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Piriformis Syndrome

  • Nicholas Kirch
  • Maunak V. RanaEmail author
Chapter
  • 42 Downloads

Abstract

Piriformis muscle is an uncommon cause of back and radicular pain. In the realm of radicular pain, piriformis syndrome is often overlooked. The diagnosis is difficult due to long list of causes that can cause gluteal and leg pain. It is classically described as a neuritis of the sciatic nerve caused by compression or irritation of the nerve by the piriformis muscle (Cass Curr Sports Med Rep 14:41–4, 2015; Hopayian and Danielyan Eur J Orthop Surg Traumatol 28:155–164, 2017; Smoll Clin Anat 23:8–17, 2010; Benzon et al. Anesthesiology 98:1442–8, 2003; Jawish et al. J Orthop Surg Res 5:3, 2010). Piriformis syndrome can be caused by anatomic variations (Benzon et al. Anesthesiology 98:1442–8, 2003) of the sciatic nerve course related to the closely proximate piriformis muscle, anatomic variations of the piriformis muscle itself, or traumatic incidents. The most common cause is macrotrauma (Jawish et al. J Orthop Surg Res 5:3, 2010), which leads to muscle spasm and resultant soft tissue inflammation. There is no one specific test to treat for piriformis syndrome, but rather the entity is best considered as a diagnosis of exclusion. Fusing the history and a constellation of physical examination tests can help cinch the syndrome as the putative cause of pain. Tests such as the Freiberg, Pace, FABER, FAIR, and Beatty tests, which show deep buttock pain, can demonstrate a hypertrophied or taught piriformis muscle (Jawish et al. J Orthop Surg Res 5:3, 2010). Additional studies, including neurophysiologic testing, CT, MR, and ultrasound, can be used in the diagnosis, especially as mechanism to rule out other confounding diagnosis, including sacroiliac pain, hip bursitis, degenerative disc disease, and lumbosacral radiculopathies, among others.

The mainstay of treatment is rest and analgesics, including therapies from NSAIDs, acetaminophen, gabapentin, muscle relaxants to opiates. Additionally a physical therapy program containing elements including heat/cold therapy, TENs, and ultrasound massage to strengthen surrounding muscles as well as stretch and relax the piriformis muscle is a critical component to recovery. If resistant to conservative management, more invasive treatments, including ultrasound-guided trigger point injections of local anesthetic and steroids as well as botulinum toxin injections, have been shown to be effective in temporarily relieving the pain. Ultimately some patients can require surgical release of the piriformis muscle to relieve impingement on the sciatic nerve.

Keywords

Piriformis syndrome Sciatic nerve Back pain and piriformis syndrome Neuritis of the sciatic nerve Piriformis muscle Chronic low back pain 

