditions of the deep gluteal space. TRUE
h. Diagnosis of DGS may include specified history and physical examination findings, plain radiographs (to rule out hip and spine pathology, and calcifications), magnetic resonance neurography (to evaluate peripheral nerves and sciatic nerve aberrancy) and endoscopic decompression. TRUE
i. Endoscopic decompression of sciatic nerve entrapment may be an effective and minimally invasive approach for deep gluteal syndrome. TRUE

Hip Pain

Hip pain often presents as a challenging symptom affecting individuals of all ages and may be associated with numerous underlying causes or etiologies. The hip forms the joint between the upper end of the femur (thighbone) and its socket in the pelvis located in the region of the groin. A stable, major weightbearing ball and socket synovial (fluid) joint, the hip joint allows for significant mobility, formed by a connection between the pelvic acetabulum (the cup-shaped socket in the hip bone) and the head of the femur (the thigh bone) [1]. Forming an articulation from the lower limb to the pelvic girdle (distinctively dissimilar in men and women as to function and size), the hip joint is, thus, intended for stability and weightbearing. Comprised of bone, cartilage, ligaments, muscle, and a lubricating fluid, painful symptoms of a hip disorder will differ depending on the cause of the underlying disorder and the part of the hip joint causing problems [2]. Once hip pain becomes progressive, burdensome and unyielding, patients have no option other than to seek assistance from their medical providers.

As noted in the article Hip Pain: Relation to Anatomical Location and Underlying Pathology [3], a consensus among experts on how to classify hip pain remains undetermined. One method to classify hip pain, however, recognizes the origin of the pain as,
(a) Anterior,
(b) Posterior and
(c) Lateral.
The location of hip pain is further identified as,
a. Within a joint (i.e., intra-articular),
b. Around a joint (i.e., periarticular) or
c. Outside a joint (i.e., extra-articular) [4].

Utilizing essential aids of careful history-taking, relevant physical examination (PE) techniques, and appropriate laboratory testing and imaging studies is fundamental to evaluate underlying causes of hip pain based on origin and location. This review will focus on posterior hip and buttock pain in the adult highlighting DGS as a recently classified and somewhat unfamiliar entity with various subtypes (i.e., piriformis syndrome, gemelli-obturator internus syndrome, proximal hamstring syndrome).

Posterior Hip and Buttock Pain

Although awareness about posterior hip and buttock pain is less recognized than anterior and lateral hip pain [5], improved understanding and knowledge of the anatomy and neural kinematics (forces which cause motion) of hip movement has helped posterior hip and buttock pain become more recognized and understood [6-8]. As a result, the ability to rule out lumbar spine pathology with corresponding lack of imaging findings, allows for other considerations of posterior hip pain or nondiscogenic sciatica (sciatica-like pain) [9]. Other considerations may include any lesion involving the sciatic nerve (originating from L4 to S3), thus making posterior hip and buttock pain often difficult to distinguish from sciatica [5]. Table 1 identifies common causes of posterior hip and buttock pain. DGS, as a separate entity, is a group of various subtypes, previously described as piriformis syndrome (PS).

Table 1: Musculoskeletal differential diagnosis of posterior hip and buttock pain.

Historical Perspective of DGS

To understand DGS, an overview of PS is important as all PS are DGS but not all DGS are PS [10]. Traditionally known as “piriformis syndrome” DGS is now the favored term to describe the presence of pain in the buttock through identification of several locations where there may be entrapment of the sciatic or pudendal nerve [5]. Often undiagnosed or mistaken for other conditions, the concept of DGS now encompasses beyond current understanding of posterior hip pain due to nerve entrapment past the traditional model of piriformis syndrome [5]. Historically, in 1928, the association between sciatic nerve pain and the piriformis muscle was first described [11]. In 1936, American surgeon Thiele described the origins of PS with the piriformis muscle (originating on the front of the sacral bone and inserting on the Major Trochanter of the Femur) compressing the sciatic nerve as it leaves the buttock just below the greater sciatic foramen [10]. In 1999, McCrory and Bell [12], described the PS as only one component of the deep gluteal syndrome (DGS), and further described a broad spectrum of pelvic conditions not associated with piriformis caused similar symptoms [5].

