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Hanna AS, Schmidt BT, Kanarek AA, Hilger KH, Blankenbaker DG, Medhat H, Moscote-Salazar LR, Hellenbrand DJ. Anatomical Proximity Between Sciatic Nerve and Ischial Spine and its Relationship to the Development of Deep Gluteal Pain Syndrome. World Neurosurg 2024:S1878-8750(24)00880-5. [PMID: 38796142 DOI: 10.1016/j.wneu.2024.05.117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Accepted: 05/19/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Deep gluteal syndrome (DGS) is a medical diagnosis in which the pathoanatomy of the subgluteal space contributes to pain. The growing recognition that gluteal neuropathies can be associated with the presence of a bone-neural conflict with irritation or compression may allow us to shed some light on this pathology. This study aims to determine whether the location of the sciatic nerve (SN) in relation to the ischial spine (IS) contributes to the development of DGS. METHODS The SN - IS relationship was analyzed based on magnetic resonance imaging (MRI) in 15 surgical patients (SPs), who underwent piriformis release, and in 30 control patients who underwent MRI of the pelvis for reasons unrelated to sciatica. The SN exit from the greater sciatic foramen was classified as either zone A (medial to the IS); zone B (on the IS); or zone C (lateral to the IS). RESULTS The SN was significantly closer to the IS in SPs than in MRI controls (P = 0.014). When analyzing patients of similar age, SNs in SPs were significantly closer (P = 0.0061) to the IS, and located in zone B significantly more (P = 0.0216) as compared to MRI controls. Patients who underwent surgery for piriformis release showed a significant decrease in pain postoperatively (P < 0.0001). CONCLUSIONS The results from this study suggest that the relationship between the IS and SN may play a role in the development of DGS. This may also help establish which patients would benefit more from surgical intervention.
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Affiliation(s)
- Amgad S Hanna
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA.
| | - Bradley T Schmidt
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Andrew A Kanarek
- Department of Radiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Keegan H Hilger
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA
| | - Donna G Blankenbaker
- Department of Radiology, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin, USA
| | - Heba Medhat
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Neurosurgery, Faculty Of Medicine Kasr Al-Ainy, Cairo University, Cairo, Egypt
| | | | - Daniel J Hellenbrand
- Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin, USA; Department of Biomedical Engineering, University of Wisconsin, Madison, Wisconsin, USA
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Lo JK, Robinson LR. Piriformis syndrome. HANDBOOK OF CLINICAL NEUROLOGY 2024; 201:203-226. [PMID: 38697742 DOI: 10.1016/b978-0-323-90108-6.00002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Piriformis syndrome is a condition that is proposed to result from compression of the sciatic nerve, either in whole or in part, in the deep gluteal space by the piriformis muscle. The prevalence of piriformis syndrome depends upon the diagnostic criteria being used and the population studied but is estimated by some to be 5%-6% in all cases of low back, buttock, and leg pain and up to 17% of patients with chronic low back pain. While the sciatic nerve may pierce the piriformis muscle in about 16% of healthy individuals, this frequency is no different in those with the syndrome; thus, the relationship to this anatomic finding is unclear. The most common symptoms are buttock pain, external tenderness over the greater sciatic notch, and aggravation of the pain through sitting. Many clinical signs are reported for piriformis syndrome, but the sensitivity and specificity are unclear, in part because of the lack of a uniformly accepted case definition. In the majority of cases in the literature, it appears that the diagnosis is more ascribed to a myofascial condition rather than a focal neuropathy. Electrodiagnostic studies can be useful to exclude other causes of symptoms, but there is no well-accepted test to confirm the presence of piriformis syndrome. Ultrasound imaging may show thickening of the piriformis muscle, but further research is required to confirm that this is correlated with the clinical diagnosis. Magnetic resonance imaging and neurography may hold promise in the future, but there are not yet sufficient data to support adopting these methods as a standard diagnostic tool. The initial treatment of piriformis syndrome is typically conservative management with the general rehabilitation principles similar to other soft tissue musculoskeletal conditions. Local anesthetic, botulinum toxin, and/or corticosteroid injections have been reported by some to be beneficial for diagnostic or treatment purposes. Surgical interventions have also been used with variable success.
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Affiliation(s)
- Julian K Lo
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada.
| | - Lawrence R Robinson
- Division of Physical Medicine and Rehabilitation, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
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3
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Anetai H, Tokita K, Kojima R, Toriumi T, Kageyama I, Kumaki K. An atypical inferior gluteal artery passing through the piriformis muscle. Surg Radiol Anat 2024; 46:59-64. [PMID: 37884741 DOI: 10.1007/s00276-023-03256-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE In this article, we report a case of an atypical inferior gluteal artery that passed through the piriformis muscle when it emerged from the pelvic cavity in an elderly Japanese female cadaver. We speculate that this atypical artery could be entrapped and compressed by the piriformis muscle and may therefore be associated with piriformis syndrome; however, the anatomical characteristics of such an atypical artery have not been previously reported. To assess this potential association, the atypical inferior gluteal artery was anatomically examined. METHODS The cadaver examined in this report was a 97-year-old Japanese female who was donated to The Nippon Dental University for use in medical education and research. The atypical inferior gluteal artery and surrounding structures in half of the pelvis were examined macroscopically. RESULTS The atypical inferior gluteal artery arose from the common arterial trunk, formed by itself and the superior gluteal artery, passed through the superior proximal part of the piriformis muscle, and left the pelvic cavity. It supplies branches to the lower half of the gluteus maximus and proximal part of the long head of the biceps femoris muscle. The piriformis muscle originates from the 2nd to 4th sacral vertebrae and attaches to the greater trochanter via a single short tendon. CONCLUSION According to our findings, when the atypical inferior gluteal artery is entrapped and compressed, ischemic signs and symptoms may emerge in the lower buttocks and proximal posterior thigh. These results provide a new perspective for the diagnosis and treatment of piriformis syndrome.
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Affiliation(s)
- Hidaka Anetai
- Department of Anatomy and Life Structure, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
- Department of Physical Therapy, Faculty of Health and Medical Care, Saitama Medical University, Saitama, Japan.
| | - Kounosuke Tokita
- Department of Physical Therapy, Faculty of Health and Medical Care, Saitama Medical University, Saitama, Japan
- Department of Anatomy, School of Life Dentistry at Niigata, The Nippon Dental University, Niigata, Japan
| | - Ryuhei Kojima
- Department of Physical Therapy, Faculty of Health and Medical Care, Saitama Medical University, Saitama, Japan
- Department of Anatomy, School of Life Dentistry at Niigata, The Nippon Dental University, Niigata, Japan
| | - Taku Toriumi
- Department of Anatomy, School of Life Dentistry at Niigata, The Nippon Dental University, Niigata, Japan
| | - Ikuo Kageyama
- Department of Anatomy, School of Life Dentistry at Niigata, The Nippon Dental University, Niigata, Japan
| | - Katsuji Kumaki
- Department of Anatomy, School of Life Dentistry at Niigata, The Nippon Dental University, Niigata, Japan
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Parodi D, Villegas D, Escobar G, Bravo J, Tobar C. Deep Gluteal Pain Syndrome: Endoscopic Technique and Medium-Term Functional Outcomes. J Bone Joint Surg Am 2023; 105:762-770. [PMID: 36943908 DOI: 10.2106/jbjs.22.00394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Sciatic nerve entrapment is an entity that generates disabling pain, mainly when the patient is sitting on the involved side. According to some studies, the presence of fibrovascular bands has been described as the main cause of this pathology, and the sciatic nerve's decompression by endoscopic release has been described as an effective treatment generally associated with a piriformis tenotomy. The aim of this study was to present the medium-term functional results of endoscopic release of the sciatic nerve without resection of the piriformis tendon. METHODS This prospective, observational study included 57 patients who underwent an endoscopic operation for sciatic nerve entrapment between January 2014 and January 2019. In all cases, a detailed medical history was obtained and a physical examination and a functional evaluation were performed using the modified Harris hip score (mHHS), the 12-item International Hip Outcome Tool (iHOT-12), and the visual analog scale (VAS) for pain. All patients had pelvic radiographs and magnetic resonance imaging (MRI) scans of the hip on the involved side and underwent a prior evaluation by a spine surgeon. RESULTS This study included 20 male and 37 female patients with a mean age of 43.6 years (range, 24 to 88 years) and a mean follow-up of 22.7 months. The median mHHS improved from 59 to 85 points. The median iHOT-12 improved from 60 to 85 points. The median VAS decreased from 7 to 2. Postoperative complications occurred in 12% of patients: 1 patient with extensive symptomatic hematoma, 3 patients with hypoesthesia, and 3 patients with dysesthesia. CONCLUSIONS Endoscopic release of the sciatic nerve by resection of fibrovascular bands without piriformis tenotomy is a technique with good to excellent functional results comparable with those of techniques in the literature incorporating piriformis tenotomy. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Dante Parodi
- Department of Orthopaedic Surgery, Clínica RedSalud Providencia, Santiago, Chile
- Fundación Médica San Cristóbal, Santiago, Chile
| | - Diego Villegas
- Department of Orthopaedic Surgery, Clínica RedSalud Providencia, Santiago, Chile
- Department of Orthopaedic Surgery, Hospital Padre Hurtado, Santiago, Chile
| | - Gonzalo Escobar
- Department of Orthopaedic Surgery, Hospital Universitario Austral, Buenos Aires, Argentina
| | - José Bravo
- Orthopaedic Residency Program, Universidad del Desarrollo, Santiago, Chile
| | - Carlos Tobar
- Department of Orthopaedic Surgery, Clínica RedSalud Providencia, Santiago, Chile
- Fundación Médica San Cristóbal, Santiago, Chile
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Abstract
Myofascial pain and myofascial pain syndromes are among some of the most common acute and chronic pain conditions. Many interventional procedures can be performed in both an acute and chronic pain setting to address myofascial pain syndromes. Trigger point injections can be performed with or without imaging guidance such as fluoroscopy and ultrasound; however, the use of imaging in years past has been recommended to improve patient outcome and safety. Injections can be performed using no injectate (dry needling), or can involve the administration of local anesthetics, botulinum toxin, or corticosteroids.