References

  1. 1.
    Cass SP. Piriformis syndrome: a cause of nondiscogenic sciatica. Curr Sports Med Rep. 2015;14(1):41–4.  https://doi.org/10.1249/JSR.0000000000000110. PMID 25574881.CrossRefPubMedGoogle Scholar
  2. 2.
    Hopayian K, Danielyan A. Four symptoms define the piriformis syndrome: an updated systematic review of its clinical features. Eur J Orthop Surg Traumatol. 2017;28:155–64.  https://doi.org/10.1007/s00590-017-2031-8. PMID 28836092.CrossRefPubMedGoogle Scholar
  3. 3.
    Smoll NR. Variations of the piriformis and sciatic nerve with clinical consequence: a review. Clin Anat. 2010;23(1):8–17.  https://doi.org/10.1002/ca.20893. PMID 19998490.CrossRefPubMedGoogle Scholar
  4. 4.
    Benzon HT, Katz JA, Benzon HA, Iqbal MS. Piriformis syndrome: anatomic considerations, a new injection technique, and a review of the literature. Anesthesiology. 2003;98(6):1442–8.  https://doi.org/10.1097/00000542-200306000-00022. PMID 12766656CrossRefPubMedGoogle Scholar
  5. 5.
    Jawish RM, Assoum HA, Khamis CF. Anatomical, clinical and electrical observations in piriformis syndrome. J Orthop Surg Res. 2010;5:3.  https://doi.org/10.1186/1749-799X-5-3. PMC 2828977 . PMID 20180984.CrossRefPubMedPubMedCentralGoogle Scholar
  6. 6.
    Hayek SM, Shah BJ, Desai MJ, Chelimsky TC. Pain medicine: an interdisciplinary case-based approach. Oxford: Oxford University Press; 2015. p. 240. ISBN 978-0-19-939081-6.CrossRefGoogle Scholar
  7. 7.
    Boyajian-O'Neill LA, McClain RL, Coleman MK, Thomas PP. Diagnosis and management of piriformis syndrome: an osteopathic approach. J Am Osteopath Assoc. 2008;108:657–64.CrossRefGoogle Scholar
  8. 8.
    Fishman L, Allen NW, Rosner B. Electrophysiologically Identified Piriformis Syndrome is successfully treated with Incobotulinum toxin A and Physical Therapy. Muscle Nerve. 2016;56:258–63.  https://doi.org/10.1002/mus.25504.CrossRefGoogle Scholar
  9. 9.
    Ro TH, Edmonds L. Diagnosis and management of piriformis syndrome: a rare anatomic variant analyzed by magnetic resonance imaging. J Clin Imaging Sci. 2018;8:6.CrossRefGoogle Scholar
  10. 10.
    Rossi P, Cardinali P, Serrao M, Parisi L, Bianco F, De Bac S. Magnetic resonance imaging findings in piriformis syndrome: a case report. Arch Phys Med Rehabil. 2001;82(4):519–21.CrossRefGoogle Scholar
  11. 11.
    Al-Al-Shaikh MF, Paratte B, Kastler B, Vidal C, Aubry S. An MRI evaluation of changes in piriformis muscle morphology induced by botulinum toxin injections in the treatment of piriformis syndrome. Diagn Interv Imaging. 2015;96(1):37–43.CrossRefGoogle Scholar
  12. 12.
    Brooks JBB, Silva CAC, Soares SA, Kai MR, Cabral RH, Fragoso YD. Anatomical variations of the sciatic nerve in a Group of Brazilian Cadavers. Rev Dor Sao Paulo. 2011;12(4):332–6.Google Scholar
  13. 13.
    Huerto APS, Yeo SN, Ho KY. Piriformis muscle injection using ultrasonography and motor stimulation-report of a technique. Pain Physician. 2007;10:687–90.PubMedGoogle Scholar
  14. 14.
    Finnoff JT, Hurdle MFB, Smith J. Accuracy of ultrasound-guided versus fluoroscopically guided contrast-controlled piriformis injections. J Ultrasound Med. 2008;27(8):1157–63. Accessed online:  https://doi.org/10.7863/jum.2008.27.8.1157.CrossRefGoogle Scholar
  15. 15.
    Smith J, Hurdle MF, Locketz AJ, Wisniewski SJ. Ultrasound-guided piriformis injection: technique description and verification. Arch Phys Med Rehabil. 2006;87(12):1664–7.CrossRefGoogle Scholar
  16. 16.
    Misirlioglu TO, Akgun K, Palamar D, Erden MG, Erbilir T. Effectiveness of local anesthetic and corticosteroid injections: a double-blinded randomized controlled study. Pain Physician. 2015;18:163–71.PubMedGoogle Scholar
  17. 17.
    Santamato A, Micello MF, Valeno G, Beatrice R, Cinone N, Baricich A, Picelli A, Panza F, Logroscino G, Fiore P, Ranieri M. Ultrasound-guided injection of botulinum toxin type a for piriformis muscle syndrome: a case report and review of the literature. Toxins (Basel). 2005;7(8):3045–56.CrossRefGoogle Scholar
  18. 18.
    Yoon SJ, Ho J, Kang HY, Lee SH, Kim KI, Shin WG, Oh JM. Low-Dose botulinum toxin type A for the treatment of refractory piriformis syndrome. Pharmacotherapy. 2007;27(5):657–65.Google Scholar
  19. 19.
    Tonley JC, Yun SM, Kochevar RJ, Dye JA, Farrokhi S, Powers CM. Treatment of an individual with piriformis syndrome focusing on hip muscle strengthening and movement reeducation: a case report. J Orthop Sports Phys Ther. 2010;40(2):103–11.CrossRefGoogle Scholar
  20. 20.
    Jeong HS, Lee GY, Lee EG, Joe EG, Lee JW, Kang HS. Long-term assessment of clinical outcomes of ultrasound-guided steroid injections in patients with piriformis syndrome. Ultrasonography. 2015;34(3):206–10.CrossRefGoogle Scholar
  21. 21.
    Kean Chen C, Nizar AJ. Prevalence of piriformis syndrome in chronic low back pain patients. A clinical diagnosis with modified FAIR test.Google Scholar
  22. 22.
    Sulak O, Sakalli B, Ozguner G, Kastamoni Y. Anatomical relation between sciatic nerve and piriformis muscle and its birfurcation level during fetal period in human. Surg Radiol Anat. 2014;36(3):265–72.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Department of Anesthesiology and Critical CareUniversity of ChicagoChicagoUSA

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