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Vaishya S, Pojskic M, Bedi MS, Oertel J, Sippl C, Robertson S, Zygourakis C. Cauda equina, conus medullaris and syndromes mimicking sciatic pain: WFNS spine committee recommendations. World Neurosurg X 2024; 22:100274. [PMID: 38496349 PMCID: PMC10943478 DOI: 10.1016/j.wnsx.2024.100274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 02/01/2024] [Indexed: 03/19/2024] Open
Abstract
Introduction Cauda equina syndrome (CES), conus medullaris syndrome (CMS), and sciatica-like syndromes or "sciatica mimics" (SM) may present as diagnostic and/or therapeutic dilemmas for the practicing spine surgeon. There is considerable controversy regarding the appropriate definition and diagnosis of these entities, as well as indications for and timing of surgery. Our goal is to formulate the most current, evidence-based recommendations for the definition, diagnosis, and management of CES, CMS, and SM syndromes. Methods We performed a systematic literature search in PubMed from 2012 to 2022 using the keywords "cauda equina syndrome", "conus medullaris syndrome", "sciatica", and "sciatica mimics". Standardized screening criteria yielded a total of 43 manuscripts, whose data was summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. Utilizing the Delphi method, we generated seven final consensus statements. Results and conclusion s: We provide standardized definitions of cauda equina, cauda equina syndrome, conus medullaris, and conus medullaris syndrome. We advocate for the use of the Lavy et al classification system to categorize different types of CES, and recommend urgent MRI in all patients with suspected CES (CESS), considering the low sensitivity of clinical examination in excluding CES. Surgical decompression for CES and CMS is recommended within 48 h, preferably within less than 24 h. There is no data regarding the role of steroids in acute CES or CMS. The treating physician should be cognizant of a variety of other pathologies that may mimic sciatica, including piriformis syndrome, and how to manage these.
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Affiliation(s)
- Sandeep Vaishya
- Department of Neurosurgery, Fortis Memorial Research Institute, Guragaon and Fortis Hospital Vasant Kunj, New Delhi, India
| | - Mirza Pojskic
- Department of Neurosurgery, University of Marburg, Germany
| | - Manbachan Singh Bedi
- Department of Neurosurgery, Fortis Memorial Research Institute, Guragaon and Fortis Hospital Vasant Kunj, New Delhi, India
| | - Joachim Oertel
- Department of Neurosurgery, Saarland University Medical Centre, Homburg, Germany
| | - Christoph Sippl
- Department of Neurosurgery, Saarland University Medical Centre, Homburg, Germany
| | - Scott Robertson
- Dept of Neurosurgery, Ochsner Medical Center Baton Rouge, USA
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Vanermen F, Van Melkebeek J. Endoscopic Treatment of Piriformis Syndrome Results in a Significant Improvement in Pain Visual Analog Scale Scores. Arthrosc Sports Med Rehabil 2022; 4:e309-e314. [PMID: 35494270 PMCID: PMC9042772 DOI: 10.1016/j.asmr.2021.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 10/08/2021] [Indexed: 11/18/2022] Open
Affiliation(s)
- Frédérique Vanermen
- Address correspondence to Frédérique Vanermen, M.D., Emmanuel Vierinlaan 3.03 – 8300 Knokke – Belgium.
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3
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Metikala S, Sharma V. Endoscopic Sciatic Neurolysis for Deep Gluteal Syndrome: A Systematic Review. Cureus 2022; 14:e23153. [PMID: 35444897 PMCID: PMC9010003 DOI: 10.7759/cureus.23153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2022] [Indexed: 11/05/2022] Open
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Piriformis Syndrome (Sciatic Nerve Entrapment) Associated With Type C Sciatic Nerve Variation: A Report of Two Cases and Literature Review. Korean J Neurotrauma 2022; 18:434-443. [DOI: 10.13004/kjnt.2022.18.e29] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 05/03/2022] [Accepted: 05/06/2022] [Indexed: 11/15/2022] Open
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Sermer C, Li ALK, Fernandes GL, Ribeiro AM, Polesello G, Tokechi D, Cancelliere L, Lemos N. Intrapelvic entrapment of sacral nerve roots by abnormal bundles of the piriformis muscle: description of an extra-spinal cause of sciatica and pudendal neuralgia. J Hip Preserv Surg 2021; 8:132-138. [PMID: 34567608 PMCID: PMC8460165 DOI: 10.1093/jhps/hnab041] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 03/21/2021] [Indexed: 11/13/2022] Open
Abstract
Piriformis syndrome is a well-known extra-spinal cause of sciatica characterized by the entrapment of the sciatic nerve by variant bundles of the piriformis muscles in the deep gluteal space. In this case series, we describe the entrapment of intrapelvic portions of the sacral nerve roots by a variant bundle of the piriformis muscle originating medially to the sacral foramina, the surgical technique for the laparoscopic treatment of this condition, and the outcomes of the first eight cases treated with this technique. Five female and three male patients presenting with sciatica, pudendal pain and lower urinary tract symptoms underwent a laparoscopic exploration of the intrapelvic portion of the sacral nerve roots and transection of the abnormal piriformis bundle. Surgical technique is demonstrated in the Supplementary Video. Clinical success was achieved in seven of the eight patients, with a reduction of pain numeric rating scale from 8.5 (±1.2; 7-10) pre-operatively to 2.1 (±2.6; 0-7), 1-year following surgery. In conclusion, entrapment of intrapelvic portions of the sacral nerve roots by variant bundles of the piriformis originating medially to the sacral foramina are an extraspinal cause of sciatica, which can be treated though a laparoscopic approach.
