臀上静脉变异压迫：靶向手术减压治疗异常解剖
本文通过视频病例展示一例33岁女性右侧非周期性坐骨神经痛伴慢性盆腔痛，影像学未见异常，腹腔镜下发现变异的臀上静脉扩张并压迫近端坐骨神经，行夹闭离断减压后6个月症状显著改善。提示盆腔静脉变异可在影像阴性时引起临床显著的坐骨神经压迫，但该单例手术演示需高度专业化技术。
要点
- 盆腔静脉变异可在影像学阴性时压迫坐骨神经引起症状
- 腹腔镜下靶向探查近端坐骨神经可识别血管压迫
- 夹闭离断压迫静脉可改善神经性疼痛且无新发神经缺损
核心结论
- 变异盆腔静脉解剖可在影像学无异常发现时引起临床显著的盆腔内坐骨神经压迫。
- 该单例手术演示在高度专业化环境中完成，需要专业技术。
- 本病例使用永久金属夹进行静脉结扎，未来可考虑双极能量设备或可吸收聚合物夹作为替代。
研究设计与样本
- 视频文章，单例手术演示。
- 对象为33岁女性，表现为右侧非周期性坐骨神经痛、慢性盆腔痛及周期性肠道膀胱症状，符合腹膜型子宫内膜异位症伴疑似神经受累。
- 患者有多次子宫内膜异位症切除、子宫切除及附件手术史；腰骶丛CT和MRI无异常。
主要发现
- 腹腔镜下腹膜种植灶切除后行逐步腹膜后分离、输尿管松解、闭孔神经标测及经侧方入路靶向探查近端坐骨神经。
- 发现明显扩张的变异臀上静脉横跨并压迫近端坐骨神经，行夹闭和精确离断。
- 减压后神经轮廓恢复正常，止血细致；6个月时右侧坐骨神经痛和活动能力显著改善，无新发神经功能缺损。
关键数值与推荐
- 主要结局指标为无并发症完成减压及6个月和12个月随访时神经性疼痛改善。
- 6个月随访时患者报告右侧坐骨神经痛和活动能力显著改善，无新发神经功能缺损。
临床怎么用
- 对影像学阴性的难治性盆腔痛伴坐骨神经痛患者，腹腔镜靶向探查近端坐骨神经和盆腔血管变异可作为诊断和治疗手段。
- 发现压迫性变异静脉可行夹闭离断减压，但需注意永久金属夹的长期神经相关并发症风险。
局限性
- 单例手术演示，结论不能推广。
- 手术在高度专业化环境中完成，需要专业技术。
- 使用永久金属夹进行静脉结扎，未来可考虑双极能量设备或可吸收聚合物夹作为替代。
以上解读依据论文摘要（全文未开放获取或许可不允许翻译转载）。
原文
OBJECTIVE: To demonstrate laparoscopic identification and treatment of aberrant superior gluteal vein-related intrapelvic sciatic nerve compression using a targeted neurovascular decompression approach. DESIGN: Video article SUBJECTS: A 33-year-old woman presented with noncyclical right-sided sciatica radiating from the buttock to the heel, requiring a cane several times weekly, along with chronic pelvic pain and cyclic bowel and bladder symptoms consistent with peritoneal endometriosis with suspected neuropathic involvement. Her surgical history included multiple endometriosis excision procedures, hysterectomy, and adnexal surgery. Computed tomography and magnetic resonance imaging of the lumbosacral plexus was unremarkable. The patient provided written consent for publication and online distribution of the video (including social media, the journal website, and scientific databases). EXPOSURE: Laparoscopic excision of peritoneal implants was followed by stepwise retroperitoneal dissection with ureterolysis, mapping of the obturator nerve, and targeted exploration of the proximal sciatic nerve with. a lateral approach. A markedly dilated aberrant superior gluteal vein crossing and compressing the proximal sciatic nerve was identified and treated with clip ligation and precise transection. MAIN OUTCOME MEASURES: Completion of decompression without complications and improvement in neuropathic pain at 6- and 12-month follow-up. RESULTS: Decompression restored normal nerve contour with meticulous hemostasis. At 6 months, the patient reported substantial improvement in right-sided sciatica and mobility without new neurologic deficits. CONCLUSION: Aberrant pelvic venous anatomy can cause clinically significant intrapelvic sciatic nerve compression even in the absence of imaging findings; however, this single-case surgical demonstration, performed in a highly specialized setting, requires expertise. It is worth acknowledging that permanent metal clips were used for venous ligation in this case. Bipolar energy devices or absorbable polymeric clips may be preferable alternatives in future applications, may reduce the risk of long-term nerve-related complications.
引用
- Kula H, Cao M, Seckin TK, et al. Superior gluteal vein entrapment: targeted surgical decompression for aberrant anatomy. Fertil Steril. 2026. PMID: 42208727. doi:10.1016/j.fertnstert.2026.05.162
供执业医师工作参考，不替代临床判断；数值与分级以指南原文为准。