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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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7
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Chiou HJ. Ultrasound-guided pain management for chronic musculoskeletal pain. J Med Ultrasound 2022; 30:165-168. [DOI: 10.4103/jmu.jmu_1_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/20/2021] [Indexed: 11/04/2022] Open
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Deep Gluteal Pain in Orthopaedics: A Challenging Diagnosis. J Am Acad Orthop Surg 2021; 29:e1282-e1290. [PMID: 34874333 DOI: 10.5435/jaaos-d-21-00707] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Accepted: 09/02/2021] [Indexed: 02/01/2023] Open
Abstract
Identifying the specific source of gluteal pain can elude the most seasoned orthopaedic diagnosticians. Patients will often present with a protracted course of symptoms, and failure to successfully identify and treat the underlying etiology leads to frustration for both patient and clinician. Pain deep in the buttocks can arise from compression, inflammation, or injury of one or more of the structures in this anatomically dense area. Although sacroiliitis, hip arthritis, and trochanteric bursitis may also masquerade as gluteal pain, sciatic nerve irritation in its various presentations causes a substantial percentage of cases. Deep gluteal syndrome, hamstring syndrome, and ischiofemoral impingement can have overlapping presentations but can be differentiated by clinical examination and judiciously placed diagnostic corticosteroid injections. Although nonsurgical management, including physical therapy, relative rest, and injections represent the mainstay of treatment, open and endoscopic surgical approaches have yielded encouraging success rates in refractory cases.
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9
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Newman DP, Zhou L. Piriformis Syndrome Masquerading as an Ischiofemoral Impingement. Cureus 2021; 13:e18023. [PMID: 34667694 PMCID: PMC8520408 DOI: 10.7759/cureus.18023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 11/05/2022] Open
Abstract
Hip pain can have a number of different etiologies. Ischiofemoral impingement (IFI), an etiology causing extra-articular hip pain, shares many of the same symptoms as other causes of gluteal or inguinal pain, making its diagnosis difficult. We present a case of a young female with persistent deep gluteal pain who was diagnosed with IFI based on radiographic findings; however, a diagnostic injection into the quadratus femoris did not confirm IFI as the primary pain generator. The patient subsequently failed several trials of physical therapy designed to address this diagnosis. The diagnosis was expanded to include piriformis syndrome and the modified treatment approach resulted in complete resolution of her pain. The similarities of these pathologies resulted in a delay of definitive treatment and would have potentially required unnecessary surgery. This case study highlights the diagnostic conundrum clinicians face in the evaluation of gluteal hip pain and provides an algorithm for considering alternate diagnoses when conservative management fails to achieve expected results.
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Affiliation(s)
- David P Newman
- Pain Management-Physiotherapy, Tripler Army Medical Center, Honolulu, USA
| | - Liang Zhou
- Orthopaedic Surgery, Tripler Army Medical Center, Honolulu, USA
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10
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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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Jardak M, Chaari F, Bouchaala F, Fendri T, Harrabi MA, Rebai H, Sahli S. Does piriformis muscle syndrome impair postural balance? A case control study. Somatosens Mot Res 2021; 38:315-321. [PMID: 34519264 DOI: 10.1080/08990220.2021.1973404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND AND PURPOSE While patients with musculoskeletal disorders reported postural balance impairments, it is unknown whether patients with piriformis muscle syndrome (PMS) may exhibit postural balance disorders compared to controls. The aim was to compare postural balance in patients with PMS to controls in static and dynamic conditions. MATERIAL AND METHODS Twelve patients with PMS and twelve controls were enrolled. Static postural balance was assessed by calculating the symmetry index (SI) in the unipedal posture. To measure vision contribution, the Romberg index (RI) was computed. Dynamic postural balance was evaluated with the Timed up and go test (TUGT). Besides, inter-limb strength asymmetry (SA), pain and the short form-36 (SF-36) were assessed. RESULTS The PMS group (PMSG) exhibited significant (p < 0.001) higher SI in eyes opened (EO) and eyes closed (EC) conditions compared to the control group (CG). Besides, PMSG had significant higher RI (p < 0.05), TUGT scores (p < 0.001), SA values (p < 0.05), pain intensity (p < 0.001), and worse SF-36 scores on all physical health (p < 0.05) and psychological health (only in vitality and mental health [p < 0.05]), compared to CG. CONCLUSION Our data revealed impaired static and dynamic postural balance, and reduced quality of life in PMSG compared to CG. Postural balance impairments could explain the poor quality of life, which are likely due to the higher SA and higher pain intensity. Clinicians and physiotherapists should consider postural balance disorders while designing rehabilitation programs in these patients.
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Affiliation(s)
- Mariem Jardak
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Fatma Chaari
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Fatma Bouchaala
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Thouraya Fendri
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Mohammed Achraf Harrabi
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Haithem Rebai
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
| | - Sonia Sahli
- Research Laboratory Education, Motricité, Sport et Santé, EM2S, LR19JS01, High Institute of Sport and Physical Education of Sfax, University of Sfax, Sfax, Tunisia
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Kale A, Başol G, Cansu Gündoğdu E, Mat E, Yıldız G, Kuru B, Aboalhasan Y, Uzun ND, Usta T, tıntaş MA, Demirhan R. Laparoscopic surgical approach for the treatment of piriformis syndrome: Intrapelvic decompression technique. JOURNAL OF ENDOMETRIOSIS AND PELVIC PAIN DISORDERS 2021. [DOI: 10.1177/22840265211045610] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Piriformis syndrome is an uncommon disease resulting from the piriformis muscle’s compression of the sciatic nerve. Pain and numbness in the buttocks and down the leg are the most common symptoms. This study analyzes the laparoscopic surgical treatment of piriformis syndrome. Methods: We report three cases of piriformis syndrome diagnosed in our hospital. The first case was a 40 years old woman with a 7-year history of intermittent low back pain and sciatica on her right side. Hyperesthesia and cutaneous allodynia were observed in the right sciatic nerve dermatome. The second case was a 30 years old woman with a 2-year history of sciatica on her left side. The third case was a 30 years old woman with a 2-year history of sciatica on her right side. All the patients underwent laparoscopic decompression surgery, which was performed to release the sciatic nerve or sacral nerve roots. Results: The patients were reexamined at the postoperative 3rd and 6th months. Their visual analog scale (VAS) scores were found to be decreased from 10/10, 9/10, and 7/10 to 0/10, 1/10, and 0/10, respectively. Conclusion: Due to the very few cases in the literature, pelvic piriformis syndrome is an exclusively clinical diagnosis. If the sciatica is refractory to conservative treatments, laparoscopic exploration and decompression surgery of the pelvic nerves and piriformis muscle could be an option.