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Affiliation(s)
- Corey Sermer
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada
| | - Adrienne L K Li
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada
| | - Gustavo L Fernandes
- Department of Gynecology, Federal University of São Paulo. Rua Napoleão de Barros, 608, São Paulo, SP, Brazil.,Department of Gynecology, Faculdade de Ciências Médicas da Santa Casa de São Paulo. Rua Doutor Cesário Mota Júnior, 42, São Paulo, SP, Brazil
| | - Augusta M Ribeiro
- Department of Gynecology, Federal University of São Paulo. Rua Napoleão de Barros, 608, São Paulo, SP, Brazil
| | - Giancarlo Polesello
- Department of Gynecology, Faculdade de Ciências Médicas da Santa Casa de São Paulo. Rua Doutor Cesário Mota Júnior, 42, São Paulo, SP, Brazil
| | - Denise Tokechi
- Department of Radiology, Hospital Sírio-Libanês, Rua Dona Adma Jafet, 91, São Paulo, SP, Brazil
| | - Laura Cancelliere
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada
| | - Nucelio Lemos
- Mount Sinai Hospital, 700 University Avenue, Room 8-917, Toronto, ON M5S 1Z5, Canada.,Department of Gynecology, Federal University of São Paulo. Rua Napoleão de Barros, 608, São Paulo, SP, Brazil
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6
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Poutoglidou F, Piagkou M, Totlis T, Tzika M, Natsis K. Sciatic Nerve Variants and the Piriformis Muscle: A Systematic Review and Meta-Analysis. Cureus 2020; 12:e11531. [PMID: 33354475 PMCID: PMC7746330 DOI: 10.7759/cureus.11531] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
The present systematic review and meta-analysis provides a comprehensive assessment of the sciatic nerve (SN) variants relative to the piriformis muscle (PM) and compares those variants’ prevalence among different geographical populations with respect to gender and laterality. A database search was conducted to identify cadaveric studies pertinent to SN variants relative to the PM. A total of 44 articles were included. The typical morphological pattern (type A, with the SN passing undivided below the PM) was found to be the most common variant, with 90% pooled prevalence. SN variants were more common among East Asians, with a 31% pooled prevalence of total variants. No significant differences were established with respect to gender and laterality. In greater than 10% of the population, the SN coursed through or above piriformis. Patients’ epidemiological characteristics may predispose them to certain variants. The common peroneal nerve (CPN) is more susceptible to injury during a total hip arthroplasty or a hip arthroscopy where anomalies are encountered. As anatomical variants are commonly associated with piriformis syndrome, they should always be considered during diagnosis and treatment.
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Affiliation(s)
| | - Maria Piagkou
- Anatomy and Surgical Anatomy, National and Kapodistrian University of Athens, Athens, GRC
| | - Trifon Totlis
- Orthopaedic Surgery, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Maria Tzika
- Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Konstantinos Natsis
- Anatomy and Surgical Anatomy, Aristotle University of Thessaloniki, Thessaloniki, GRC
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Abstract
Entrapment neuropathies are frequently encountered by rheumatologists, not only because they are common but also because of their association with certain rheumatological and systemic disorders. Recognizing entrapment neuropathy early can help avoid progressive neurological deficits, as well as facilitate appropriate treatment measures, which can effectively minimize a patient's symptoms. Entrapment neuropathies may be distinguished from other musculoskeletal causes of lower extremity pain by identifying characteristic patterns of weakness and/or sensory loss, so a focused bedside neurological examination is key for diagnosis. In this chapter, we review the most common entrapment neuropathies that occur in the lower extremities, review the relevant neuroanatomy, outline a diagnostic approach to distinguish them from other mimics, and highlight appropriate management options.
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Affiliation(s)
- Sarah Madani
- Department of Neurology, 60 Fenwood Road, 1st Floor, Boston, MA, 02115, USA.
| | - Christopher Doughty
- Department of Neurology, 60 Fenwood Road, 4th Floor, Boston, MA, 02115, USA.
