SHORT REPORT

ABSTRACT: Injuries to the superior gluteal nerve (SGN) have been reported as a result of trauma, pyriformis muscle entrapment, injections, and
lumbar lordosis and inadequate back stabilization. We report 3 patients who
developed isolated SGN injuries, 1 after a partial nephrectomy and 2 following revision of a total hip arthroplasty. SGN should be suspected in anyone
developing an abnormal gait after hip or pelvic surgery or after prolonged
lateral decubitus positioning.
1998 John Wiley & Sons, Inc. Muscle Nerve 21: 17941796, 1998

IATROGENIC SUPERIOR
GLUTEAL MONONEUROPATHY
PETER D. DONOFRIO, MD,1 SHAWN J. BIRD, MD,2 DEAN G. ASSIMOS, MD,3
and DONALD D. MATHES, MD4
1

Department of Neurology, Bowman Gray School of Medicine, Medical Center

Boulevard, Winston-Salem, North Carolina 27157-1078, USA
2
Department of Neurology, University of Pennsylvania School of Medicine,
Philadelphia, Pennsylvania, USA
3
Department of Urology, Bowman Gray School of Medicine,
Winston-Salem, North Carolina, USA
4
Department of Anesthesia, Bowman Gray School of Medicine,
Winston-Salem, North Carolina, USA
Accepted 30 April 1998

Injuries to the superior gluteal nerve (SGN) usually

occur in association with other mononeuropathies
in the pelvic region. Isolated superior gluteal mononeuropathy is unusual, having been reported after
needle4 and blunt trauma7 and other rare causes.1
We report 3 patients who developed SGN injuries, 1
after a partial nephrectomy for renal calculus disease
and 2 following revision of a hip arthroplasty.
CASE 1

A 23-year-old man with left renal calculus disease was

admitted for a partial nephrectomy. His stones were
located in a calyceal diverticulum in the lower pole
of his kidney. He had previously undergone multiple
surgical procedures including extracorporeal lithotripsy and percutaneous and open surgical nephrolithotomy. Despite those treatments, he developed
recurrent symptomatic stones requiring a lower pole
partial nephrectomy.
During the 7-h surgery, the patient was placed in
Abbreviations: EMG, electromyography; PSW, positive sharp wave;
SGN, superior gluteal nerve
Key words: superior gluteal neuropathy; mononeuropathy; nerve injury;
iatrogenic
Correspondence to: Dr. Peter D. Donofrio
CCC 0148-639X/98/121794-03
1998 John Wiley & Sons, Inc.

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Short Reports

the right flexed lateral decubitus position on a padded table and a raised kidney bolster. All pressure
points were padded. The length of the procedure
was due to extensive cicatrization surrounding his
kidney from prior interventions.
On the first postoperative day, the patient complained of right flank and hip pain and numbness.
Physical examination was unremarkable except for
induration of the right hip. Laboratory tests showed
elevations of serum creatine kinase, aldolase, and
myoglobinuria. He was treated with intravenous hydration, sodium bicarbonate, and mannitol, leading
to resolution of the rhabdomyolysis after 5 days.
Three weeks after surgery, the patient was evaluated by the first author for numbness over the right
flank, iliac crest, and the upper lateral thigh; mild
right lower lumbar pain; and external rotation of the
right leg when ambulating. Physical examination disclosed paralysis of right hip abductors. Subtle and
ill-defined diminished pinprick and cold perception
was detected over the right lower flank, iliac crest,
and a small region over the superior aspect of the
hip. Straight leg raising was unremarkable and
muscle stretch reflexes were symmetric.
Nerve conduction studies of the right leg were
normal. EMG revealed fibrillation potentials, positive sharp waves (PSWs), and absent recruitment in

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December 1998

muscles innervated by the right SGN (gluteus medius, minimus, and tensor fascia lata). Minor abnormalities at rest were noted in the right gluteus maximus and L3S1 paraspinal muscles.
The patient was diagnosed as having a right superior gluteal mononeuropathy from prolonged surgical positioning on a kidney bolster and pressure
necrosis of the gluteus maximus and lumbosacral
paraspinal muscles resulting in rhabdomyolysis. He
was treated conservatively with physical therapy. At
his 4-month follow-up visit, he was fully recovered.

gait was notable for a dropped left pelvis and limited

swing of the left leg.
Nerve conduction studies were normal in the left
leg. EMG of the left gluteus medius muscle showed
no abnormal spontaneous activity at rest and moderately reduced recruitment of chronic neurogenic
motor unit potentials. All other muscles were normal
in the left leg and lumbosacral paraspinal muscles.
Her gluteus medius strength and ambulation returned to normal over 23 months.
DISCUSSION