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Affiliation(s)
- Ahmet Kale
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Gülfem Başol
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Elif Cansu Gündoğdu
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Emre Mat
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Gazi Yıldız
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Betül Kuru
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Yasmin Aboalhasan
- Department of Obstetrics and Gynecology, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Navdar Doğuş Uzun
- Department of Obstetrics and Gynecology, Mardin Midyat State Hospital, Mardin, Turkey
| | - Taner Usta
- Department of Obstetrics and Gynecology, Acibadem University, Altunizade Hospital, Istanbul, Turkey
| | - Mehmet Al tıntaş
- Department of General Surgery, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
| | - Recep Demirhan
- Department of Thoracic Surgery, University of Health Science, Kartal Dr. Lutfi Kirdar City Hospital, Istanbul, Turkey
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Abstract
ABSTRACT While buttock pain is a common complaint in sports medicine, deep gluteal syndrome (DGS) is a rare entity. DGS has been proposed as a unifying term referring to symptoms attributed to the various pain generators located in this region. While not all-inclusive, the diagnosis of DGS allows for focus on pathology of regionally associated muscles, tendons, and nerves in the clinical evaluation and management of posterior hip and buttock complaints. An understanding of the anatomic structures and their kinematic and topographic relationships in the deep gluteal space is pivotal in making accurate diagnoses and providing effective treatment. Because presenting clinical features may be unrevealing while imaging studies and diagnostic procedures lack supportive evidence, precise physical examination is essential in obtaining accurate diagnoses. Management of DGS involves focused rehabilitation with consideration of still clinically unproven adjunctive therapies, image-guided injections, and surgical intervention in refractory cases.
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Danazumi MS, Yakasai AM, Ibrahim AA, Shehu UT, Ibrahim SU. Effect of integrated neuromuscular inhibition technique compared with positional release technique in the management of piriformis syndrome. J Osteopath Med 2021; 121:693-703. [PMID: 34049428 DOI: 10.1515/jom-2020-0327] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 03/29/2021] [Indexed: 11/15/2022]
Abstract
CONTEXT Studies have indicated that the muscle energy technique (MET) and the positional release technique (PRT) are effective in the management of piriformis syndrome (PS); however, evidence is scarce regarding the combination of these techniques in the form of an integrated neuromuscular inhibition technique (INIT) in the management of individuals with PS. Although a previous trial investigated the effect of INIT for PS, that study did not integrate Ruddy's reciprocal antagonist facilitation (RRAF) method into the INIT protocol, nor did the authors diagnose PS according to established criteria. OBJECTIVES To examine the effects of INIT with integrated RRAF compared with PRT in the management of patients diagnosed with PS. METHODS This study was designed as a single blind randomized clinical trial in which participants diagnosed with PS were randomly allocated into INIT and PRT groups. Each group attended two treatment sessions per week for 8 weeks. Patients in the INIT group received a protocol in which the patient's tender point or trigger point was palpated in the belly of the piriformis approximately halfway between the inferior lateral angle of the sacrum and the greater trochanter, at which point the therapist applied an intermittent or sustained pressure and maintained the pressure for 20-60 seconds (depending on the participant's response to pain reduction). For INIT patients, that protocol was also followed by RRAF, a method in which a patient introduces a series of tiny/miniature contractions or efforts (20 times per 10 seconds) against a therapist's resistance. Patients in the PRT group were treated by palpating the same trigger point described in the INIT group, followed by application of light pressure at the location of the trigger point, which was maintained the pressure for 2 minutes or until the pain subsided (determined by asking the participant to report a pain score using a visual analog scale at 30 second intervals). For both groups, three repetitions of the INIT or PRT treatment were performed over 10 minutes at each clinical visit. Additionally, each group also received stretching exercises immediately after the INIT or PRT treatment session. Each participant was assessed at baseline, immediately posttreatment, and at 4 months posttreatment for pain, sciatica, functional mobility, quality of life, hip abduction, and internal rotation. A repeated measures analysis of variance (ANOVA) of within-between group interactions was used to analyze the treatment effect. RESULTS Forty eight participants (age range, 25-47 years; mean age ± standard deviation, 32.81 ± 3.27 years) were randomized into the INIT and PRT groups, with 24 participants in each group. No significant between-group differences (p>0.05) were observed in the baseline demographic and clinical variables of the participants. A repeated-measures ANOVA indicated that there was a significant time effect for all outcomes, with a significant interaction between time and intervention (p<0.001). The Bonferroni post hoc analyses of time and intervention effects indicated that the INIT group improved significantly compared with the PRT group in all outcomes (p<0.05) immediately posttreatment and at the 4 months follow up period. CONCLUSIONS INIT was more effective than PRT in the management of individuals with PS. It should be noted the significant improvement achieved in both the groups may have also been contributed to by the stretching exercises that were used as adjunct therapies by both groups.
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Affiliation(s)
- Musa S Danazumi
- Department of Physiotherapy, Federal Medical Center, Nguru, Yobe State, Nigeria.,Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
| | - Abdulsalam M Yakasai
- Medical Rehabilitation Therapists (Reg.) Board of Nigeria, North-West Zonal Office, Kano, Nigeria.,Department of Physiotherapy, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Aminu A Ibrahim
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria.,Department of Physiotherapy, Muhammad Abdullahi Wase Teaching Hospital, Hospitals Management Board, Kano, Kano State, Nigeria
| | - Usman T Shehu
- Department of Public Health, School of Health Sciences, University of Salford Manchester, Manchester, UK
| | - Shehu U Ibrahim
- Department of Physiotherapy, Faculty of Allied Health Sciences, College of Health Sciences, Bayero University, Kano, Nigeria
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Shahzad M, Rafique N, Shakil-Ur-Rehman S, Ali Hussain S. Effects of ELDOA and post-facilitation stretching technique on pain and functional performance in patients with piriformis syndrome: A randomized controlled trial. J Back Musculoskelet Rehabil 2021; 33:983-988. [PMID: 32894238 DOI: 10.3233/bmr-181290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Piriformis syndrome (PS) is a neuro-muscular condition, which is often underdiagnosed in clinical settings. This study will determine the effects of myofascial stretching Elongation Longitudinaux Avec Decoaption Osteo Articulaire (ELDOA) and post-facilitation stretching of the piriformis muscle in patients with PS. OBJECTIVE We aimed to compare the effects of ELDOA and post-facilitation stretching of the piriformis muscle on pain, muscle length and functional performance in patients with PS. METHODS A randomized clinical trial was conducted with 40 PS patients including both males and females, between the ages of 30-70. Patients were randomly assigned to the ELDOA or post-facilitation group after assessments with the Numeric Pain Rating Scale (NPRS), Lower Extremity Functional Scale (LEFS), Piriformis Length Test and Straight Leg Raise (SLR). The assessments were done at baseline and at the end of the sixth week of treatment. RESULTS The patients treated with ELDOA demonstrated significant improvement in pain (pre = 7.00 ± 2.75, post = 3.00 ± 1.75), piriformis length (pre = 27.6 ± 5.54, post = 36.8 ± 3.13), SLR (pre = 36.40 ± 7.24, post = 67.5 ± 8.36) and LEFS (pre = 26.90 ± 12.24, post = 58.10 ± 8.62), as compared with the group treated with post-facilitation stretching: pain: pre = 6.00 ± 1.00, post = 2.00 ± 1.50; piriformis length: pre = 28.55 ± 4.03, post = 38.8 ± 2.70; SLR: pre = 40.60 ± 7.48, post = 74.25 ± 5.19, and LEFS: pre = 25.20 ± 7.66, post = 66.30 ± 7.27). CONCLUSION It can be concluded that the post-facilitation stretching technique shows more improvement in pain, muscle length, SLR, and LEFS in patients with PS as compared to ELDOA.
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16
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Imaging of peripheral nerve causes of chronic buttock pain and sciatica. Clin Radiol 2021; 76:626.e1-626.e11. [PMID: 33827758 DOI: 10.1016/j.crad.2021.03.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 01/23/2021] [Accepted: 02/17/2021] [Indexed: 11/21/2022]
Abstract
Chronic buttock pain is a common and debilitating symptom, which severely impacts daily activities, sleep, and may affect athletic performance. Lumbar spine, posterior hip, or hamstring pathology are usually considered as the primary diagnoses; however, pelvic neural pathology may be a significant cause of chronic buttock pain, particularly if there are prolonged (>6 months) buttock and/or radicular symptoms. The subgluteal space is the site of most pelvic causes of neural-mediated buttock pain, primarily relating to entrapment neuropathy of the sciatic nerve (deep gluteal syndrome), although other nerves within the subgluteal space including the gluteal nerves, pudendal nerve, and posterior cutaneous nerve of thigh may also be involved. Additionally, cluneal nerve entrapment at the iliac crest may result in "pseudo-sciatica". Anatomical variants of the pelvic girdle muscles and functional factors, including muscle spasm and pelvic instability, may contribute to development of deep gluteal syndrome, along with neural senescence. Imaging findings primarily relate to the presence of sciatic neuritis and peri-sciatic pathology, including neural compression and peri-neural adhesions or fibrosis. This imaging review describes the causes, magnetic resonance imaging and ultrasound imaging findings and imaging-guided treatment of pelvic neural causes of chronic buttock pain and sciatica.