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8
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Park JW, Lee YK, Lee YJ, Shin S, Kang Y, Koo KH. Deep gluteal syndrome as a cause of posterior hip pain and sciatica-like pain. Bone Joint J 2020; 102-B:556-567. [PMID: 32349600 DOI: 10.1302/0301-620x.102b5.bjj-2019-1212.r1] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Deep gluteal syndrome is an increasingly recognized disease entity, caused by compression of the sciatic or pudendal nerve due to non-discogenic pelvic lesions. It includes the piriformis syndrome, the gemelli-obturator internus syndrome, the ischiofemoral impingement syndrome, and the proximal hamstring syndrome. The concept of the deep gluteal syndrome extends our understanding of posterior hip pain due to nerve entrapment beyond the traditional model of the piriformis syndrome. Nevertheless, there has been terminological confusion and the deep gluteal syndrome has often been undiagnosed or mistaken for other conditions. Careful history-taking, a physical examination including provocation tests, an electrodiagnostic study, and imaging are necessary for an accurate diagnosis. After excluding spinal lesions, MRI scans of the pelvis are helpful in diagnosing deep gluteal syndrome and identifying pathological conditions entrapping the nerves. It can be conservatively treated with multidisciplinary treatment including rest, the avoidance of provoking activities, medication, injections, and physiotherapy. Endoscopic or open surgical decompression is recommended in patients with persistent or recurrent symptoms after conservative treatment or in those who may have masses compressing the sciatic nerve. Many physicians remain unfamiliar with this syndrome and there is a lack of relevant literature. This comprehensive review aims to provide the latest information about the epidemiology, aetiology, pathology, clinical features, diagnosis, and treatment. Cite this article: Bone Joint J 2020;102-B(5):556-567.
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Affiliation(s)
- Jung Wee Park
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Young-Kyun Lee
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yun Jong Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea.,Department of Internal Medicine, Seoul National University College of Medicine, Seoul, South Korea Seongnam, South Korea
| | - Seunghwan Shin
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yusuhn Kang
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Kyung-Hoi Koo
- Department of Orthopedic Surgery, Seoul National University Bundang Hospital, Department of Orthopedic Surgery, Seoul National University College of Medicine Seongnam, South Korea
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Koh E, Webster D, Boyle J. Case report and review of the potential role of the Type A piriformis muscle in dynamic sciatic nerve entrapment variant of piriformis syndrome. Surg Radiol Anat 2020; 42:1237-1242. [PMID: 32112284 DOI: 10.1007/s00276-020-02440-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2019] [Accepted: 02/10/2020] [Indexed: 11/29/2022]
Abstract
Piriformis syndrome (PS) is an underdiagnosed but common cause of chronic buttock pain and sciatica. Anatomical variants of the piriformis muscle and sciatic nerve have not been thought to be significant in the pathophysiology of PS however, recent description of the piriformis musculotendinous junction has identified a common variant that we believe frequently results in dynamic sciatic nerve entrapment at the infra-piriformis fossa. We performed ultrasound guided low-dose Botulinum Toxin-A (BTX-A) injection to the lower piriformis muscle belly in an elite Australian Rules football player with PS and Type A piriformis muscle to relieve symptomatic sciatic nerve compression. Positive response to targeted BTX-A piriformis muscle injections support the hypothesis that sciatic nerve compression by Type A piriformis muscles may contribute to the pathophysiology of neuropathic PS, along with other functional factors. Sciatic nerve compression due to Type A piriformis at the infra-piriformis fossa has not been described previously and is a potentially common cause of neuropathic PS, especially when combined with other functional factors such as piriformis muscle spasm/hypertrophy and sacroiliac joint counternutation.
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Affiliation(s)
- Eamon Koh
- Envision Medical Imaging, 178 Cambridge St, Wembley, WA, 6009, Australia. .,Medical Department, Fremantle Football Club, Cockburn Central, WA, Australia.
| | - Daniel Webster
- Medical Department, Claremont Football Club, Claremont, WA, Australia
| | - Jeffrey Boyle
- Medical Department, Fremantle Football Club, Cockburn Central, WA, Australia.,School of Physiotherapy and Exercise Science, Curtin University, Bentley, WA, Australia
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10
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Probst D, Stout A, Hunt D. Piriformis Syndrome: A Narrative Review of the Anatomy, Diagnosis, and Treatment. PM R 2019; 11 Suppl 1:S54-S63. [PMID: 31102324 DOI: 10.1002/pmrj.12189] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Piriformis syndrome is a form of sciatica caused by compression of the sciatic nerve by the piriformis muscle. It is a relatively uncommon, but not insignificant, cause of sciatica. The diagnosis of piriformis syndrome is complicated by the large differential diagnosis of low back and buttock pain with many diagnoses having overlapping symptoms. This narrative review highlights the relevant anatomy, history, physical exam maneuvers, electrodiagnostic findings, and imaging findings that are used to diagnose piriformis syndrome. Also discussed are posterior gluteal myofascial pain syndromes that mimic piriformis syndrome. The review then outlines the different treatment options for piriformis syndrome including conservative treatment, injections, and surgical treatment. In addition, it provides the reader with a clinical framework to better understand and treat the complex, and often misunderstood, diagnosis of piriformis syndrome.