Anatomical variations of the sciatic nerve, however, may contribute to other conditions other than PS, such as coccygodynia and muscle atrophies, if it divides into other nerve components within the pelvis [10]. As a result, the prevalence and the clinical signs related to chronic muscle contractions in the deep gluteal area appear to be more abundant than previously described [10]. In addition to the Piriformis muscle, other deep pelvic muscles like M. Obturator Internus, M. Levator Ani, M. Gemelli and M. Coccygeus may be involved in the pathology and may lie within the space [13]. Thus, the term “deep gluteal syndrome” has evolved to denote many different pathological and etiological conditions, with similar treatment, but with a more well-defined and precise diagnostic term now labelled DGS [10]. Because of ongoing innovations in the understanding of anatomy and neural kinematics of hip movement, identification of DGS is now possible. Traditionally, prolonged and/ or excessive contraction of the piriformis muscles were clinical symptoms associated with PS [11].

Advances in hip and joint kinematics, however, involving the mechanics of pure joint motion without reference to the masses or forces involved, now provide better awareness of hip function and anatomy [14]. In addition, hip kinematics identify a number of areas within the deep gluteal space where the sciatic nerve may be susceptible to entrapment [11]. Any contents of deep gluteal space, including the space that contains piriformis, obturator internus/ externus, gemelli, quadratus femoris, hamstring, gluteal nerves and lateral ascending vessels of the medial femoral circumflex artery, can cause sciatic nerve entrapment syndrome [8]. Furthermore, hip kinematics identifies the occurrence of posttraumatic DGS with development of scar tissue around the piriformis muscle and the sciatic nerve or with adherence of the nerve to the posterior pelvic column [15]. Distinct clinical symptoms and specific physical examination techniques, including provocation tests, are essential to diagnose sciatic (and pudendal) nerve entrapment [8,16]. Use of magnetic resonance imaging (MRI) of the pelvis and electrodiagnostics studies is significant in diagnosing DGS and identifying pathological conditions entrapping the nerves [14]. As such, early detection and treatment of DGS as an entity should now be the standard of care. Nonsurgical and surgical treatment options as presented below may assist in the management of patients with posterior hip and buttock pain related to DGS.

Common Causes of Posterior Hip and Buttock Pain

Pain at the posterior hip and buttock is an often underrecognized manifestation of femoroacetabular joint disease and most commonly includes radicular origins referred from the lumbar spine and sacroiliac joint [4]. Other sources include pathology within the hip joint itself (labral tears, synovitis or chondral injuries) that can refer pain to the buttock or lower back [17,18]. Similarly, proximal hamstring pathology, piriformis syndrome, tendinopathy of the obturator internus/gemelli complex, ischiofemoral impingement and sacral stress fractures are important considerations as causes of posterior hip and buttock pain [4]. As previously noted, early descriptions of PS postulate that prolonged or excessive contraction of the piriformis muscle over time might precipitate deep gluteal pain [11]. If anatomic piriformis abnormalities involve the sciatic nerve, clinical symptoms may include extreme gluteal and lower back pain [11]. Hip joint pathology may refer pain to the knee, while pain referred to the leg or foot generally indicates lumbar spine radiculopathy.

Sciatic and pudendal neuropathies can refer pain to the posterior hip [14]. Posterior hip or nondiscogenic sciatica (sciaticalike pain) can be caused by any lesion originating from L4 to S3 involving the sciatic nerve can cause posterior hip or nondiscogenic sciatica (sciatic-like pain [19]. Genitourinary causes (e.g., intrapelvic impingement) [20,21], gastrointestinal and vascular pathology [4] while beyond the scope of this review should be considered as other potential sources pf posterior hip and buttock pain. (See Table 1 for differential diagnosis of posterior hip and buttock pain.)

