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Case Report: K. Mannan, F. Altaf, S. Maniar, R. Tirabosco, M. Sinisi, and T. Carlstedt Cyclical sciatica: ENDOMETRIOSIS OF THE SCIATIC NERVE J Bone Joint Surg Br 2008; 90-B: 98-101 [Abstract] [Full text] [PDF]

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Cyclical sciatica: endometriosis of the sciatic nerve

Kaori Koga, Yutaka Osuga, Yuji Taketani   (16 September 2008)

Cyclical sciatica: endometriosis of the sciatic nerve 16 September 2008
Kaori Koga, gynecologist Department of Obstetrics and Gynecology, University of Tokyo; Tokyo, Japan, Yutaka Osuga, Yuji Taketani Send letter to journal: Re: Cyclical sciatica: endometriosis of the sciatic nerve kawotan-tky{at}umin.ac.jp Kaori Koga, et al.	Sir, We read this paper with interest. The authors described a case of sciatic endometriosis, treated by local excision. We agree that an early diagnosis is critical. However, we would like to raise a point with respect to the treatment in this case. With regard to endometriosis, clinicians need to be mindful that the recurrence rate is high following surgical treatment.1,2 Therefore, the treatment should be carefully chosen from a variety of options: medication, surgery or their combination. Guidelines are provided by two major gynaecological authorities, the American College of Obstetricians and Gynecologists (ACOG) and the European Society of Human Reproduction and Embryology (ESHRE), which recommend treatments such as NSAIDs, oral contraceptive, danazol and GnRH agonists for the treatment of extrapelvic endometriosis.1,3 Notwithstanding the lack of previous accounts of post-surgery prognosis of sciatic endometriosis, these treatment options should be considered since endometriosis can recur. Previously, we reported a case involving a patient with sciatic endometriosis who desired pregnancy in the future.4 Given that recurrence may follow either surgical or medical treatment, and to avoid repeated surgery, we treated the patient with an oral contraceptive, until she desired pregnancy. Surgery can then be recommended if the disease recurs at a later date. It is noteworthy that we also avoided dissection and instead performed percutaneous CD-guided needle biopsy, to make a histological diagnosis. According to the case reported by Mannan et al, "the patient refused hormonal treatment since she was of reproductive age". We were concerned that this patient may have been misinformed since other treatment options are available. Due to the oestrogen-dependent nature of this disease, most women with endometriosis are within a reproductive age. It is therefore critical to carefully plan the treatment of endometriosis according to the symptoms and the desire for pregnancy, so that the least invasive and most effective treatment can be achieved. K. Koga MD, PhD, Y. Osuga MD, PhD, Y. Taketani MD, PhD, Department of Obstetrics and Gynecology, University of Tokyo, Tokyo, Japan. 1. ACOG Practice Bulletin. Clinical Management Guidelines for Obstetrician-Gynecologists: Medical Management of Endometrosis Number 11, December 1999. http://www.acog.org/publications/educational_bulletins/pb011.cfm (accessed 15/09/08). 2. Koga K, Takemura Y, Osuga Y, et al. Recurrence of ovarian endometrioma after laparoscopic excision. Hum Reprod 2006;21:2171-4. 3. ESHRE Guideline for the Diagnosis and Treatment of Endometriosis. http://guidelines.endometriosis.org (accessed 15/09/08). 4. Koga K, Osuga Y, Harada M, et al. Sciatic endometriosis diagnosed by computerized tomography-guided biopsy and CD10 immunohistochemical staining. Fertil Steril 2005;84:1508.