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Affiliation(s)
- Daniel Probst
- Division of Physical Medicine and Rehabilitation, Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Alison Stout
- EvergreenHealth Sport & Spine Care, Kirkland, WA
| | - Devyani Hunt
- Division of Physical Medicine and Rehabilitation, Department of Orthopaedics, Washington University School of Medicine, St. Louis, MO
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11
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Coulomb R, Khelifi A, Bertrand M, Mares O, May O, Marchand P, Kouyoumdjian P. Does endoscopic piriformis tenotomy provide safe and complete tendon release? A cadaver study. Orthop Traumatol Surg Res 2018; 104:1193-1197. [PMID: 29852320 DOI: 10.1016/j.otsr.2018.02.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 01/31/2018] [Accepted: 02/06/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Endoscopic piriformis release (EPR) is among the available treatments for piriformis syndrome. This procedure typically involves dividing the muscle near the sciatic nerve in the sub-gluteal space, which contains numerous blood vessels and nerves. The objectives of this prospective cadaver study were: 1) to assess the reproducibility and quality of endoscopic piriformis tenotomy near the greater trochanter; 2) to detect iatrogenic injuries to the lateral hip rotators, nerves, and vessels; 3) and to define the surgical safety margins relative to the sciatic nerve and inferior gluteal bundle. HYPOTHESIS EPR at the greater trochanter ensures full release of the muscle with a limited risk of neuro-vascular injury. MATERIAL AND METHODS EPR was performed via two portals on 10 cadaver hips preserved in zinc chloride and placed in the prone position. A third, ancillary portal was required in 7 cases. The area was then dissected with the Kocher-Langenbeck approach to allow an assessment of the tenotomy, detect iatrogenic injuries, and measure the distances separating the tenotomy site from the sciatic nerve and inferior gluteal artery. RESULTS Complete tenotomy was achieved in 9 (90%) cases. The tendon adhered to the capsule in 2 (20%) cases and showed acquired avulsion in 1 case. No injuries to the sciatic nerve or inferior gluteal artery occurred. Mean distances from the tenotomy site were 5.21±0.59cm (range, 4.5-6.6cm) for the sciatic nerve and 7.1±0.89cm (range, 5.4-8.5cm) for the inferior gluteal artery. DISCUSSION EPR by a tenotomy at the greater trochanter without sciatic nerve release provides full release of the muscle with satisfactory safety margins and a short learning curve. LEVEL OF EVIDENCE III, prospective cadaver case-control study.
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Affiliation(s)
- Rémy Coulomb
- Service de chirurgie orthopédique et traumatologique, CHU de Carémeau, place du Pr-Debré, 30029 Nîmes cedex 9, France.
| | - Anis Khelifi
- Service de chirurgie orthopédique et traumatologique, CHU de Carémeau, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Martin Bertrand
- Service de chirurgie orthopédique et traumatologique, CHU de Carémeau, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Olivier Mares
- Service de chirurgie orthopédique et traumatologique, CHU de Carémeau, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Olivier May
- Clinique Médipole-Garonne, 45, rue Gironis, 31036 Toulouse cedex 1, France
| | - Philippe Marchand
- Service de chirurgie orthopédique et traumatologique, CHU de Carémeau, place du Pr-Debré, 30029 Nîmes cedex 9, France
| | - Pascal Kouyoumdjian
- Service de chirurgie orthopédique et traumatologique, CHU de Carémeau, place du Pr-Debré, 30029 Nîmes cedex 9, France
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12
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Ilizaliturri VM, Arriaga R, Villalobos FE, Suarez-Ahedo C. Endoscopic Release of the Piriformis Tendon and Sciatic Nerve Exploration by the Lateral Decubitus Approach Through an Incision on the Iliotibial Band. Arthrosc Tech 2018; 7:e785-e790. [PMID: 30094152 PMCID: PMC6074723 DOI: 10.1016/j.eats.2018.03.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 03/27/2018] [Indexed: 02/03/2023] Open
Abstract
Entrapment of the sciatic nerve is considered a challenging problem for orthopaedic surgeons. Many surgical interventions (open or endoscopic) have been described as treatments. We describe an endoscopic technique for release of the piriformis tendon and sciatic nerve exploration by the lateral approach through an incision on the iliotibial band.