CASE 2

A 69-year-old woman was referred for a gait abnormality. She had long-standing hip disease, secondary
to osteoarthritis, and two previous hip replacements.
Nine months prior to this evaluation she underwent
a revision of a right hip arthroplasty. Immediately
postoperatively she experienced difficulty walking
due to weakness in the right leg.
On examination, there was no observed leg atrophy. Strength was normal except for the right gluteus medius, which was 2/5. Reflexes were normal at
the knees and ankles. Sensation was intact except for
a patch of hypesthesia adjacent to the right hip scar.
There was a significant drop of the right pelvis during ambulation.
Motor conduction studies were normal in both
legs. Sural sensory responses were absent bilaterally,
a result considered within normal limits for her age.9
EMG demonstrated a few fibrillation potentials and
PSWs in the right gluteus medius muscle and reduced recruitment of chronic neurogenic motor
units in the right gluteus medius and tensor fascia
lata muscles. All other muscles studied were normal
including lumbar paraspinals.
The patient did not return for follow-up care.
CASE 3

A 54-year-old woman with rheumatoid arthritis was

evaluated for gait difficulty following revision of a
hip replacement. She had had previous bilateral hip
replacements for treatment of rheumatoid arthritis.
She underwent revision of a left hip replacement 10
weeks prior to this evaluation. Postoperatively, her
activity was limited by pain in the left hip. She denied
back pain or pain radiating down the leg. As the pain
resolved, she experienced weakness of the left leg
that limited her walking.
Physical examination was unremarkable except
for the left leg. Strength was 4/5 in the left gluteus
medius, but was otherwise normal. No atrophy was
observed. Reflexes and sensation were normal. Her

Short Reports

The SGN arises from nerve roots L4, L5, and S1 and
the posterior surface of the lumbosacral plexus.3
The nerve travels laterally, exiting the pelvis at the
greater sciatic foramen. Thereafter it enters the buttock by passing above the pyriformis muscle and
eventually innervates the gluteus medius, gluteus
minimus, and tensor fascia lata muscles. No sensory
fibers run in the SGN. At the bedside, a SGN mononeuropathy manifests as an externally rotated leg,
weakness of hip abductors, and an ipsilateral
dropped pelvis.
Injuries to the SGN have been described after
needle injection into the posterior gluteal region,4
after blunt trauma,7 by entrapment within the pyriformis muscle,5 and in association with lumbar lordosis and inadequate back stabilization.1 No reports
exist of SGN injuries from hip surgery or surgical
positioning.
Clinically and electrodiagnostically, the first patient manifested a SGN mononeuropathy and local
myonecrosis of the gluteus maximus and lumbosacral paraspinal muscles. This mononeuropathy most
likely occurred during surgery from prolonged pressure by the kidney bolster either at the nerves exit
from the greater sciatic foramen or where it traverses
the pyriformis muscle. The patients subtle sensory
symptoms and signs may be attributed to pressure
injury to cutaneous nerve fibers compressed by the
kidney bolster. A less likely explanation would be a
polyradiculopathy involving roots L4S1, yet sparing
root fibers to other anterior myotomes. Equally unlikely is ischemia or infarction of the superior gluteal
artery, as the latter blood vessel perfuses the gluteus
maximus and minimus muscles and its pathology
would not explain the clinical and electromyographic findings in this case, nor the rapid recovery
in 4 months.
The second and third patients experienced a
SGN mononeuropathy after revision of a hip arthroplasty. This procedure requires a larger exposure
and more time than an initial hip arthroplasty, two
features that would predispose to traumatic mono-

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December 1998

1795

neuropathies.2 SGN is rare after hip replacement.

More common are sciatic and femoral mononeuropathies.6,8 In the 2 cases we describe, the surgeons,
in their effort to identify and protect the sciatic and
femoral nerves, may have inadvertently stretched or
traumatized the SGN. We speculate that the SGN
may have been damaged by the anterior portion of
the gluteus medius muscle when it was retracted anteriorly, or prolonged traction compressed the nerve
against the pyriformis muscle or the sciatic notch.2
SGN injury should be suspected in anyone developing hip weakness, an externally rotated leg, or a
dropped pelvis after surgery. Particularly suspect
would be those patients who have undergone a revised hip procedure or were positioned in the flexed
lateral decubitus position during surgery. Fortunately, the prognosis after injury to the SGN appears
to be good. Both patients who returned for follow-up
visits achieved a full recovery within 34 months.
Presented in part at the annual scientific meeting of the American
Association of Electrodiagnostic Medicine, October 1996, Minneapolis, Minnesota.

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