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17
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Pearce JMS. The deep gluteal (piriformis) syndrome. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2021. [DOI: 10.47795/ejiz4910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Piriformisa syndrome is a subgroup of the deep gluteal syndrome, an important differential diagnosis of sciatica. Piriformis is a short external rotator muscle of the hip joint passing close to the sciatic nerve as it passes through the great sciatic foramen. Compression causes numbness, ache or tingling in the buttocks, posterolateral aspect of the leg and foot. The causes of sciatic nerve entrapment in the deep gluteal syndrome are best shown by endoscopic exploration. The frequency of anatomical variants in normal subjects however, should caution that such anomalies are not necessarily the cause of symptoms.
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18
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VĂCĂRAȘ V, FRUNZE S, CORDOȘ MA, PERCIULEAC T, MUREȘANU FD. A clinical approach of neuropathic pain in piriformis syndrome: case presentation and rehabilitation particularities. BALNEO RESEARCH JOURNAL 2020. [DOI: 10.12680/balneo.2020.408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Piriformis syndrome is a rare cause of sciatica and buttock pain and is usually considered as a diagnosis of exclusion for patients with a history of trauma. It usually presents without abnormalities regarding sensory and motor functions and tends to have a favorable evolution with pharmacological treatment. We present the case of a patient with posttraumatic piriformis syndrome who came to our department with significant pain and muscle weakness. The diagnosis was confirmed using clinical tests, imaging techniques and electroneurography. The patient did not respond to pharmacologic treatment alone and therefore surgery was performed. Surgery along with pharmacological treatment, complementary pain treatment and physical rehabilitation provided a favorable outcome. Keywords: neurology, rehabilitation, piriformis syndrome, deep gluteal syndrome, traumatic neuropathy, neuropathic pain,
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Affiliation(s)
- Vitalie VĂCĂRAȘ
- 1. “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania 2. Cluj-Napoca County Emergency Hospital, Neurology Department, Cluj-Napoca, Romania
| | - Sorina FRUNZE
- 2. Cluj-Napoca County Emergency Hospital, Neurology Department, Cluj-Napoca, Romania
| | - Mihai Adrian CORDOȘ
- 2. Cluj-Napoca County Emergency Hospital, Neurology Department, Cluj-Napoca, Romania
| | - Tatiana PERCIULEAC
- 2. Cluj-Napoca County Emergency Hospital, Neurology Department, Cluj-Napoca, Romania
| | - Fior Dafin MUREȘANU
- 1. “Iuliu Haţieganu” University of Medicine and Pharmacy Cluj-Napoca, Romania 2. Cluj-Napoca County Emergency Hospital, Neurology Department, Cluj-Napoca, Romania
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19
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Yudin AL, Shomakhov MA, Yumatova EA, Abovich YA. [Piriformis syndrome. Treatment under control of CT fluoroscopy]. Zh Nevrol Psikhiatr Im S S Korsakova 2020; 120:85-90. [PMID: 33244963 DOI: 10.17116/jnevro202012010185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To demonstrate one of the effective methods of treatment of the piriformis syndrome under the control of a highly technological visualization method. MATERIAL AND METHODS Eight patients (7 women and 1 man), aged 44 to 63 years, with piriformis syndrome, were studied from 2016 to 2018. The main complaints of the patients were pain in the lumbosacral spine with irradiation to the gluteal region and/or legs. All patients underwent MRI and/or MSCT of the lumbosacral spine, the pelvic ultrasound, according to the results of which 1 patient was diagnosed with uterine myoma, 5 with lesions of intervertebral discs in the L4-L5 and L5-S1 segments of varying severity in combination with changes in posture. For therapeutic purposes, all patients under the control of CT fluoroscopy were administered to xeomin (n=3), dexamethasone (n=1) or betamethasone (n=4). RESULTS In all patients, a positive therapeutic effect was observed after 4-12 months for xeomin injections, 2-3 weeks for dexamethasone and up to 3 months for betamethasone. No complications during the manipulations were observed. The authors present a clinical case to describe the botulinum therapy technique under the control of CT fluoroscopy, which allows effective treatment of the piriformis syndrome. CONCLUSION In the treatment of the piriformis syndrome it is necessary to apply an integrated approach, the leading of which are methods of local impaction on the suffering muscle. Only a methodologically correct injection can increase the effectiveness of treatment in these patients and reduce the risk of complications.
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Affiliation(s)
- A L Yudin
- Pirogov Russian National Research Medical University, Moscow, Russia.,Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - M A Shomakhov
- Central Clinical Hospital of the Russian Academy of Sciences, Moscow, Russia
| | - E A Yumatova
- Pirogov Russian National Research Medical University, Moscow, Russia
| | - Yu A Abovich
- Pirogov Russian National Research Medical University, Moscow, Russia
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20
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Fahmi A, Rahmadhan MA, Aprianto DR, Subianto H, Turchan A. Complete resolution of recurrent piriformis syndrome after piriformis resection with 3 years' follow up: A case report. Int J Surg Case Rep 2020; 77:576-579. [PMID: 33395849 PMCID: PMC7708764 DOI: 10.1016/j.ijscr.2020.11.099] [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: 10/18/2020] [Revised: 11/16/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022] Open
Abstract
Some of piriformis syndrome intractable with conservative treatment. Surgery was indicated for intractable piriformis syndrome. Piriformis resection can be a feasible option for intractable piriformis syndrome. Piriformis resection decrease visual analog scale in intractable piriformis syndrome.
Introduction Piriformis syndrome (PS) is an uncommon neuromuscular condition characterized by buttock pain radiating to the leg. Although the goal of PS treatment is symptom relief, it is difficult in some patients using conservative treatment alone. Presentation of case A 72-year-old male underwent piriformis resection after failed sequential steroid injection of the piriformis. The patient ultimately underwent surgery for resection of the piriformis muscle and experienced satisfactory pain relief (pain reduction > 75% according to visual analog scale for at least 12 months) following surgery and in the 3-year follow-up period. Discussion Conservative treatment is first-choice treatment for managing PS. Surgery was indicated when the patient did not achieve satisfactory pain relief with conservative treatment. Surgical resection of the piriformis muscle has been shown to be effective and feasible. Conclusion Piriformis resection is effective and can be a feasible option for the treatment of PS following failure of appropriate conservative treatment(s).
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Affiliation(s)
- Achmad Fahmi
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia.
| | - Mustaqim Apriyansa Rahmadhan
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Dirga Rachmad Aprianto
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia; Department of Surgery, Faculty of Medicine, Universitas Islam Sutan Agung, Semarang, Indonesia
| | - Heri Subianto
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
| | - Agus Turchan
- Faculty of Medicine, Universitas Airlangga, Surabaya, Indonesia; Department of Neurosurgery, Dr. Soetomo General Academic Hospital, Surabaya, Indonesia
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21
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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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22
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Siddiq MAB, Clegg D, Hasan SA, Rasker JJ. Extra-spinal sciatica and sciatica mimics: a scoping review. Korean J Pain 2020; 33:305-317. [PMID: 32989195 PMCID: PMC7532296 DOI: 10.3344/kjp.2020.33.4.305] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/30/2020] [Accepted: 08/03/2020] [Indexed: 11/21/2022] Open
Abstract
Not all sciatica-like manifestations are of lumbar spine origin. Some of them are caused at points along the extra-spinal course of the sciatic nerve, making diagnosis difficult for the treating physician and delaying adequate treatment. While evaluating a patient with sciatica, straightforward diagnostic conclusions are impossible without first excluding sciatica mimics. Examples of benign extra-spinal sciatica are: piriformis syndrome, walletosis, quadratus lumborum myofascial pain syndrome, cluneal nerve disorder, and osteitis condensans ilii. In some cases, extra-spinal sciatica may have a catastrophic course when the sciatic nerve is involved in cyclical sciatica, or the piriformis muscle in piriformis pyomyositis. In addition to cases of sciatica with clear spinal or extra-spinal origin, some cases can be a product of both origins; the same could be true for pseudo-sciatica or sciatica mimics, we simply don’t know how prevalent extra-spinal sciatica is among total sciatica cases. As treatment regimens differ for spinal, extra-spinal sciatica, and sciatica-mimics, their precise diagnosis will help physicians to make a targeted treatment plan. As published works regarding extra-spinal sciatica and sciatica mimics include only a few case reports and case series, and systematic reviews addressing them are hardly feasible at this stage, a scoping review in the field can be an eye-opener for the scientific community to do larger-scale prospective research.