DGS as a Cause of Posterior Hip and Buttock Pain

As a relatively unknown but increasingly recognized disorder, DSG describes the presence of pain in the posterior hip and buttock caused by compression or entrapment of the sciatic or pruendal nerve by any anatomical structure or nondiscogenic pelvis lesions in the deep gluteal space [5,13,22] The structures that can be involved in sciatic or pudendal nerve entrapment within the gluteal space include the piriformis muscle [23,24], fibrous bands containing blood vessels, gluteal muscles [24,25], hamstring muscles [24,25], the gemelli-obturator internus complex [24,25], vascular abnormalities [21] and space occupying lesions [24,25]. The DGS includes piriformis syndrome, gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome and the proximal hamstring syndrome [13,14]. As described by Martin, et al. [14,8], the borders of the deep gluteal space are defined by the following;
i. Posteriorly, the gluteus maximus,
ii. Anteriorly, posterior acetabular column, hip joint capsule and proximal femur,
iii. Laterally, lateral lip of linea aspera and gluteal tuberosity,
iv. Medially, sacrotuberous ligament and falciform fascia,
v. Superiorly, inferior margin of the sciatic notch,
vi. Inferiorly, proximal origin of the hamstrings at ischial tuberosity [11,8].

The anatomy of the deep gluteal space is unique in that the nerve enters the pelvis through the sciatic notch and demonstrates a significant mobility with hip movements [26]. A careful history and physical examination assists to exemplify this unique factor by defining the specific site where the sciatic or pudendal nerve is entrapped [14].

Pathogenesis of Deep Gluteal Syndrome

Normal healthy nerve roots generally emerge from the spinal column from the L2 to S4 levels through the neural foramina and join to form a complex entity known as the lumbosacral plexus [27]. Two main components to the lumbosacral plexus include the lumbar plexus (made up of nerve fibers from the L2 through L5 roots) and the sacral plexus (made up of nerve fibers from the S1 through S4 roots) [28]. Divisions from the lower lumbar plexus and upper sacral plexus give rise to the sciatic nerve [27]. The sciatic nerve is the longest and thickest (almost finger-width) nerve in the body and is comprised of five nerve roots: two from the lower back region called the lumbar spine and three from the final section of the spine called the sacrum [29]. The five nerve roots come together to form a right and left sciatic nerve [29]. On each side of your body, one sciatic nerve runs through your hips, buttocks and down a leg, ending just below the knee. Branching into other nerves, the sciatic nerve passes through the sciatic foramen and descends into the posterior aspect of the leg until it reaches the popliteal fossa, just below the knee, where it divides into the tibial and common peroneal nerves [27,28].

These nerves continue down into the leg, foot and toes. Branches from both the lumbar and sacral plexus also form the inferior and superior gluteal nerves innervating the lateral and posterior hip musculature [27,28]. Branches from the sacral plexus alone converge to form the pudendal nerves, innervating the pelvic floor musculature and perineal sensation [27,28]. Sciatic and pudendal neuropathy associated with DGS may occur following damage to or dysfunction of the nervous system. Compression is commonly proximally where a herniated disc may compress a spinal nerve root [9,30]. The pathogenesis of DGS involves compression affecting the neuronal structures in the lower extremities and involves pain in the buttock caused from entrapment of the sciatic and/or pudendal nerves in the deep gluteal space [31]. Compression of the sciatic nerve in a mild state may present as intermittent due to positioning, with associated reversible ischemia of the nerve [32,33]. Demyelination (i.e., a condition that results in damage to the protective covering (myelin sheath) surrounding nerve fibers) occurs, as compression grows more consistent and chronic [27,34].