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Affiliation(s)
- Víctor M. Ilizaliturri
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of Mexico, Mexico City, Mexico
| | - Rubén Arriaga
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of Mexico, Mexico City, Mexico
| | - Félix E. Villalobos
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of Mexico, Mexico City, Mexico
| | - Carlos Suarez-Ahedo
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of Mexico, Mexico City, Mexico,American Hip Institute, Westmont, Illinois, U.S.A.,Address correspondence to Carlos Suarez-Ahedo, M.D., Department of Adult Joint Reconstruction, National Rehabilitation Institute of Mexico, Av. Mexico Xochimilco 289, Col. Arenal de Guadalupe, Mexico City, Mexico.
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13
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Ilizaliturri VM, Arriaga R, Villalobos FE, Suarez-Ahedo C. Endoscopic release of the piriformis tendon and sciatic nerve exploration. J Hip Preserv Surg 2018; 5:301-306. [PMID: 30393558 PMCID: PMC6206698 DOI: 10.1093/jhps/hny018] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/18/2018] [Accepted: 05/19/2018] [Indexed: 11/24/2022] Open
Abstract
Robinson, in 1947 introduced for the first time the term ‘piriformis syndrome’. More recently, many etiologies of sciatic nerve entrapment around the gluteal region or the non-discogenic area have been identified, resulting in the use of a new term ‘The Deep Gluteal Syndrome’. The purpose of this study was to assess the outcomes following the endoscopic release of sciatic nerve entrapment. Type of study is a consecutive case series. Fifteen patients were diagnosed with sciatic nerve entrapment from January 2012 to December 2015, all of them were treated with endoscopic release of the piriformis tendon and sciatic nerve exploration on lateral decubitus position. Every patient had a minimum follow-up to 2 years. The patient-reported outcome scores used included the modified Harris Hip Score (mHHS), pain was estimated on a visual analog scale (VAS) and the Benson outcomes questionnaire. The patient’s mean age was 40.2 years (range, 28–50 years). The score improvement from pre-operative to 24-month follow-up was 46.8–84.9 for mHHS (P <0.05). The VAS decreased from pre-operative to 24-month follow-up was 7.4–1.86 (P < 0.05). The Benson outcome ratings were excellent for 11 patients, good for 3 and fair for 1. The Endoscopic Release of the Piriformis Tendon and Sciatic Nerve Exploration showed an improvement of functions, diminishing pain and allowing patients to return to daily activities without symptoms (Level of Evidence: IV).
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Affiliation(s)
- Víctor M Ilizaliturri
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of México, Av. México-Xochimilco No. 289, Col. Arenal de Guadalupe, México D.F. C.P, México
| | - Rubén Arriaga
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of México, Av. México-Xochimilco No. 289, Col. Arenal de Guadalupe, México D.F. C.P, México
| | - Félix E Villalobos
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of México, Av. México-Xochimilco No. 289, Col. Arenal de Guadalupe, México D.F. C.P, México
| | - Carlos Suarez-Ahedo
- Department of Adult Joint Reconstruction, National Rehabilitation Institute of México, Av. México-Xochimilco No. 289, Col. Arenal de Guadalupe, México D.F. C.P, México.,American Hip Institute, Suite 1010 Executive Ct No. 250, Westmont, IL, USA
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14
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Kay J, de Sa D, Morrison L, Fejtek E, Simunovic N, Martin HD, Ayeni OR. Surgical Management of Deep Gluteal Syndrome Causing Sciatic Nerve Entrapment: A Systematic Review. Arthroscopy 2017; 33:2263-2278.e1. [PMID: 28866346 DOI: 10.1016/j.arthro.2017.06.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 06/15/2017] [Accepted: 06/20/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the causes, surgical indications, patient-reported clinical outcomes, and complications in patients with deep gluteal syndrome causing sciatic nerve entrapment. METHODS Three databases (PubMed, Ovid [MEDLINE], and Embase) were searched by 2 reviewers independently from database inception until September 7, 2016. The inclusion criteria were studies reporting on both arthroscopic and open surgery and those with Level I to IV evidence. Systematic reviews, conference abstracts, book chapters, and technical reports with no outcome data were excluded. The methodologic quality of the studies was assessed with the MINORS (Methodological Index for Non-randomized Studies) tool. RESULTS The search identified 1,539 studies, of which 28 (481 patients; mean age, 48 years) were included for assessment. Of the studies, 24 were graded as Level IV, 3 as Level III, and 1 as Level II. The most commonly identified causes were iatrogenic (30%), piriformis syndrome (26%), trauma (15%), and non-piriformis (hamstring, obturator internus) muscle pathology (14%). The decision to pursue surgical management was made based on clinical findings and diagnostic investigations alone in 50% of studies, whereas surgical release was attempted only after failed conservative management in the other 50%. Outcomes were positive, with an improvement in pain at final follow-up (mean, 23 months) reported in all 28 studies. The incidence of complications from these procedures was low: Fewer than 1% and 8% of open surgical procedures and 0% and fewer than 1% of endoscopic procedures resulted in major (deep wound infection) and minor complications, respectively. CONCLUSIONS Although most of the studies identified were case series and reports, the results consistently showed improvement in pain and a low incidence of complications, particularly for endoscopic procedures. These findings lend credence to surgical management as a viable option for buttock pain caused by deep gluteal syndrome and warrant further investigation. LEVEL OF EVIDENCE Level IV, systematic review of Level II through IV studies.