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Affiliation(s)
- Md Abu Bakar Siddiq
- Physical Medicine and Rehabilitation Department, Brahmanbaria Medical College, Brahmanbaria, Bangladesh.,School of Health Sport and Professional Practice, University of South Wales, Pontypridd, United Kingdom
| | - Danny Clegg
- School of Health and Social Care, London South Bank University, London, United Kingdom
| | - Suzon Al Hasan
- Physical Medicine and Rehabilitation Department, Rajshahai Medical College, Rajshahai, Bangladesh
| | - Johannes J Rasker
- Faculty of Behavioral Management and Social Sciences, Psychology Health and Technology, University of Twente, Enschede, The Netherlands
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23
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Aquino‐Jose VM, Blinder V, Johnson J, Havryliuk T. Ultrasound-guided trigger point injection for piriformis syndrome in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:876-879. [PMID: 33145535 PMCID: PMC7593435 DOI: 10.1002/emp2.12153] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/18/2020] [Accepted: 05/22/2020] [Indexed: 11/11/2022] Open
Abstract
Piriformis syndrome, a myofascial pain disorder characterized by deep gluteal pain that radiates to the ipsilateral lower back and/or posterior thigh, is an underreported cause of low back pain frequently misdiagnosed in the emergency department (ED). Often refractory to oral pain medications, this syndrome can be debilitating. Ultrasound-guided trigger point injection of the piriformis muscle can treat piriformis syndrome, but no previous reports exist in the emergency medicine literature. This case series describes 2 patients who presented to our emergency department with low back pain and were diagnosed with piriformis syndrome. Both patients received an ultrasound-guided trigger point injection of the affected piriformis muscle with a significant reduction of pain at 15 minutes and 48 hours after the procedure.
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Affiliation(s)
- Victor M. Aquino‐Jose
- Department of Surgery, Division of Trauma, Emergency Surgery, and Critical CareStony Brook University HospitalStony BrookNew YorkUSA
| | - Veronika Blinder
- Department of Emergency MedicineNorth Shore University Hospital–Northwell HealthManhassetNew YorkUSA
| | - Jennifer Johnson
- Department of Emergency MedicineNorth Shore University Hospital–Northwell HealthManhassetNew YorkUSA
| | - Tatiana Havryliuk
- Department of Emergency MedicineThe Brooklyn Hospital CenterBrooklynNew YorkUSA
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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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25
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Ismail ET, Abbas T, Javad S, Reza S. Gait analysis of patients with piriformis muscle syndrome compared to healthy controls. Musculoskelet Sci Pract 2020; 48:102165. [PMID: 32560868 DOI: 10.1016/j.msksp.2020.102165] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Accepted: 04/03/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Piriformis muscle syndrome (PMS) is a condition that can causes local buttock pain and tenderness. The symptoms of PMS are related to the hip joint position and may affect repetitive daily tasks such as walking. OBJECTIVES What is the difference between the gait characteristics of patients with PMS and those of matched-healthy controls? DESIGN Observational study. METHODS Thirty patients with PMS and 30 age-, sex-, and height-matched healthy participants underwent three-dimensional walking analysis. RESULTS The results showed no significant differences in the spatiotemporal characteristics of gait between the groups (p > 0.1). The PMS group flexed the hip joint significantly more (-7.2 [-11.9 to -2.2], p = 0.003) and extended the hip joint to a lesser degree (-2.48 [-4.91 to -0.5], p = 0.04) than the control group. Patients with PMS needed a statistically significantly longer time to reach the peak angles of hip internal (1.3 [1 to 1.9], p = 0.003) and external (5.5 [0.9 to 10.1], p = 0.01) rotations during the gait cycle. Further, the results showed that the sagittal range of motion of the knee joint was significantly lesser in patients with PMS than in controls (3.45 [0.4 to 6.4], p = 0.02). CONCLUSIONS Patients with PMS seem to have different kinematic changes during level walking. Changing the peak flexion and extension of the hip joint is considered a strategy to enable pain-free gait in patients with PMS. Further, the knee kinematics are modified consequent to the change of hip joint kinematics.
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Affiliation(s)
- Ebrahimi Takamjani Ismail
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Tabatabaiee Abbas
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Sarrafzadeh Javad
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Salehi Reza
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
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26
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Ahmed MAA. Dexamethasone Versus Magnesium Sulfate as an Adjuvant to Local Anesthetics in the Ultra-Sound Guided Injection of Piriformis Muscle for the Treatment of Piriformis Syndrome. ACTA ACUST UNITED AC 2020. [DOI: 10.2174/2589645802014010035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background:Piriformis Syndrome (PS) is an underdiagnosed cause of buttock, thigh and leg pain, most probably because it is thought to be a rare cause of sciatica. PS is widely believed to be myofascial in origin.Materials and Methods:This prospective, randomized, controlled, double-blind study was conducted at the pain management department. 50 patients aged from 20 to 60 years old were included in this study. The selected patients were randomly allocated into 2 groups containing 25 patients each; Group D received a total of 5 mL which included 2mL lidocaine 2%, 2mL (8 mg) dexamethasone and 1mL normal saline 0.9%, and Group M received a total of 5mL which included 2mL lidocaine 2%, 3mL magnesium sulphate (MgSO4) (2.5%) . Patients demographic characteristics, baseline physical examination findings of the patients as well as the duration of pain were all recorded. Patients were re-assessed immediately after injection, 1 week, 1 month, and 3 months after the injection. Numeric Rating Scale (NRS) values were used at each evaluation time to assess the pain, while patients were in sitting, standing, and lying positions. All patients were assessed immediately and for 4 hours post-injection for any side effects related to the drugs used.Results:In the pre-injection time, immediately after and 1 week after injection, there were no statistically significant differences between groups D and M in pain values. While, on comparison between both groups, group M, was significantly better than group D, in NRS values 1 month and 3 months after injection. In group D, pain score values were significantly better immediately, 1 week, and 1 month after injection compared to the pre-injection values, while these values were not significantly different 3 months after injection compared with the pre-injection values. In group M, pain score values were significantly better immediately, 1 week, 1 month, and 3 months after injection compared to the pre-injection values.Conclusion:Magnesium sulfate was more effective, especially for long term pain relief (3 months) when compared to dexamethasone as they were used as adjuvants to lidocaine, if injected into the piriformis muscle (PM) guided by ultrasound in the management of PS refractory as initial conservative treatment.
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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: 25] [Impact Index Per Article: 6.3] [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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Hermann W. [The piriformis syndrome-a special indication for botulinum toxin]. DER NERVENARZT 2020; 91:99-106. [PMID: 32020236 DOI: 10.1007/s00115-020-00866-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The piriformis syndrome (PiS) is a possible cause of gluteal pain radiating into the legs. From a pathophysiological anatomical point of view a division into primary and secondary PiS is made. A primary PiS is based on variants of the course of the sciatic nerve with respect to the piriformis muscle. A secondary PiS occurs as a result of hypertrophy, tension and hardening of the piriformis muscle. Muscular hypertrophy causes an impingement syndrome with pressure on the sciatic nerve in the infrapiriform foramen more often than course variants. A tentative diagnosis of PiS can be made based on anamnestic information, clinical signs of strain and the flexion adduction internal rotation (FAIR) test. If asymmetry or hypertrophy exists, the tentative diagnosis is substantiated with the representation of the piriformis muscle in computed tomography (CT). Thus, a CT-supported botulinum injection (BTX) into the piriformis muscle is indicated. This is a pathogenetic treatment approach leading to a reduction in volume. In most cases a single treatment is sufficient. Since there are no adverse consequences, the BTX into the piriformis muscle is also justified from a diagnostic and therapeutic point of view in cases of primary PiS if the clinical indications are clear and other causes can be ruled out. In an in-house case series the tentative diagnosis of PiS could be made for 19 patients and the effectiveness of BTX was confirmed.
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Affiliation(s)
- W Hermann
- SRO AG Langenthal, St. Urbanstraße 67, 4900, Langenthal, Deutschland.