Symptoms are usually persistent at this point, and pain and weakness may become more obvious. As compression progresses further, the distal nerve segments will no longer function and Wallerian degeneration may occur [27,28]. In severe cases, the entire distal segment of the nerve can degenerate, similar to the degeneration seen in a nerve transection [27]. Based on current understanding, sciatic pain is usually a result of a mechanical anatomic variant (contrasted to a primary neuropathy) with secondary mechanical compression of the nerve or nerve roots in the deep gluteal region [35]. The narrowing of space between the ischial tuberosity and femur causes hip pain and may contribute to sciatic nerve entrapment. DGS may also include sciatic nerve entrapment resulting from abnormal hamstring pathology [14,11,13]. The hamstring may be strained or sustain an “injury” such as a tendon detachment, avulsion, manifest apophysitis, or tendinopathy [11]. Also known as the hamstring syndrome or the ischial tunnel syndrome, this may also play a role in sciatic nerve entrapment during hip motion [11,36].

Although there are difference etiologies of nondiscogenic sciatic nerve entrapment, large studies confirm that within the pelvis, the most common site of entrapment is beneath the piriformis (67.8%) [11]. The sciatic foramen is the second most common site of sciatic nerve entrapment (6%) [11]. In the case of the DGS involving the piriformis, if sciatic pain is involved, it is most often because of an abnormality within the piriformis muscle, sometimes associated with a fibrous band that entraps the nerve and decreases sciatic nerve mobility. This can result in painful stretching of the nerve during normal hip and knee movement. Fibrous bands compress the sciatic nerve at the level of the greater sciatic notch extending down to the inferior border of the piriformis. Pathological hypertrophy of the piriformis results in asymmetric enlargement that may also compress the sciatic nerve. The variability in sciatic nerve position as it transverses the piriformis has been considered as a risk factor but to date there is no concrete evidence that variances play a role in sciatic nerve entrapment [11].

The kinematic behavior of the sciatic nerve plays a role in the pathophysiology of DGS as the position of the hip and knee joints affects the tension in the nerve. The sciatic nerve stretches by an excursion of 28.0 mm during a modified straight leg raise with knee extension [8]. This excursion can be limited when the position of the hip joint is flexed, abducted, and externally rotated. [31] With hip flexion at 90° and knee extension in full, the sciatic strain increases by a mean of 26%, which may result in neural dysfunction [29]. Thus, impaired gliding of the sciatic nerve can disrupt its normal excursion and induce the deep gluteal syndrome [5]. (See Table 2 for pathogenesis of DGS.)

Table 2: Pathogenesis of DGS.

Prevalence of PS/DGS

Table 3: Causes of sciatic neuropathy.

Table 4: Causes of DGS due to sciatic nerve entrapment [40].

Reported hip pain affects approximately 14% of the population over the age of 60 [37]. Piriformis syndrome may be responsible for 0.3% to 6% of all cases of low back pain and/or sciatica. With an estimated amount of new cases of low back pain and sciatica at 40 million annually, the incidence of PS would be roughly 2.4 million per year [35]. In the majority of cases, PS occurs in middleaged patients with a reported ratio of male to female patients being affected 1:6 [35,38] In a study of 73 patients who fulfilled strict electrophysiological criteria for sciatic neuropathy, hip surgery was the cause in 22 percent, acute external compression in 14 percent, infarction in 10 percent, gunshot wound in 10 percent, hip fracture/dislocation in 10 percent, femur fracture in 4 percent, possible contusion in 4 percent, and unclear etiology in 16 percent [39]. See Table 3 for common causes of sciatic neuropathy. (See Table 3 for causes of sciatic neuropathy.) In a recent systematic review of 481 patients with DGS causing sciatic nerve entrapment undergoing surgical treatment, the most common causes identified were iatrogenic (30%), piriformis syndrome in 124 (26%), trauma (15%), nonpiriformis (hamstring, obturator internus) muscle pathology (14%), sciatic nerve entrapment by non-piriformis muscle in 68 (41%), endometriosis in 27 (6%), and compression by the inferior gluteal vein in eight (2%) [40]. (See Table 4 for common causes of DGS due to sciatic nerve entrapment.)