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Affiliation(s)
- Jeffrey Kay
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Darren de Sa
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Laura Morrison
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emily Fejtek
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Simunovic
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Hal D Martin
- Hip Preservation Center, Baylor University Medical Center at Dallas, Dallas, Texas, U.S.A
| | - Olufemi R Ayeni
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada.
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Yıldırım P, Guler T, Misirlioglu TO, Ozer T, Gunduz OH. A case of drop foot due to piriformis syndrome. Acta Neurol Belg 2015; 115:847-9. [PMID: 25676003 DOI: 10.1007/s13760-015-0443-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 02/06/2015] [Indexed: 11/25/2022]
Affiliation(s)
- Pelin Yıldırım
- Department of Physical Medicine and Rehabilitation, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey.
| | - Tuba Guler
- Department of Physical Medicine and Rehabilitation, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey.
| | - Tugce Ozekli Misirlioglu
- Department of Physical Medicine and Rehabilitation, Koc University Faculty of Medicine, Istanbul, Turkey.
| | - Tulay Ozer
- Department of Radiology, Kocaeli Derince Training and Research Hospital, Kocaeli, Turkey.
| | - Osman Hakan Gunduz
- Department of Physical Medicine and Rehabilitation, Marmara University Faculty of Medicine, Istanbul, Turkey.
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Michel F, Decavel P, Toussirot E, Tatu L, Aleton E, Monnier G, Garbuio P, Parratte B. Answer to D. Palamar's letter to the editor: "Comment on 'Piriformis muscle syndrome: Diagnostic criteria and treatment of a monocentric series of 250 patients' by F. Michel et al." Ann Phys Rehabil Med (2015) doi:10.1016/j.rehab.2015.01.005. Ann Phys Rehabil Med 2015; 58:195-6. [PMID: 25979179 DOI: 10.1016/j.rehab.2015.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 02/19/2015] [Indexed: 10/23/2022]
Affiliation(s)
- F Michel
- Physical Medicine and Rehabilitation Department, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France; Department of Neuromuscular Examinations and Diseases, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France.
| | - P Decavel
- Department of Neuromuscular Examinations and Diseases, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France
| | - E Toussirot
- Clinical Investigation, Biotherapy Department CBT-506 & Rheumatology, CHRU of Besançon, Besançon, France; University Department of Therapy and Reception Team 4266 Pathogenic Agents and Inflammation, IFR133, université de Franche-Comté, Besançon, France
| | - L Tatu
- Physical Medicine and Rehabilitation Department, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France; Anatomy Laboratory, université de Franche-Comté, Besançon, France
| | - E Aleton
- Department of Neuromuscular Examinations and Diseases, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France
| | - G Monnier
- Physical Medicine and Rehabilitation Department, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France; Anatomy Laboratory, université de Franche-Comté, Besançon, France
| | - P Garbuio
- Department of Orthopedic and Traumatology Surgery, Plastic and Reconstruction Surgery, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France
| | - B Parratte
- Department of Neuromuscular Examinations and Diseases, CHRU - hôpital Jean-Minjoz, 25000 Besançon, France; Anatomy Laboratory, université de Franche-Comté, Besançon, France
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Drampalos E, Sadiq M, Thompson T, Lomax A, Paul A. Intrapiriformis lipoma: an unusual cause of piriformis syndrome. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2014; 24 Suppl 4:S551-4. [DOI: 10.1007/s00586-014-3695-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Revised: 11/17/2014] [Accepted: 11/18/2014] [Indexed: 11/29/2022]
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Cramp F, Bottrell O, Campbell H, Ellyatt P, Smith C, Wilde B. Non-surgical management of piriformis syndrome: a systematic review. PHYSICAL THERAPY REVIEWS 2013. [DOI: 10.1179/108331907x175014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Michel F, Decavel P, Toussirot E, Tatu L, Aleton E, Monnier G, Garbuio P, Parratte B. Piriformis muscle syndrome: Diagnostic criteria and treatment of a monocentric series of 250 patients. Ann Phys Rehabil Med 2013; 56:371-83. [DOI: 10.1016/j.rehab.2013.04.003] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2011] [Revised: 04/08/2013] [Accepted: 04/09/2013] [Indexed: 11/28/2022]
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Socolovsky M, Masi GD. Exposure of the sciatic nerve in the gluteal region without sectioning the gluteus maximus: Analysis of a series of 18 cases. Surg Neurol Int 2012; 3:15. [PMID: 22439106 PMCID: PMC3307246 DOI: 10.4103/2152-7806.92929] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Accepted: 01/02/2012] [Indexed: 11/13/2022] Open