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29
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Barbosa ABM, Santos PVD, Targino VA, Silva NDA, Silva YCDM, Gomes FB, Assis TDO. Sciatic nerve and its variations: is it possible to associate them with piriformis syndrome? ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:646-653. [DOI: 10.1590/0004-282x20190093] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/05/2019] [Indexed: 11/21/2022]
Abstract
ABSTRACT The sciatic nerve forms from the roots of the lumbosacral plexus and emerges from the pelvis passing inferiorly to the piriformis muscle, towards the lower limb where it divides into common tibial and fibular nerves. Anatomical variations related to the area where the nerve divides, as well as its path, seem to be factors related to piriformis syndrome. Objective: To analyze the anatomical variations of the sciatic nerve and its clinical implications. Methods: This was a systematic review of articles indexed in the PubMed, LILACS, SciELO, SpringerLink, ScienceDirect and Latindex databases from August to September 2018. Original articles covering variations of the sciatic nerve were included. The level of the sciatic nerve division and its path in relation to the piriformis muscle was considered for this study. The collection was performed by two independent reviewers. Results: At the end of the search, 12 articles were selected, characterized according to the sample, method of evaluation of the anatomical structure and the main results. The most prevalent anatomical variation was that the common fibular nerve passed through the piriformis muscle fibers (33.3%). Three studies (25%) also observed anatomical variations not classified in the literature and, in three (25%) the presence of a double piriformis muscle was found. Conclusion: The results of this review showed the most prevalent variations of the sciatic nerve and point to a possible association of this condition with piriformis syndrome. Therefore, these variations should be considered during the semiology of disorders involving parts of the lower limbs.
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Affiliation(s)
| | | | | | | | | | | | - Thiago de Oliveira Assis
- Centro Universitário UNIFACISA, Brasil; Universidade Federal da Paraíba, Brasil; Universidade Estadual da Paraíba, Brasil
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30
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Tabatabaiee A, Takamjani IE, Sarrafzadeh J, Salehi R, Ahmadi M. Ultrasound-guided dry needling decreases pain in patients with piriformis syndrome. Muscle Nerve 2019; 60:558-565. [PMID: 31415092 DOI: 10.1002/mus.26671] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/06/2019] [Accepted: 08/10/2019] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Piriformis muscle syndrome (PMS) is a disorder that can lead to symptoms of buttock pain and limited hip-joint mobility, and may have an impact on quality of life. METHODS Thirty-two patients with PMS were randomized to the treatment group, which included three sessions of ultrasound-guided dry needling (DN) of the piriformis muscle (n = 16), or a waitlist control group (n = 16). The primary outcome was pain intensity measured on the visual analog scale recorded at baseline and then at 72 hours and 1 week after treatment. RESULTS At 1-week follow-up, pain intensity was significantly less in the DN group than in the waitlist control group (-2.16 [-1.01 to -3.32], P = .007) by an amount consistent with clinically meaningful improvement. DISCUSSION The findings suggest that DN resulted in clinically meaningful short-term improvement in pain intensity of patients with PMS.
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Affiliation(s)
- Abbas Tabatabaiee
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Ismail Ebrahimi Takamjani
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Javad Sarrafzadeh
- Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Reza Salehi
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Maryam Ahmadi
- Rehabilitation Research Center, Department of Physiotherapy, School of Rehabilitation Sciences, Iran University of Medical Sciences, Tehran, Iran
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31
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Robinson LR. Is the FAIR-test a fair method of detecting piriformis syndrome? Muscle Nerve 2019; 60:E20. [PMID: 31298740 DOI: 10.1002/mus.26634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 05/14/2019] [Accepted: 05/17/2019] [Indexed: 11/06/2022]
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32
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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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33
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Fishman LM, Hosseini M. In response to Dr Robinson's letter on piriformis syndrome. Muscle Nerve 2019; 60:E21. [PMID: 31298729 DOI: 10.1002/mus.26635] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 07/05/2019] [Accepted: 07/09/2019] [Indexed: 11/10/2022]
Affiliation(s)
- Loren M Fishman
- Columbia University Medical School, Rehabilitation and Regenerative Medicine, New York, New York
| | - Maryam Hosseini
- Albert Einstein College of Medicine, Physical Medicine and Rehabilitation, Bronx, New York
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34
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Huang ZF, Lin BQ, Torsha TT, Dilshad S, Yang DS, Xiao J. Effect of Mannitol plus Vitamins B in the management of patients with piriformis syndrome. J Back Musculoskelet Rehabil 2019; 32:329-337. [PMID: 30412481 DOI: 10.3233/bmr-170983] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Piriformis syndrome (PS) is an entrapment of the sciatic nerve by the piriformis muscle, or myofascial pain from the piriformis muscle. OBJECTIVE The aim of this study was to investigate the effectiveness of Mannitol plus Vitamins B regime in the management of PS. METHODS Twenty two patients were included in this study and received 250 ml of mannitol 20% intravenous infusion for 5 days + Vitamins B (vitamin B1 10 mg + vitamin B2 10 mg + vitamin B12 50 μg PO) for 6 weeks. Clinical outcomes were assessed systematically by clinical tests (tenderness, FAIR test, Beatty's, Freiberg's and Pace's maneuver), Numeric Rating Scale (NRS), Likert Analogue Scale (LAS), and MR examination. RESULTS The clinical evaluations showed a significant reduction (p< 0.05) of tenderness, FAIR test, Beatty's maneuver, Freiberg's maneuver and Pace's maneuver when compared with baseline evaluation during the 3rd and 6th month follow-ups. A statistically significant improvement of pain was measured by NRS at resting (p< 0.001), at night (p< 0.001) and during activities (p< 0.001) and LAS with prolonged sitting (p< 0.001), standing (p< 0.001) and lying (p< 0.001). Concomitantly, swelling of SN revealed a significant reduction (p= 0.003) from 86.4% to 18.2%. CONCLUSIONS Mannitol plus Vitamins B is effective in the management of piriformis syndrome and it could be an alternative regime in treating PS.
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Affiliation(s)
- Zhi-Fa Huang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Orthopaedic Surgery, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China.,Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Bing-Quan Lin
- Department of Medical Imaging, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China.,Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | | | - Sabil Dilshad
- Southern Medical University, Guangzhou, Guangdong, China
| | - De-Sheng Yang
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
| | - Jun Xiao
- Department of Orthopaedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China
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35
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Stecco A, Pirri C, Stecco C. Fascial entrapment neuropathy. Clin Anat 2019; 32:883-890. [PMID: 31004463 DOI: 10.1002/ca.23388] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Accepted: 04/16/2019] [Indexed: 12/26/2022]
Abstract
Entrapment neuropathies are debilitating clinical conditions, creating significant morbidity in the upper and lower extremities in terms of pain, sensory abnormalities, and motor weakness, becoming a challenge to diagnose and treat. Because entrapments can have multiple origins, a misinterpretation of anatomy during examination can lead to incorrect diagnosis and treatment. This review addresses understanding of the anatomy of fascia that can play an important role in this syndrome. There is a specific microenvironment around the nerve composed of connective tissues that include deep fascia, intermuscular septa, epineurium, and perineurium. The microenvironmental modifications can be translated into change in mobility with consequence decreasing of the independency of the nerve from the surrounding structures lading to entrapments and "internal stretch lesion." The entrapments reported in this article reinforce the importance of fascia tissue in generating common symptoms that pose more difficult diagnostic challenges and may often be confused with more common clinical conditions. Clin. Anat. 32:883-890, 2019. © 2019 Wiley Periodicals, Inc.