Clinical Presentation of DGS

Clinical evaluation of patients with DGS may appear vague and ambiguous since symptoms can be inexact and may be mistaken with other lumbar and intra-or extra-articular hip diseases [13]. Characterized by a set of signs and symptoms occurring in isolation or in combination, patients with DGS commonly present with intermittent, paroxysmal, unrelenting and/or persistent pain and/dysesthesias (chronic pain produced by the central nervous system) in the buttock, posterior hip or thigh in contrast to lower back pain [13]. Patients may report sitting pain with inability to tolerate sitting for 20-30 minutes, walking pain, lower back or hip radicular pain, and paresthesia of the affected buttock and inguinal area [13,16,41,42]. In addition, tenderness in the gluteal and retro-trochanteric region and sciatic-like pain, often unilateral but sometimes bilateral, exacerbated with rotation of the hip in flexion and knee extension is another common symptom [13]. Thus, DGS pain can by exacerbated by activity associated with hip flexion, including walking, sitting, reclining, lifting or standing [10].

In addition, antalgic gait or limp, disturbed or loss of sensation in the affected extremity, lumbago and pain at night with improvement during the day are other commonly reported symptoms [5,10,13]. The degree of pain associated with DGS can limit activities and result in sleep deprivation [11]. In contrast, patients with ischiofemoral impingement usually experience a worsening of pain when running or taking larger steps since the distance between the ischium and lesser trochanter becomes narrower during terminal hip extension (long-stride walking test) [43]. Patients with proximal hamstring syndrome, however, may report ischial pain during the initial heel strike (long-stride heel strike test) [5]. Focal neurological signs, including foot drop, are not the typical presentation of DGS [5].

Associated Risk Factors for Posterior Hip and Buttock Pain

Local risk factors for posterior hip and buttock pain, and in particular DGS, include acute trauma, iatrogenic inflammatory conditions, infectious diseases, vascular abnormalities, and gynecologic and other space occupying lesions [11]. Historically, trauma is the most common etiology related to DGS; this includes hip pathologies presenting with instability including labral tears, hip dysplasia, and ligament teres injury [6]. There is insufficient and unsubstantiated evidence that individuals who run, bicycle, or do similar activities are more susceptible (especially if they do not routinely stretch and strengthen laterally before exercise). Dormant activities, such as prolonged sitting without physical activity may also lead to DGS. In understanding the mechanics of DGS, an awareness of potential exogenous causes of DGS, including hip anatomy, and biomechanics and pelvic kinetics as well as sciatic nerve anatomy are important to consider [11]. Variances of sciatic nerve position may present as a potential risk factor sciatic nerve entrapment, although concrete evidence is lacking. Female gender due to the particular anatomical characteristics of the female pelvis possibly related to hormonal changes, pregnancy, structural abnormalities such as hip dysplasia and femoral anteversion [6]. (See Table 5 for risk factors for posterior hip and buttock pain.) (See Table 6 for potential risk factors for posterior hip and buttock pain.)

Table 5: Risk factors for posterior hip and buttock pain.

Table 6: Potential risk factors for posterior hip and buttock pain.

History and Physical Examination

The primary aim for the clinician is to determine anatomical distribution and type of nerve fiber compromised, and the severity of presentation [44]. A careful medical history and physical examination (PE) can identify the specific site of sciatic nerve entrapment complemented by several radiological signs that support the suspected diagnosis. The medical history should include a review of relevant past medical and surgical history, medications, allergies, and associated risk factors for posterior hip and buttock pain. When evaluating a patient with reported hip pain, it is wise to ask the patient to point to where the pain is. With sciatic neuropathy, typically there is a history of total hip arthroplasty [4]. A focused clinical examination of the affected hip with comparison to the contralateral hip is essential. Neurodynamic testing utilizing the straight leg raise is useful [4]. With pudendal neuropathy, there may be associated perineal pain. Palpation of the inferomedial sciatic notch/ischial spine elicits symptoms [4].