Abstract
Background: Dissecting through the gluteus maximus muscle by splitting its fibers, instead of complete sectioning of the muscle, is faster, involves less damage to tissues, and diminishes recovery time. The objective of the current paper is to present a clinical series of sciatic nerve lesions where the nerve was sufficiently exposed via the transgluteal approach. Methods: We retrospectively selected 18 traumatic sciatic nerve lesions within the buttock, operated upon from January 2005 to December 2009, with a minimum follow-up of 2 years. In all patients, a transgluteal approach was employed to explore and reconstruct the nerve. Results: Ten males and eight females, with a mean age of 39.7 years, were studied. The etiology of the nerve lesion was previous hip surgery (n = 7), stab wound (n = 4), gunshot wound (n = 3), injection (n = 3), and hip dislocation (n = 1). In 15 (83.3%) cases, a motor deficit was present; in 12 (66.6%) cases neuropathic pain and in 12 (66.6%) cases sensory alterations were present. In all cases, the transgluteal approach was adequate to expose the injury and treat it by neurolysis alone (10 cases), neurolysis and neurorrhaphy (4 cases), and reconstruction with grafts (4 cases; three of these paired with neurolysis). The mean pre- and postoperative grades for the tibial nerve (LSUHSC scale) were 1.6 and 3.6, respectively; meanwhile, for the peroneal division, preoperative grade was 1.2 and postoperative grade was 2.4. Conclusions: The transgluteal approach adequately exposes sciatic nerve injuries of traumatic origin in the buttock and allows for adequate nerve reconstruction without sectioning the gluteus maximus muscle.
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Affiliation(s)
- Mariano Socolovsky
- Department of Neurosurgery, Hospital de Clínicas, University of Buenos Aires School of Medicine, Buenos Aires, Argentina
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Ilizaliturri VM, Camacho-Galindo J, Evia Ramirez AN, Gonzalez Ibarra YL, McMillan S, Busconi BD. Soft tissue pathology around the hip. Clin Sports Med 2011; 30:391-415. [PMID: 21419963 DOI: 10.1016/j.csm.2010.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
Abstract
Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.
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Affiliation(s)
- Victor M Ilizaliturri
- National Rehabilitation Institute of Mexico, Universidad Nacional Autónoma de México, Avenue México Xochimilco 289, Col. Arenal de Guadalupe, Mexico City, Mexico.
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Socolovsky M, Garategui L, Campero A, Conesa H, Basso A. Exposure of the sciatic nerve in the gluteal region without sectioning the gluteus maximus: an anatomical and microsurgical study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2011; 108:233-240. [PMID: 21107965 DOI: 10.1007/978-3-211-99370-5_36] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Complete sectioning of the gluteus maximus muscle is an extensive procedure when approaching the sciatic nerve in the buttock, resulting in significant morbidity and a prolonged postoperative recovery period. By contrast, dissecting through the muscle by splitting its fibers is faster, involves less damage to tissues and diminishes recovery time. The objective of the present work was to perform a cadaveric study to obtain measurements of the maximum, minimum and mean exposure that this minimally invasive approach can offer. METHODS Both gluteal regions from each of ten fresh cadavers were dissected via a transgluteal approach, using a transverse curvilinear incision. After exposure of the sciatic nerve, the maximum length of exposed nerve was measured. As a final step, a 6 cm long sural graft reconstruction was performed, aided by a surgical microscope and microscopic techniques. FINDINGS The mean sciatic nerve exposure obtained was 115.4 ± 17.9 mm, ranging from a maximum of 152 mm to a minimum of 90 mm. In all 20 cases, it was possible to perform microsurgical reconstruction under the microscope. We further illustrate these findings with three live patients in whom the transgluteal approach was employed to successfully expose and repair the sciatic nerve. CONCLUSIONS The transgluteal approach is useful in the operative repair of lesions of the proximal sciatic nerve. It is a less invasive technique than classical complete sectioning of the gluteus maximus muscle, and yields better aesthetic results and a faster return to normal daily activities. Complex lesions, like nerve trauma requiring grafts and nerve tumours, can be treated with minimal risk. Nevertheless, it is less comfortable for the surgeon, and the entire extent of the exposed nerve might not be visualized simultaneously during surgery.
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Affiliation(s)
- Mariano Socolovsky
- Hospital de Clínicas, University of Buenos Aires School of Medicine, La Pampa 1175 Apt 5ºA, Buenos Aires, Argentina.