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Affiliation(s)
- Antonio Stecco
- RUSK Rehabilitation, New York University School of Medicine, New York, New York
| | - Carmelo Pirri
- Physical and Rehabilitation Medicine, University of Rome "Tor Vergata", Rome, Italy
| | - Carla Stecco
- Molecular Medicine Department, University of Padua, Padua, Italy
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36
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Fishman LM, Hosseini M. Piriformis syndrome - a diagnosis comes into its own. Muscle Nerve 2019; 59:395-396. [PMID: 30623985 DOI: 10.1002/mus.26417] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 01/01/2019] [Accepted: 01/05/2019] [Indexed: 11/08/2022]
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37
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Demirel A, Baykara M, Koca TT, Berk E. Ultrasound elastography findings in piriformis muscle syndrome. Indian J Radiol Imaging 2019; 28:412-418. [PMID: 30662201 PMCID: PMC6319104 DOI: 10.4103/ijri.ijri_133_18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background: Piriformis muscle syndrome (PMS) is relatively less known and underestimated because it is confused with other clinical pathological conditions. Delays in its diagnosis may lead to chronic somatic dysfunction and muscle weakness. Objective: Here, we aimed to evaluate the diagnostic performance of the ultrasound elastography (UE) as an easy, less-invasive, and cost-effective method for early diagnosis of PMS. Materials and Methods: Twenty-eight cases clinically diagnosed as PMS at the outpatient clinic were evaluated by UE. The elastographic strain ratio was calculated by dividing the strain value of the subcutaneous fat tissue by the mean stress value of the muscle beneath. The diagnostic performances of the strain rate measures were compared using the receiver operating characteristic curve analysis. Results: Twenty-one (N = 21) cases were female, and seven (N = 7) of the cases were male. The mean age was 45 years (ranged 24–62 years). The strain rates of piriformis muscle (PM) and gluteus maximus (GM) muscles were significantly higher on the PMS-diagnosed side (P < 0.001). The cutoff value of UE strain ratio for the PM and GM were 0.878 [95% confidence interval (CI) 0.774–0.981] and 0.768 (95% CI 0.622–0.913), respectively, and the sensitivity and specificity values were, respectively, 80.95% and 85.71% for the PM, and they were, respectively, 85.71% and 66.67% for the GM. Conclusion: We showed that the muscle elasticity and tissue hardening increased on the problematic side both on PM and GM. UE may provide early diagnosis of PMS, thereby increasing the possibility of treatment with less invasive methods.
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Affiliation(s)
- Adnan Demirel
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Sütçü İmam University, Kahramanmaraş, Turkey
| | - Murat Baykara
- Department of Radiology, Faculty of Medicine, Sütçü İmam University, Kahramanmaraş, Turkey
| | - Tuba Tülay Koca
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Sütçü İmam University, Kahramanmaraş, Turkey
| | - Ejder Berk
- Department of Physical Medicine and Rehabilitation, Faculty of Medicine, Sütçü İmam University, Kahramanmaraş, Turkey
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38
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Lim JY, Lee IW, Kim DH. A Movement-System-Impairment Approach to the Evaluation and Treatment
of a Patient with Piriformis Syndrome: A Case Report. ACTA ACUST UNITED AC 2018. [DOI: 10.29273/jmst.2018.2.2.43] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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39
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Najdi H, Mouarbes D, Abi-Akl J, Karnib S, Chamsedine AH, Jawish R. EMG in piriformis syndrome diagnosis: Reliability of peroneal H-reflex according to results obtained after surgery, Botox injection and medical treatment. J Clin Neurosci 2018; 59:55-61. [PMID: 30501920 DOI: 10.1016/j.jocn.2018.11.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2018] [Revised: 09/29/2018] [Accepted: 11/04/2018] [Indexed: 11/29/2022]
Abstract
Diagnosing piriformis syndrome (PS) throughout the past decades was not that easy, however peroneal H-reflex was proved as reliable test for PS with the change in wave amplitude and delay in conduction as parameters for diagnosis. We interpreted these parameters according to treatment's results carried out for patients presenting clinical PS, aiming to define a threshold value for peroneal H-reflex delay to accurately diagnose. A retrospective mono-centric review of 27 patients, 9 females and 18 males, aged 22-65 years, benefited from peroneal H-reflex test and treated for clinical PS. These patients were classified into 3 groups according to treatment modality they received: 11 patients underwent surgical treatment, 7 patients underwent Botox injections (4 of them benefited from surgery later on) and 9 patients received pharmacological treatment. From 11 operated patients with 4 < delay < 9 ms, 10 had complete improvement and 1 remained in pain. For 7 patients having injection of Botox 100-300 IU, with 5 < delay < 7 ms had a transient recovery, 4 of them have benefited later from surgery, the 3 others reproved pain. Between 9 patients who have declined invasive treatment, 7 patients with 4 < delay < 10 ms didn't demonstrate any improvement after medical treatment and are suspected of PS, 2 others with delay < 4 ms recovered from a non-confirmed PS. A threshold value to diagnose PS was reached through peroneal H-reflex delay ranges, classified as: high with a delay > 5 ms, moderate: 4 < delay < 5 ms and poor: <4 ms.
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Affiliation(s)
- Hassan Najdi
- Orthopedic Surgery Department, Sacré-Coeur Hospital, P.O. Box 116, Hazmieh, Lebanon.
| | - Dany Mouarbes
- Orthopedic Surgery Department, Sacré-Coeur Hospital, P.O. Box 116, Hazmieh, Lebanon
| | - Joe Abi-Akl
- Orthopedic Surgery Department, Sacré-Coeur Hospital, P.O. Box 116, Hazmieh, Lebanon
| | - Soha Karnib
- Orthopedic Surgery Department, Sacré-Coeur Hospital, P.O. Box 116, Hazmieh, Lebanon
| | - Ali Hassan Chamsedine
- Head Division of Orthopedic and Trauma Surgery at the Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon; Sahel General Hospital, Beirut, Lebanon
| | - Roger Jawish
- Orthopedic Surgery Department, Sacré-Coeur Hospital, P.O. Box 116, Hazmieh, Lebanon
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40
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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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41
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Iwanaga J, Eid S, Simonds E, Schumacher M, Loukas M, Tubbs RS. The majority of piriformis muscles are innervated by the superior gluteal nerve. Clin Anat 2018; 32:282-286. [PMID: 30408241 DOI: 10.1002/ca.23311] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 11/01/2018] [Indexed: 12/25/2022]
Abstract
The piriformis muscle is clinically implicated in pain disorders, posterior approaches for total hip arthroplasty, and iatrogenic injury to the muscle and the surrounding nerves. The piriformis muscle has been said to receive innervation from L5 to S3 ventral rami with most sources using S1 and S2 ventral rami as the most common innervation this muscle. However, descriptions of the nerve in the literature are vague. Therefore, the aim of this study was to clarify the anatomy of the nerve supply to the piriformis muscle. Twenty sides from ten fresh-frozen cadavers were studied. Specifically, via anterior dissection of the sacral plexus, branches to the piriformis were identified. Once identified, the nerves to the piriformis muscle were traced proximally to clarify their origin. Nerves supplying the piriformis muscle existed on all sides. On 80% of sides, the piriformis was innervated by two to three nerves. The origin of these nerves was from the superior gluteal nerve on 14 sides (70%), inferior gluteal nerve on one side (5%), L5 ventral ramus on one side (5%), S1 ventral ramus on 17 sides (85%), and S2 ventral ramus on 14 sides (70%), respectively. The most common nerve branches to the piriformis are from the superior gluteal nerve, and the ventral rami of S1 and S2. Based on our study, a single "nerve to piriformis" does not exist in the majority of specimens thus this term should be abandoned. Clin. Anat. 32:282-286, 2019. © 2018 Wiley Periodicals, Inc.
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Affiliation(s)
- Joe Iwanaga
- Seattle Science Foundation, Seattle, Washington.,Division of Gross and Clinical Anatomy, Department of Anatomy, Kurume University School of Medicine, Kurume, Japan
| | - Seif Eid
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | | | | | - Marios Loukas
- Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
| | - R Shane Tubbs
- Seattle Science Foundation, Seattle, Washington.,Department of Anatomical Sciences, St. George's University, St. George's, Grenada, West Indies
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42
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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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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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Great trochanter bursitis vs sciatica, a diagnostic–anatomic trap: differential diagnosis and brief review of the literature. 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 2018; 27:1509-1516. [DOI: 10.1007/s00586-018-5486-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 01/10/2018] [Accepted: 01/20/2018] [Indexed: 01/01/2023]
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Abstract
PURPOSE OF REVIEW The clinical diagnostic dilemma of low back pain that is associated with lower limb pain is very common. In relation to back pain that radiates to the leg, the International Association for the Study of Pain (IASP) states: "Pain in the lower limb should be described specifically as either referred pain or radicular pain. In cases of doubt no implication should be made and the pain should be described as pain in the lower limb." RECENT FINDINGS Bogduks' editorial in the journal PAIN (2009) helps us to differentiate and define the terms somatic referred pain, radicular pain, and radiculopathy. In addition, there are other pathologies distal to the nerve root that could be relevant to patients with back pain and leg pain such as plexus and peripheral nerve involvement. Hence, the diagnosis of back pain with leg pain can still be challenging. In this article, we present a patient with back and leg pain. The patient appears to have a radicular pain syndrome, but has no neurological impairment and shows signs of myofascial involvement. Is there a single diagnosis or indeed two overlapping syndromes? The scope of our article encompasses the common diagnostic possibilities for this type of patient. A discussion of treatment is beyond the scope of this article and depends on the final diagnosis/diagnoses made.