The first diagnostic criterion for DGS is tense muscles in the DG area that are extremely pain sensitive. In normal cases, the deep gluteal (DG) area is not particularly pain sensitive, nor tense. Palpation of the parasacrococcygeal region from the back, or with more accuracy from the front, per rectum allow for the proposed diagnostic criteria for DGS. Passive internal and external rotation of the hip and resisted hip abduction and adduction at 90 degrees of hip extension may elicit symptoms [4]. A comprehensive assessment of the hip and lumbar spine can help to recognize the specific problem in each individual case [14]. (For a list of specific evaluation questions about posterior hip and buttock pain, see Table 7). Using specific tests and spine imaging to rule out lumbar spine pathology, the focus of the physical examination should shift toward considering the deep gluteal space as a cause of posterior pain [14].

Table 7: Posterior hip and buttock pain. Specific evaluation questions to ask.

Laboratory Testing

A complete blood count (CBC) and inflammatory markers (e.g., erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) concentration) may be helpful for a suspected infectious etiology of posterior hip and buttock pain.

Diagnostic Imaging

a. Plain film radiographs of the pelvis and hips may suggest a specific cause such as hip pathology, lumbar spine degeneration, sacroiliitis, or a calcified shadow in the pelvic cavity.
b. Magnetic resonance imaging (MRI) is the most useful imaging tool for the diagnosis of DGS. 3-Tesla MRI provides high resolution pelvic imaging and offers visualization of deep gluteal structures and the sciatic nerve with identification of underlying pathology in the deep gluteal space (i.e., entrapped sciatic nerve, compressive fibrous bands, and pathological muscle changes) [14]. Imaging findings include narrowing or loss of joint space, surrounding reactive bony sclerosis and osteophyte formation [4,45].
c. MR Neurography (MRN) using a fluid-sensitive fat-suppressed T2 weighted sequence and T1 weighted sequence evaluates the fascicles and the peripheral nerve itself both of which encompass abundant fat. Normal nerves show intermediateto- minimal hyperintensity on T2-weighted images and have a fascicular pattern, while neuropathic nerves have an abnormally increased T2-signal intensity, similar to that of the vessels. T1-weighted images evaluate the course of the nerve, its caliber, fascicular pattern and size, and presence of space-occupying lesions along the nerve, whereas axial fatsuppressed T2-weighted images assess signal intensity and fascicular shape [5]. Performed in the sagittal plane, with T1- or intermediate-weighted sequences without fat suppression, MR neurography also detects aberrant anatomy of the sciatic nerve [5]. Denervation-induced muscle signal intensity changes can indicate the presence of neuropathy and aid in determining the chronicity or level of nerve pathology [5]. Use of advanced (MRN) techniques when combined with surgical endoscopic correlation has increased awareness of the anatomy and pathologic conditions of the deep gluteal space.
d. Electrodiagnostic testing is useful in excluding lumbosacral radiculopathy as a cause.

Treatment Options

Nonsurgical Options: The main goals for optimal management of DGS involve multidisciplinary treatment and should include, [3] short-term rest (not more than 48 hours) and activity modification, [4] oral pharmacological agents [5] physiotherapy for a 6 week period [46] deep tissue massage [47] corticosteroid injections (CSI) and [14] anesthetic/trigger point injections [5,18,13]. Implementation of a structured and tailored educational program targeted to avoid certain provoking positions such as avoidance of prolonged cross-legged sitting or internal rotation of the hips [5]and factors that increase or decrease the pain can dictate the diagnostic approach and is an important element of conservative management [25]. Oral medication may include both nonsteroidal anti-inflammatory agents (NSAIDs) and neuropathic agents such as gabapentin and pregabalin, and muscle relaxants [5]. Physiotherapy should include heat, muscle stimulation, soft tissue mobilization, stretching and strengthening exercises, and aerobic conditioning [46]. If palpation in the gluteal muscles reveals taut bands leading to suspicion of myofascial pain syndrome, trigger point injection or massage can be used [47]. Diagnostic and therapeutic local anesthetic injections can be performed using anatomical landmarks or under ultrasound (US), CT scan or MRI guidance [5]. (See Table 8 for nonsurgical treatment options for DGS.)

