Piriformis syndrome
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Transcript of Piriformis syndrome
Piriformis SyndromeAre We Missing It?
Dr. Jayant Sharma MS (ortho) ,DNB, MNAMS Consultant (Sports Medicine)
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
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.
The muscle
Origin Insertion Its relation to sciatic nerve
Abnormal anatomy
Approximately 15% of Cadavers exhibit that instead of Sciatic Nerve passing below the muscle it,
Passes through Or Above the Piriformis.
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.
CausesOVERLOAD: Exercise on hard
surface Exercise on uneven
surface Exercise after long
layoff Exercise with worn
out shoes Prolonged Sitting
BIOMECHANICSBIOMECHANICS:: On toe running On toe running
Banked road runningBanked road running
Stiff back musclesStiff back muscles
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.
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.
ClassificationA.PrimaryMyofascial pain caused by trauma.
B. Secondary Tumors Endometreosis Adhesions of T.H.R. Inflammation Malunited fractures Pelvic Outlet Syndrome
Papadopoulos SM, Arch Neurl.1990-1144-6Papadopoulos SM, Arch Neurl.1990-1144-6
Diagnostic criteria
History C/O - pain radiating to ipsilateral
hip, thigh, below knee. Exacerbated by activity -
adduction & internal rotation. Sitting Intolerance.
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
FAdIR
PACE PACE
In few cases when patient showed strong clinical signs and was not responding to physiotherapy, we asked for an MRI.
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
Treatment protocolFor first 72 hrs Rest NSAIDS Muscle relaxants ULTRASONIC MASSAGEAfter 72 hrs Stretching DTFM US Massage
After two weeks Local injection(3)1. LA2. LA + Depo medrol3. Perisciatic
Parziale J, American Journ.Orthop,1996;25,819-23Parziale J, American Journ.Orthop,1996;25,819-23
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)
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.
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
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.
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.
Take home message
Piriformis syndrome should be considered
as an important differential diagnosis in backache patients.
With best wishes
ARIHANT HOSPITAL AND RESEARCH CENTRE, INDORE