2. Piriformis Syndrome
Are We Missing It?
Dr. Jayant Sharma MS (ortho) ,DNB, MNAMS
Consultant (Sports Medicine)
3. Introduction
In the United States each year,
1.5 million people have lumbar MRI scans to look
for the cause of the buttock and leg pain called
'sciatica'.
More than 1.2 million of those scans fail to find the
cause in the spine.
Three hundred thousand of the scans are sufficiently
positive that the patient has lumbar spine surgery. Of
the 300,000 surgeries, as many as 25% fail to
relieve the pain
In many cases this is because the diagnosis of a
spinal cause for the sciatica was incorrect.
www.neurography.com/Images/Piriformis/Piriformis1
4. Introduction
Piriformis syndrome also causes
sciatica. Its treatment is much less
invasive and severe than the
treatment of herniated lumbar disks.
However, many doctors never
consider piriformis syndrome as a
possible diagnosis. Many physicians
who are aware of it are uncertain how
to properly diagnose and treat it.
7. Abnormal anatomy
Approximately 15% of Cadavers
exhibit that instead of Sciatic
Nerve passing below the muscle
it,
Passes through
Or
Above the Piriformis.
8. Pathophysiology
Pecina : Hypothesized that
Sciatic Nerve passing thru
Tendinous portion of Piriformis
is susceptible to compression.
Pace & Nigle : Myofascial pain
syndromes caused by trauma.
McCrory : “PELVIC OUTLET
SYNDROME”; due to extra
spinal compression.
Mccory P, Bell.S-Sports Medicine 1999:27:261-74.Mccory P, Bell.S-Sports Medicine 1999:27:261-74.
9. Causes
OVERLOAD:
Exercise on hard
surface
Exercise on uneven
surface
Exercise after long
layoff
Exercise with worn
out shoes
Prolonged Sitting
BIOMECHANICSBIOMECHANICS::
On toe runningOn toe running
Banked road runningBanked road running
Stiff back musclesStiff back muscles
10. AIMS
To study the patients of radicular low
backache for Pirifomis syndrome
To follow up these cases for 6 months
and evaluate the present protocol of
management.
11. Materials and methods
This study was conducted at AHRC,
Indore from Feb. 06 to July 2006.
All patients complaining of low
backache at Ortho OPD,LBA Clinic,
and sports medicine clinic were
considered for screening for
Piriformis syndrome.
13. Diagnostic criteria
History
C/O - pain radiating to ipsilateral
hip, thigh, below knee.
Exacerbated by activity -
adduction & internal rotation.
Sitting Intolerance.
14. FADIR TEST
STRECHING TEST OF FREIBERG
PACE TEST - lying with painful buttock up
and knee on table, resisted lifting up of
knee in fixed position elicits pain, rules out
pain of O.A., Disc
SLRT +ve with relief of pain on ER.
P/R Examination - tender mass spindle
shaped, this is the intrapelvic part of
the muscle
19. In few cases when patient showed
strong clinical signs and was not
responding to physiotherapy, we
asked for an MRI.
20. No role of X-rays,
Neurophysiological Tests are
consistent with Peroneal
Division of Sciatic Nerve.
Nerve conduction shows delayed
F&H waves reflex.
MRI is diagnostic
21.
22. Treatment protocol
For first 72 hrs
Rest
NSAIDS
Muscle relaxants
ULTRASONIC MASSAGE
After 72 hrs
Stretching
DTFM
US Massage
23.
24.
25.
26. After two weeks
Local injection(3)
1. LA
2. LA + Depo medrol
3. Perisciatic
Parziale J, American Journ.Orthop,1996;25,819-23Parziale J, American Journ.Orthop,1996;25,819-23
27. Surgery
Robinson
Piriformis muscle release
Sciatic nerve Neurolysis.
No effect on power of the external
rotators and abductors of hip.
Position - Lateral
Incision - Posterior approach
(Southern’s)
28. Steps - insertion of
piriformis is palpated
after splitting gluteus
maximus.
Tendon is palpated
and divided & grasped
with Allis forceps, and
dissected till its exit at
Sciatic notch.
Full weight bearing in
5-10 days.
Avoid prolonged
sitting for 4-6 weeks.
29.
30. Neurotoxin
Clostridium botulinum
Inhibits release of Acetylcholine
Leads to functional denervation of
muscles
Effective for SIX months
U.S.F.D.A.approved since December
2000.
Botox
31. Observations
Total patients of LBA- 754
Patients of PS 67
11 males and 56 females (1:5)
36 right sided and 31 left sided
No. of patients with significant reduction of
pain on VAS at two weeks- 50
At four weeks 64
17 patients were subjected to injections
Of the remaining four two lost to f/up
Two were subjected to MRI and when
confirmed they were operated.
32. Conclusion
Piriformis syndrome is underdiagnosed
and undertreated entity.
It is easy to diagnose with few physical
signs.
When in doubt ask for an MRI
The radiologist should be asked to look for
piriformis syndrome while screening the
spine
With this many cases can be saved from
undergoing surgery.
33. Take home message
Piriformis syndrome
should be considered
as an important
differential diagnosis
in backache patients.