Table 8: Nonsurgical treatment options for DGS.

Surgical Options: Surgical treatment for DGS is reserved for recalcitrant cases that have failed optimal conservative treatment options, and functional outcomes following surgery are generally good [42,48]. Surgical procedures are dependent on underlying pathology and generally reserved for those with more severe or recurring symptoms. If patients present with lesions that are suspect to cause a mass effect (i.e., development of hematoma, lipoma and heterotopic ossifications), patients may be indicated for surgery without preoperative conservative management [5]. The criteria for surgical intervention in refractory cases are ambiguous and imprecise [5]. What is clear, however, is that when planning surgery, it is important to understand and consider the underlying pathological conditions. Surgical procedures in DGS focus on exploration of the sciatic nerve regardless of the etiology of DGS [49]. Both endoscopic decompression and open decompression of the nerve are surgical options available depending on degree of adherence of the sciatic nerve and the surgical skill of the surgeon [8,16,22].

Endoscopic decompression of the sciatic nerve is useful in improving function and diminishing posterior hip and buttock pain in sciatic nerve entrapments within the subgluteal space [22]. The prognosis for postoperative outcomes in individuals undergoing endoscopic and open procedures is good [5,48]. Endoscopic decompression (neural release) is an effective minimally invasive approach for DGS and is generally preferred over open decompression because it provides fewer complications [8,16]. Limitations to endoscopic treatment include requiring experienced surgeons who possess a high level of knowledge and skill about the deep gluteal space [8,11,16,25]. In addition, there may be difficult release using the endoscopic technique with a severely adherent sciatic nerve [8,16,22]. (See Table 9 for surgical treatment options for DGS.)

Table 9: Surgical treatment options – for exploration of the sciatic nerve.

Discussion

Although the term piriformis syndrome is still commonly designated to describe symptoms related to the piriformis muscle and sciatic nerve, newer observations of hip kinematics lead to a more informed term deep gluteal syndrome (DGS) which better distinguishes the underlying pathophysiology and clinical manifestations. While attributing sciatic nerve irritation to the anatomic relationship between the piriformis muscle and the sciatic nerve, where the latter passes through the greater sciatic notch, DGS describes more. DGS has been associated with radicular type pain related to nondiscogenic sciatic nerve entrapment in other structures within the subgluteal space. The radicular symptoms, historically and singularly attributed to abnormal pathology in the piriformis muscle, are multifactorial and encompass DSG [11]. A level of understanding of the potential exogenous causes of DGS, including hip anatomy, and biomechanics and pelvic kinetics, and sciatic nerve anatomy are important considerations in understanding the mechanics of DGS.

This level of understanding differentiates experts in diagnosis and treatment of DGS from less expert medical providers. Knowledge of all the contributing factors of DGS, focusing on the specific skills of the examination, utilizing appropriate imaging and diagnostic testing, and being the aware of the different treatment options separates and defines those who are usually the most skilled in the diagnosis and treatment of nondiscogenic sciatic nerve pathology associated with DGS [11,50].

Conclusion

Often mislabeled or misdiagnosed due to lack of definitive diagnostic criteria, it is worthwhile to consider DGS as a significant cause of posterior hip and buttock pain. A diagnosis related to lumbosacral spine pathology when the deep gluteal structures are the cause of the pain etiology is common. Thus, diagnosing DGS in a methodical and reasonable approach utilizing MR imaging as a cornerstone diagnostic aid is key to accurate diagnosis. Delay and mismanagement can worsen prognosis due to progression of recalcitrant symptoms leading to burdensome and ongoing intolerable pain and disability. Recommended conservative measures, including rest, activity modification, medication, various therapeutic modalities, and targeted education are essential to alleviate pain and improve functional outcomes. For those refractory to optimal nonsurgical treatment options, surgical options involving decompression of the sciatic or pudendal nerves may be available in patients with severe symptoms to treat specific dependent underlying pathology.

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