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Affiliation(s)
- Simon Vulfsons
- Institute for Pain Medicine, Rambam Health Care Campus, 11 Ephron Street, Bat Galim, 3109601, Haifa, Israel. .,Rappaport Faculty of Medicine, Technion Institute for Technology, Haifa, Israel.
| | - Negev Bar
- Department of Family Medicine, Haifa, Israel.,Clalit Health Services, Haifa, Haifa and Western Galilee, Israel
| | - Elon Eisenberg
- Institute for Pain Medicine, Rambam Health Care Campus, 11 Ephron Street, Bat Galim, 3109601, Haifa, Israel.,Rappaport Faculty of Medicine, Technion Institute for Technology, Haifa, Israel
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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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Piriformis muscle syndrome with assessment of sciatic nerve using diffusion tensor imaging and tractography: a case report. Skeletal Radiol 2017; 46:1399-1404. [PMID: 28616638 DOI: 10.1007/s00256-017-2690-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/25/2017] [Accepted: 05/30/2017] [Indexed: 02/02/2023]
Abstract
Piriformis muscle syndrome (PMS) is difficult to diagnose by objective evaluation of sciatic nerve injury. Here we report a case of PMS diagnosed by diffusion tensor imaging (DTI) and tractography of the sciatic nerve, which can assess and visualize the extent of nerve injury. The patient was a 53-year-old man with a 2-year history of continuous pain and numbness in the left leg. His symptoms worsened when sitting. Physical examination, including sensorimotor neurologic tests, the deep tendon reflex test, and the straight leg raise test, revealed no specific findings. The hip flexion adduction and internal rotation test and resisted contraction maneuvers for the piriformis muscle were positive. There were no abnormal findings on magnetic resonance imaging (MRI) of the lumbar spine. The transverse diameter of piriformis muscle was slightly thicker in affected side on MRI of the pelvis. A single DTI sequence was performed during MRI of the pelvis. Fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) of the sciatic nerve were quantified at three levels using the fiber-tracking method. FA values were significantly lower and ADC values were significantly higher distal to the piriformis muscle. We performed endoscopic-assisted resection of the piriformis tendon. Intraoperatively, the motor-evoked potentials in the left gastrocnemius were improved by resection of the piriformis tendon. The patient's symptoms improved immediately after surgery. There was no significant difference in FA or ADC at any level between the affected side and the unaffected side 3 months postoperatively. MRI-DTI may aid the diagnosis of PMS.
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Eastlack J, Tenorio L, Wadhwa V, Scott K, Starr A, Chhabra A. Sciatic neuromuscular variants on MR neurography: frequency study and interobserver performance. Br J Radiol 2017; 90:20170116. [PMID: 28830192 DOI: 10.1259/bjr.20170116] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To evaluate the frequency of sciatic neuromuscular variants on MR neurography and determine the interobserver variability. METHODS A retrospective evaluation of 137 consecutive lumbosacral plexus magnetic resonance neurography examinations was performed. All examinations were performed using nerve selective 3D imaging and independently reviewed by two readers for the presence of sciatic neuromuscular variants and piriformis muscle asymmetry. Inter- and intraobserver performance were evaluated. RESULTS There were a total of 44/268 (16.4%) extremities with sciatic neuromuscular variants. The interobserver performance in the identification of sciatic nerve variants was excellent (kappa values from 0.8-0.9). There was a total of 45/134 (33.6%) patients with piriformis muscle asymmetry. Of these, 7/134 (5.2%) had piriformis muscle atrophy and 38/134 (28.4%) had piriformis muscle hypertrophy. The interobserver performance in the identification of piriformis muscle atrophy and hypertrophy was moderate to good (kappa values from 0.39-0.61). The intraobserver performance revealed kappa values of 0.735 and 0.821 on right and left, respectively. CONCLUSION Sciatic neuromuscular variants and piriformis muscle asymmetry are frequent on lumbosacral plexus MRN with moderate to excellent interobserver performance. Advances in knowledge: Sciatic neuromuscular variants and piriformis asymmetry on MR neurography are frequent and the prevalence is similar to cumulative prevalence from available scientific series. Interobserver performance for identification of sciatic neuromuscular variants is excellent, and moderate-good for piriformis muscle asymmetry.
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Affiliation(s)
- Jason Eastlack
- 1 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lulu Tenorio
- 1 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Vibhor Wadhwa
- 2 Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Kelly Scott
- 3 Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Adam Starr
- 4 Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Avneesh Chhabra
- 1 Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX, USA.,4 Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Han SK, Kim YS, Kim TH, Kang SH. Surgical Treatment of Piriformis Syndrome. Clin Orthop Surg 2017; 9:136-144. [PMID: 28567214 PMCID: PMC5435650 DOI: 10.4055/cios.2017.9.2.136] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 01/01/2017] [Indexed: 11/30/2022] Open
Abstract
Background Piriformis syndrome (PS) is an uncommon disease characterized by symptoms resulting from compression/irritation of the sciatic nerve by the piriformis muscle. Uncertainty and controversy remain regarding the proper diagnosis and most effective form of treatment for PS. This study analyzes the diagnostic methods and efficacy of conservative and surgical treatments for PS. Methods From March 2006 to February 2013, we retrospectively reviewed 239 patients who were diagnosed with PS and screened them for eligibility according to our inclusion/exclusion criteria. All patients underwent various conservative treatments initially including activity modification, medications, physical therapy, local steroid injections into the piriformis muscle, and extracorporeal shock wave therapy for at least 3 months. We resected the piriformis muscle with/without neurolysis of the sciatic nerve in 12 patients who had intractable sciatica despite conservative treatment at least for 3 months. The average age of the patients (4 males and 8 females) was 61 years (range, 45 to 71 years). The average duration of symptoms before surgery was 22.1 months (range, 4 to 72 months), and the mean follow-up period was 22.7 months (range, 12 to 43 months). We evaluated the degree of pain and recorded the responses using a visual analog scale (VAS) preoperatively and 3 days and 12 months postoperatively. Results Buttock pain was more improved than sciatica with various conservative treatments. Compared with preoperatively, the VAS score was significantly decreased after the operation. Overall, satisfactory results were obtained in 10 patients (83%) after surgery. Conclusions PS is thought to be an exclusively clinical diagnosis, and if the diagnosis is performed correctly, surgery can be a good treatment option in patients with refractory sciatica despite appropriate conservative treatments.
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Affiliation(s)
- Suk Ku Han
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yong Sik Kim
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Hyeon Kim
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soo Hwan Kang
- Department of Orthopaedic Surgery, St. Paul's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Fishman LM, Wilkins AN, Rosner B. Electrophysiologically identified piriformis syndrome is successfully treated with incobotulinum toxin a and physical therapy. Muscle Nerve 2017; 56:258-263. [PMID: 27935076 DOI: 10.1002/mus.25504] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Revised: 10/20/2016] [Accepted: 11/25/2016] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Piriformis syndrome is entrapment of the sciatic nerve by the piriformis muscle. METHODS In this article we describe a 56-person randomized, double-blind, controlled study involving physical therapy and incobotulinum toxin A or placebo. Inclusion criteria were 3-SD delay of posterior tibial (PT) or fibular (FN) H-reflexes on flexion, adduction, and internal rotation (FAIR) testing, and normal paraspinal electromyographic findings. Outcome measures included adverse side effects, visual analog scale (VAS) findings, and H-reflex delay on the FAIR test. RESULTS Mean intervention VAS score decreased significantly more compared with placebo at 2, 4, 6, 8, 10, and 12 weeks post-injection (P < 0.0001). FAIR test scores for PT, but not FN, decreased significantly more compared with placebo at 2, 4, 6, and 8 weeks post-injection (PT: P = 0.038, 0.003, 0.003, and 0.046). Adverse effects were minimal. VAS slope and PT FAIR test results varied significantly (P < 0.0001). CONCLUSION Incobotulinum toxin A chemodenervation may be useful for treating piriformis syndrome as identified by the FAIR test. Muscle Nerve 56: 258-263, 2017.
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Affiliation(s)
- Loren M Fishman
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons, 133 East 58th Street, New York, New York, 10022, USA
| | - Allen N Wilkins
- Department of Rehabilitation and Regenerative Medicine, Columbia University College of Physicians and Surgeons, 133 East 58th Street, New York, New York, 10022, USA
| | - Bernard Rosner
- Department of Biostatistics, Harvard School of Public Health, Boston, Massachusetts, USA
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