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Hopayian K, Song F, Riera R, Sambandan S. The clinical features of the piriformis syndrome: a systematic review. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2010; 19:2095-109. [PMID: 20596735 PMCID: PMC2997212 DOI: 10.1007/s00586-010-1504-9] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2010] [Revised: 04/14/2010] [Accepted: 06/16/2010] [Indexed: 11/30/2022]
Abstract
Piriformis syndrome, sciatica caused by compression of the sciatic nerve by the piriformis muscle, has been described for over 70 years; yet, it remains controversial. The literature consists mainly of case series and narrative reviews. The objectives of the study were: first, to make the best use of existing evidence to estimate the frequencies of clinical features in patients reported to have PS; second, to identify future research questions. A systematic review was conducted of any study type that reported extractable data relevant to diagnosis. The search included all studies up to 1 March 2008 in four databases: AMED, CINAHL, Embase and Medline. Screening, data extraction and analysis were all performed independently by two reviewers. A total of 55 studies were included: 51 individual and 3 aggregated data studies, and 1 combined study. The most common features found were: buttock pain, external tenderness over the greater sciatic notch, aggravation of the pain through sitting and augmentation of the pain with manoeuvres that increase piriformis muscle tension. Future research could start with comparing the frequencies of these features in sciatica patients with and without disc herniation or spinal stenosis.
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Affiliation(s)
- Kevork Hopayian
- School of Medicine, Health Policy and Practice, University of East Anglia, Norwich NR4 7TJ, UK.
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Smoll NR. Variations of the piriformis and sciatic nerve with clinical consequence: a review. Clin Anat 2010; 23:8-17. [PMID: 19998490 DOI: 10.1002/ca.20893] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
The deep gluteal region is often encountered when performing injections, when performing surgery such as total hip replacements, or diagnosing problems of this region or lower limbs using clinical or imaging techniques. Previously, the prevalence figures of piriformis and sciatic nerve anomalies have ranged from 1.5 to 35.8% in dissected specimens. This study systematically reviews and meta-analyses the prevalence of piriformis and sciatic nerve anomalies in humans using previously published literature. A further review is conducted regarding the anatomical abnormalities present in surgical case series of procedures for patients suffering from piriformis syndrome. After pooling the results of 18 studies and 6,062 cadavers, the prevalence of the anomaly in cadavers was 16.9%; 95% confidence interval (CI) 16.0-17.9%. The prevalence of the piriformis and sciatic nerve anomaly in the surgical case series was 16.2%, 95% CI: 10.7-23.5%. The difference between the two groups was not found to be significant 0.74%; 95% CI: -5.66 to 7.13; P = 0.824. Because of the high likelihood of an anomaly being present in a patient, clinicians and surgeons should be aware of the potential complications this anomaly may have on medical or surgical interventions. Furthermore, because the prevalence of the anomaly in piriformis syndrome patients is not significantly different from what is thought to be a normal population, it indicates that this anomaly may not be as important in the pathogenesis of piriformis syndrome as previously thought.
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Labat JJ, Robert R, Riant T, Louppe JM, Lucas O, Hamel O. [Buttocks sciatic pain]. Neurochirurgie 2009; 55:459-62. [PMID: 19744678 DOI: 10.1016/j.neuchi.2009.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2009] [Accepted: 07/03/2009] [Indexed: 11/29/2022]
Abstract
Confusion between radicular and nerve trunk syndrome is not rare. With sciatic pain, any nerve trunk pain or an atypical nerve course should suggest nerve trunk pain of the sciatic nerve in the buttocks. The usual reflex with sciatic pain is vertebral-radicular conflict. The absence of spinal symptoms and the beginning of pain in the buttocks and not in the lumbar region should reorient the etiologic search. Once a tumor of the nerve trunk has been ruled out (rarely responsible for pain other than that caused by tumor pressure), a myofascial syndrome should be explored searching for clinical, electrophysiological, and radiological evidence of compression of the sciatic trunk by the piriform muscle but also the obturator internus muscle. Hamstring syndrome may be confused with this syndrome. Treatment is first and foremost physical therapy. Failures can be treated with classical CT-guided infiltrations with botulinum toxin. Surgery should only be entertained when all these solutions have failed.
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Affiliation(s)
- J-J Labat
- Service de neurotraumatologie, Hôtel-Dieu, 2, place Alexis-Ricordeau, 44035 Nantes cedex 1, France
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Abstract
Highly reliable evidence for piriformis syndrome and other pelvic sciatic syndromes arises from three major categories of data: magnetic resonance neurography diagnostic imaging, open magnetic resonance-guided injection studies, and patient treatment outcome studies. This article reviews the evidence in each category. This is part of a Point-Counterpoint discussion with Dr. Robert Tiel's presentation of "Myth and Fallacy".
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Affiliation(s)
- Aaron G Filler
- Institute for Nerve Medicine, 2716 Ocean Park Boulevard, Suite 3082, Santa Monica, CA 90405, USA.
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